No. of teeth with decay, missing, or filling

@ Caries experience

\$ Edentulism

% Extraction

& Conservative treatment

Table 4. The oral health status of people with psychiatric disorders

Oral Health of People with Psychiatric Disorders 295

prescribed for treating their psychiatric disorders. Despite of the increased needs for dental prophylaxes and care, oral health care programs for psychiatric patients are rare,

In addition to boost oral health services provided for patients with psychiatric disorders in the community, it is important for the health policy-makers to support oral health promotion programs. The programs will aim at the patients and their families/carers to empower their belief that oral health is essential and attainable through their own efforts. The government should initiate on-the-job education programs for the dental and psychiatric professionals to enhance their capability and motivation to provide proper services to their psychiatric patients' oral health through integrated efforts. Oral health is an essential part of general health, and it is certainly true for patients with psychiatric

A. A. Pinkney, G. J. G., H. G. Lafave,. (1991). Quality of life after psychiatric rehabilitation:

Almomani, F., Brown, C., Williams, K. B., Almomani, F., Brown, C., & Williams, K. B. (2006).

Almomani, F., Williams, K., Catley, D., & Brown, C. (2009). Effects of an oral health

APA. (1995). Diagnostic and statistical manual of mental disorders, 4th edn. . In W. DC

Barnes, G. P., Allen, E. H., Parker, W. A., Lyon, T. C., Armentrout, W., & Cole, J. S. (1988).

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Chien, I.-C., Chou, Y.-J., Lin, C.-H., Bih, S.-H., & Chou, P. (2004). Prevalence of Psychiatric

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**5. References** 

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#### **3. Oral health care for people with psychiatric disorders**

Oral health programs for people with psychiatric disorders are rare. Researchers have demonstrated the feasibility and efficacy of the combination of mechanical toothbrush, dental instructions and reminders which resulted in additional improvements for the oral health of people with psychiatric disorders. (Almomani et al., 2006) Studies also showed that people with psychiatric disorders receiving motivational interviewing (MI) had significantly better oral health than those receiving oral health education only. Furthermore MI has been shown to be effective for enhancing short-term oral health behavior change for people with severe mental illness. (Almomani, Williams, Catley, & Brown, 2009)

#### **3.1 Barriers to oral health care for people with psychiatric disorders**

Most oral health professionals have limited experiences in providing care for people with psychiatric disorders. (Waldman, Perlman, Waldman, & Perlman, 2002) The barriers exist in organization and financing of the care needed as well as in proposing strategies to enhance the delivery of appropriate treatment. (Ridgely, Goldman, & Willenbring, 1990)

General health services are widely utilized by people with psychiatric disorders under psychiatric care in long-term care institutions. However, oral health services remain underutilized, and there is a high prevalence of perceived barriers to receiving dental care in this population. (Dickerson et al., 2003)

#### **3.2 Special requirements of oral health care delivery system for people with psychiatric disorders**

Psychiatric disorders have psychopathological characteristics. In particular, there are specific oral health care requirements and management models for patients with psychiatric disorders. (Clark, 1992) These major requirements for people with psychiatric disorders include prophylaxes, calculus removal, and periodontal therapy Patients' dental treatment needs vary depending on several demographic factors, length of stay in institutions and the patient's psychiatric diagnosis. (Barnes et al. 1988)

#### **4. Implications for the oral health policies**

Since the psychiatric health care system has not yet been fully established in some countries, patients with psychiatric disorders there are not likely to obtain the necessary care in their communities. Individuals suffering from severe psychiatric disorders may be able to attain a more dignified life if they could avail themselves of personalized, private, and high quality care services in pertinent institutions. To stay in long-term care institutions is, perhaps, the alternative solution to living in the community. Therefore, the reform of institutions, particularly for the provision of relevant services and continued care, can compensate for a little imparity of dental care for these patients, and is a more practical solution than de-institutionalization of patients with psychiatric disorders. (Chu et al. 2010)

Being not life-threatening in most cases, oral diseases have obvious impacts on patients' quality of life. However, patients with psychiatric disorders also suffer from stigma outside and inside themselves. They are vulnerable to oral diseases due to their limited ability/motivation to take care of themselves and also to the side effects of medications prescribed for treating their psychiatric disorders. Despite of the increased needs for dental prophylaxes and care, oral health care programs for psychiatric patients are rare, underutilized and receiving less attention from the public sectors.

In addition to boost oral health services provided for patients with psychiatric disorders in the community, it is important for the health policy-makers to support oral health promotion programs. The programs will aim at the patients and their families/carers to empower their belief that oral health is essential and attainable through their own efforts. The government should initiate on-the-job education programs for the dental and psychiatric professionals to enhance their capability and motivation to provide proper services to their psychiatric patients' oral health through integrated efforts. Oral health is an essential part of general health, and it is certainly true for patients with psychiatric disorders.

#### **5. References**

294 Oral Health Care – Prosthodontics, Periodontology, Biology, Research and Systemic Conditions

Oral health programs for people with psychiatric disorders are rare. Researchers have demonstrated the feasibility and efficacy of the combination of mechanical toothbrush, dental instructions and reminders which resulted in additional improvements for the oral health of people with psychiatric disorders. (Almomani et al., 2006) Studies also showed that people with psychiatric disorders receiving motivational interviewing (MI) had significantly better oral health than those receiving oral health education only. Furthermore MI has been shown to be effective for enhancing short-term oral health behavior change for people with

Most oral health professionals have limited experiences in providing care for people with psychiatric disorders. (Waldman, Perlman, Waldman, & Perlman, 2002) The barriers exist in organization and financing of the care needed as well as in proposing strategies to enhance

General health services are widely utilized by people with psychiatric disorders under psychiatric care in long-term care institutions. However, oral health services remain underutilized, and there is a high prevalence of perceived barriers to receiving dental care in

Psychiatric disorders have psychopathological characteristics. In particular, there are specific oral health care requirements and management models for patients with psychiatric disorders. (Clark, 1992) These major requirements for people with psychiatric disorders include prophylaxes, calculus removal, and periodontal therapy Patients' dental treatment needs vary depending on several demographic factors, length of stay in institutions and the

Since the psychiatric health care system has not yet been fully established in some countries, patients with psychiatric disorders there are not likely to obtain the necessary care in their communities. Individuals suffering from severe psychiatric disorders may be able to attain a more dignified life if they could avail themselves of personalized, private, and high quality care services in pertinent institutions. To stay in long-term care institutions is, perhaps, the alternative solution to living in the community. Therefore, the reform of institutions, particularly for the provision of relevant services and continued care, can compensate for a little imparity of dental care for these patients, and is a more practical solution than de-institutionalization of patients with psychiatric disorders. (Chu et al.

Being not life-threatening in most cases, oral diseases have obvious impacts on patients' quality of life. However, patients with psychiatric disorders also suffer from stigma outside and inside themselves. They are vulnerable to oral diseases due to their limited ability/motivation to take care of themselves and also to the side effects of medications

**3. Oral health care for people with psychiatric disorders** 

severe mental illness. (Almomani, Williams, Catley, & Brown, 2009)

this population. (Dickerson et al., 2003)

patient's psychiatric diagnosis. (Barnes et al. 1988)

**4. Implications for the oral health policies** 

**psychiatric disorders** 

2010)

**3.1 Barriers to oral health care for people with psychiatric disorders** 

the delivery of appropriate treatment. (Ridgely, Goldman, & Willenbring, 1990)

**3.2 Special requirements of oral health care delivery system for people with** 


Oral Health of People with Psychiatric Disorders 297

Keski-Rahkonen, A., Hoek, H. W., Susser, E. S., Linna, M. S., Sihvola, E., Raevuori, A., et al.

Kumar, M., Chandu, G. N., Shafiulla, M. D., & Kumar, M. (2006). Oral health status and

Lewis, S., Jagger, R. G., & Treasure, E. (2001). The oral health of psychiatric in-patients in

Llewellyn, C. D., Warnakulasuriya, S., Llewellyn, C. D., & Warnakulasuriya, S. (2003). The

Locker, D. (2003). Dental status, xerostomia and the oral health-related quality of life of an elderly institutionalized population. *Special Care in Dentistry, 23*(3), 86-93. McGrath, J., Saha, S., Chant, D., & Welham, J. (2008). Schizophrenia: A Concise Overview of Incidence, Prevalence, and Mortality. *Epidemiologic Reviews, 30*(1), 67-76. McGrath, J., Saha, S., Welham, J., El Saadi, O., MacCauley, C., & Chant, D. (2004). A

Ramon, T., Grinshpoon, A., Zusman, S. P., & Weizman, A. (2003). Oral health and

Rekha, R., Hiremath, S. S., & Bharath, S. (2002). Oral health status and treatment

Ridgely, M. S., Goldman, H. H., & Willenbring, M. (1990). Barriers to the Care of Persons

Rudolph, M. J., & Chikte, U. M. (1993). Dental caries experience and periodontal disease in

Sandanger, I., Nygård, J. F., Ingebrigtsen, G., Sørensen, T., & Dalgard, O. S. (1999).

Somers, J. M., Goldner, E. M., Waraich, P., & Hsu, L. (2006). Prevalence and Incidence

Tang, W. K., Sun, F. C. S., Ungvari, G. S., & O'Donnell, D. (2004). Oral Health of

Thomas, A., Lavrentzou, E., Karouzos, C., & Kontis, C. (1996). Factors which influence the

*Psychiatry and Psychiatric Epidemiology, 34*(11), 570-579.

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systematic review of the incidence of schizophrenia: the distribution of rates and the influence of sex, urbanicity, migrant status and methodology. *BMC Medicine,* 

treatment needs of institutionalized chronic psychiatric patients in Israel. *European Psychiatry: the Journal of the Association of European Psychiatrists, 18*(3),

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**19** 

*México* 

**Structural Changes on Human Dental Enamel** 

*1Centro de Investigación y Estudios Avanzados en Odontología, Facultad de Odontología* 

*2Centro Conjunto de Investigación en Química Sustentable UAEM-UNAM, Facultad de* 

It has been reported that common lasers employed for caries prevention on the enamel surface include CO2 and Er:YAG types (Ana, et al., 2006); however, CO2 lasers appear to be more appropriate for preventing dental caries (Rodrigues, et al., 2004). The irradiation of teeth with a laser results in an interaction between the light and the biological constituents of the dental hard substance. In the case of absorption by the specific components of the dental enamel, the irradiated energy is converted directly into heat. This thermal effect is the cause of the structural and chemical changes occurring in the enamel after laser irradiation

The association of laser irradiation with fluoride has demonstrated the best results in the inhibition of caries development. The combined treatment of laser irradiation with fluoride propitiates an expressive fluoride uptake, reducing the progression of caries-like lesions, and this treatment is more effective than laser or fluoride alone. The available data suggest that lasers combined with fluoride are a promising treatment in caries prevention (Ana, et al., 2006). In the same way, the effect of remineralizing solution has been evaluated on caries formation and its progression in the primary tooth enamel. Remineralizing solution has been considered an effective measure for the prevention of white spot lesions because it has the ability to provide mineral sources of calcium (Ca), phosphate and fluoride to demineralized or hypomineralized enamel surfaces, making them less soluble during cariogenic challenges (Westerman et al., 2006). Caries prevention has been evaluated by several techniques, including atomic absorption spectrometry (to obtain Ca and P (phosphorus) concentrations liberated into acid solution), polarized light microscopy (to determine lesion depth) and SEM (to examine morphological changes). However, only minimal research has focused on enamel chemical composition after laser irradiation and acid dissolution. For this purpose, FT-Raman microscopy, X-ray photoelectron spectroscopy

(XPS) and energy dispersive spectroscopy (EDS) have been used.

**1. Introduction** 

(Apel, et al., 2002).

**Treated with Er:YAG, CO2 Lasers and** 

Rosalía Contreras-Bulnes1, Oscar Fernando Olea-Mejía2,

and Claudia Centeno-Pedraza1

*de la Universidad Autónoma del Estado de México* 

*Química de la Universidad Autónoma del Estado de México* 

**Remineralizing Solution: EDS Analysis** 

Laura Emma Rodríguez-Vilchis1, Rogelio José Scougall-Vilchis1

Zusman, S. P., Ponizovsky, A. M., Dekel, D., Masarwa, A.-e.-S., Ramon, T., Natapov, L., et al. (2010). An assessment of the dental health of chronic institutionalized patients with psychiatric disease in Israel. *Special Care in Dentistry, 30*(1), 18-22.

### **Structural Changes on Human Dental Enamel Treated with Er:YAG, CO2 Lasers and Remineralizing Solution: EDS Analysis**

Rosalía Contreras-Bulnes1, Oscar Fernando Olea-Mejía2, Laura Emma Rodríguez-Vilchis1, Rogelio José Scougall-Vilchis1 and Claudia Centeno-Pedraza1 *1Centro de Investigación y Estudios Avanzados en Odontología, Facultad de Odontología de la Universidad Autónoma del Estado de México 2Centro Conjunto de Investigación en Química Sustentable UAEM-UNAM, Facultad de Química de la Universidad Autónoma del Estado de México* 

#### *México*

#### **1. Introduction**

298 Oral Health Care – Prosthodontics, Periodontology, Biology, Research and Systemic Conditions

Waldman, H. B., Perlman, S. P., Waldman, H. B., & Perlman, S. P. (2002). What about dental

Zusman, S. P., Ponizovsky, A. M., Dekel, D., Masarwa, A.-e.-S., Ramon, T., Natapov, L., et al.

psychiatric disease in Israel. *Special Care in Dentistry, 30*(1), 18-22.

*College of Dentists, 69*(2), 35-38.

care for people with mental retardation? A commentary. *Journal of the American* 

(2010). An assessment of the dental health of chronic institutionalized patients with

It has been reported that common lasers employed for caries prevention on the enamel surface include CO2 and Er:YAG types (Ana, et al., 2006); however, CO2 lasers appear to be more appropriate for preventing dental caries (Rodrigues, et al., 2004). The irradiation of teeth with a laser results in an interaction between the light and the biological constituents of the dental hard substance. In the case of absorption by the specific components of the dental enamel, the irradiated energy is converted directly into heat. This thermal effect is the cause of the structural and chemical changes occurring in the enamel after laser irradiation (Apel, et al., 2002).

The association of laser irradiation with fluoride has demonstrated the best results in the inhibition of caries development. The combined treatment of laser irradiation with fluoride propitiates an expressive fluoride uptake, reducing the progression of caries-like lesions, and this treatment is more effective than laser or fluoride alone. The available data suggest that lasers combined with fluoride are a promising treatment in caries prevention (Ana, et al., 2006). In the same way, the effect of remineralizing solution has been evaluated on caries formation and its progression in the primary tooth enamel. Remineralizing solution has been considered an effective measure for the prevention of white spot lesions because it has the ability to provide mineral sources of calcium (Ca), phosphate and fluoride to demineralized or hypomineralized enamel surfaces, making them less soluble during cariogenic challenges (Westerman et al., 2006). Caries prevention has been evaluated by several techniques, including atomic absorption spectrometry (to obtain Ca and P (phosphorus) concentrations liberated into acid solution), polarized light microscopy (to determine lesion depth) and SEM (to examine morphological changes). However, only minimal research has focused on enamel chemical composition after laser irradiation and acid dissolution. For this purpose, FT-Raman microscopy, X-ray photoelectron spectroscopy (XPS) and energy dispersive spectroscopy (EDS) have been used.

Structural Changes on Human Dental Enamel Treated

and widely varying amounts (Eanes, 1979).

**3. Incipient caries lesions around brackets** 

(Pasteris, et al., 2008).

2006).

**3.1 Etiology and development** 

with Er:YAG, CO2 Lasers and Remineralizing Solution: EDS Analysis 301

elements found in enamel are Ca, P, sodium (Na), magnesium (Mg) and chlorine(Cl), and their mean concentrations are 37% Ca, 18% P, 0.4% Mg, 0.7% Na and 0.28% Cl (Reitznwrová, et al., 2000). Other elements reported to be consistently at or above the 1000-ppm level are Zinc (Zn) and silicon(Si), although some 40 other elements are known to be present in small

Ca and P are two biologically abundant elements, and P is an element shared by the collagen that directs biomineral precipitation. Apatite is a "sparingly soluble salt," making it a safe reservoir for Ca and P for use in other biological functions. Apatite's properties can be tailored to some extent through its ability to accept a wide range of chemical substitutions, each of which affects its chemical and physical properties. The most important property is apatite's extensive carbonate substitution, which controls lattice strain, solubility, the nature of substitution, and perhaps apatite's maximum crystal size

One common negative side effect of orthodontic treatment with fixed appliances is the

The demineralization of enamel adjacent to orthodontic brackets is a significant clinical problem. It has been reported that there is a significant increase in the prevalence and severity of enamel demineralization after orthodontic treatment when compared with untreated control subjects. The overall prevalence of white spot lesions among orthodontic

Once active orthodontic treatment has been completed, the demineralization process is normally expected to decelerate due to changes in local environmental factors. Some white spot lesions may remineralize and return either to normal or at least to a visually acceptable appearance. However, white spot lesions may also persist, resulting in aesthetically unacceptable results. In severe cases, restorative treatment may be required (Sudjalim, et al.,

It usually takes a period of months or even years for a carious lesion to develop; dental caries is not simply a continual, cumulative loss of mineral, but rather a dynamic process, characterized by alternating periods of demineralization and remineralization (Harris & García-Godoy, 1999). White spot lesions develop as a result of a dietary carbohydrate and saliva-modified bacterial infection (*Streptococcus mutans*), resulting in an imbalance between

Demineralization is the dissolution of the calcium and phosphate ions from the hydroxyapatite crystals, which are lost into the plaque and saliva. In remineralization, calcium, phosphate, and other ions in the saliva and plaque are redeposited onto previously demineralized areas (Harris & García-Godoy, 1999). This is an interrupted process, with periods of remineralization and demineralization occurring (Sudjalim, et al., 2006). It is possible to have demineralization and remineralization occur without any loss of tooth mass (Harris & García-Godoy, 1999). However, depending on the state of the oral environment in terms of the prolonged accumulation and retention of bacterial plaque on the enamel surface, the standard of individual oral hygiene and the inherent resistance of that person (Sudjalim, et al., 2006), a lesion can result when the cumulative, negative mineral balance

demineralization and remineralization of the enamel (Sudjalim, et al., 2006).

development of incipient caries lesions around the brackets (Behnan, et al., 2010).

patients has been reported as anywhere between 2 and 96 percent.

Energy dispersive spectroscopy (EDS) is an analytical technique that allows the detection of the elements present in the studied material. It is very versatile and can be used with any type of solid sample, from metals and ceramics to biological tissues. It is usually coupled with an electron microscope to simultaneously observe the exact area of interest from which the signal will be collected.

EDS analysis provides a specific method to determine the concentration of chemical elements on substratum surfaces, and it has been largely used in engineering and chemistry, but its application has not been widespread in dentistry (Paradella et al., 2008). At first, EDS analysis was introduced into dental research for the basic characterization of restorative dental materials used to repair damaged teeth and/or replace missing teeth (Marshall et al., 1988). More recently, this technique has been used to assess structural changes in tooth surfaces produced by the application of dental materials (Caltabiano, et al., 1996; Papagiannoulis, et al., 2002; Rosin-Grgewt, et al., 2006; Weerasinghe, et al., 2007; Della, et al., 2008; Markovic, et al., 2008; Paradella, et al., 2008; Scougall-Vilchis, et al., 2009; Keinan, et al., 2010) and of laser irradiation (Rodríguez-Vilchis, et al., 2010; Rodríguez-Vilchis, et al., 2011).

The purpose of this chapter is to present the use of EDS as a useful technique for dental research, taking as references previous reports on this area of the knowledge. Additionally, the authors present original research, based on the application of EDS to assess the microstructural changes on the enamel surface achieved through the application of two types of dental lasers and a remineralizing solution, to avoid the development of white spot lesions as a side effect of orthodontic treatment.

#### **2. Enamel structure**

To comprehend the nature of the structural changes in human dental enamel treated with Er:YAG and CO2 lasers and remineralizing solution, it is important to understand the structure of untreated human dental enamel.

Tooth enamel, the hardest mineralized human tissue, (Harris & García-Godoy, 1999; Wang, et al., 2005), is composed almost exclusively (more than 95 wt%) of hydroxyapatite (Ca10(PO4)6(OH)2, HAP) (Pan, et al., 2008), with incorporated trace elements (Reitznwrová, et al., 2000). However, enamel is also porous, with the inorganic component representing only 87% of the total volume. This fact means that approximately 13% of the volume of enamel is composed of organic material (matrix). This organic, protein-rich matrix is mainly water (11 percent of the total volume of enamel) (Harris & García-Godoy, 1999).

Apatite-like crystallites are highly organized hierarchical structures, and scanning electron microscopy (SEM) of enamel surfaces shows well-organized, rod-like apatite crystals, bundled in ordered prisms and elongated in their *c*-axis directions, which lie predominantly parallel to the rod axes. Despite these complex hierarchical structures, the basic building blocks for mineralized tissues are of nanoscale dimensions (Wang, et al., 2005; Pan, et al., 2008).

The hydroxyapatite crystals are oriented by a protein network that makes up the enamel matrix (Harris & García-Godoy, 1999). Amelogenin proteins constitute the primary structural entity of the extracellular protein framework of the developing enamel matrix (Wang, et al., 2005). Although enamel is not considered a living tissue because it has no cells or blood vessels, the overall protein network facilitates the diffusion of fluids, ions and small-sized molecules throughout the enamel (Harris & García-Godoy, 1999). The principal

Energy dispersive spectroscopy (EDS) is an analytical technique that allows the detection of the elements present in the studied material. It is very versatile and can be used with any type of solid sample, from metals and ceramics to biological tissues. It is usually coupled with an electron microscope to simultaneously observe the exact area of interest from which

EDS analysis provides a specific method to determine the concentration of chemical elements on substratum surfaces, and it has been largely used in engineering and chemistry, but its application has not been widespread in dentistry (Paradella et al., 2008). At first, EDS analysis was introduced into dental research for the basic characterization of restorative dental materials used to repair damaged teeth and/or replace missing teeth (Marshall et al., 1988). More recently, this technique has been used to assess structural changes in tooth surfaces produced by the application of dental materials (Caltabiano, et al., 1996; Papagiannoulis, et al., 2002; Rosin-Grgewt, et al., 2006; Weerasinghe, et al., 2007; Della, et al., 2008; Markovic, et al., 2008; Paradella, et al., 2008; Scougall-Vilchis, et al., 2009; Keinan, et al., 2010) and of laser irradiation (Rodríguez-Vilchis, et al., 2010; Rodríguez-Vilchis, et al.,

The purpose of this chapter is to present the use of EDS as a useful technique for dental research, taking as references previous reports on this area of the knowledge. Additionally, the authors present original research, based on the application of EDS to assess the microstructural changes on the enamel surface achieved through the application of two types of dental lasers and a remineralizing solution, to avoid the development of white spot

To comprehend the nature of the structural changes in human dental enamel treated with Er:YAG and CO2 lasers and remineralizing solution, it is important to understand the

Tooth enamel, the hardest mineralized human tissue, (Harris & García-Godoy, 1999; Wang, et al., 2005), is composed almost exclusively (more than 95 wt%) of hydroxyapatite (Ca10(PO4)6(OH)2, HAP) (Pan, et al., 2008), with incorporated trace elements (Reitznwrová, et al., 2000). However, enamel is also porous, with the inorganic component representing only 87% of the total volume. This fact means that approximately 13% of the volume of enamel is composed of organic material (matrix). This organic, protein-rich matrix is mainly

Apatite-like crystallites are highly organized hierarchical structures, and scanning electron microscopy (SEM) of enamel surfaces shows well-organized, rod-like apatite crystals, bundled in ordered prisms and elongated in their *c*-axis directions, which lie predominantly parallel to the rod axes. Despite these complex hierarchical structures, the basic building blocks for mineralized tissues are of nanoscale dimensions (Wang, et al., 2005; Pan, et al.,

The hydroxyapatite crystals are oriented by a protein network that makes up the enamel matrix (Harris & García-Godoy, 1999). Amelogenin proteins constitute the primary structural entity of the extracellular protein framework of the developing enamel matrix (Wang, et al., 2005). Although enamel is not considered a living tissue because it has no cells or blood vessels, the overall protein network facilitates the diffusion of fluids, ions and small-sized molecules throughout the enamel (Harris & García-Godoy, 1999). The principal

water (11 percent of the total volume of enamel) (Harris & García-Godoy, 1999).

the signal will be collected.

**2. Enamel structure** 

lesions as a side effect of orthodontic treatment.

structure of untreated human dental enamel.

2011).

2008).

elements found in enamel are Ca, P, sodium (Na), magnesium (Mg) and chlorine(Cl), and their mean concentrations are 37% Ca, 18% P, 0.4% Mg, 0.7% Na and 0.28% Cl (Reitznwrová, et al., 2000). Other elements reported to be consistently at or above the 1000-ppm level are Zinc (Zn) and silicon(Si), although some 40 other elements are known to be present in small and widely varying amounts (Eanes, 1979).

Ca and P are two biologically abundant elements, and P is an element shared by the collagen that directs biomineral precipitation. Apatite is a "sparingly soluble salt," making it a safe reservoir for Ca and P for use in other biological functions. Apatite's properties can be tailored to some extent through its ability to accept a wide range of chemical substitutions, each of which affects its chemical and physical properties. The most important property is apatite's extensive carbonate substitution, which controls lattice strain, solubility, the nature of substitution, and perhaps apatite's maximum crystal size (Pasteris, et al., 2008).

#### **3. Incipient caries lesions around brackets**

One common negative side effect of orthodontic treatment with fixed appliances is the development of incipient caries lesions around the brackets (Behnan, et al., 2010).

The demineralization of enamel adjacent to orthodontic brackets is a significant clinical problem. It has been reported that there is a significant increase in the prevalence and severity of enamel demineralization after orthodontic treatment when compared with untreated control subjects. The overall prevalence of white spot lesions among orthodontic patients has been reported as anywhere between 2 and 96 percent.

Once active orthodontic treatment has been completed, the demineralization process is normally expected to decelerate due to changes in local environmental factors. Some white spot lesions may remineralize and return either to normal or at least to a visually acceptable appearance. However, white spot lesions may also persist, resulting in aesthetically unacceptable results. In severe cases, restorative treatment may be required (Sudjalim, et al., 2006).

#### **3.1 Etiology and development**

It usually takes a period of months or even years for a carious lesion to develop; dental caries is not simply a continual, cumulative loss of mineral, but rather a dynamic process, characterized by alternating periods of demineralization and remineralization (Harris & García-Godoy, 1999). White spot lesions develop as a result of a dietary carbohydrate and saliva-modified bacterial infection (*Streptococcus mutans*), resulting in an imbalance between demineralization and remineralization of the enamel (Sudjalim, et al., 2006).

Demineralization is the dissolution of the calcium and phosphate ions from the hydroxyapatite crystals, which are lost into the plaque and saliva. In remineralization, calcium, phosphate, and other ions in the saliva and plaque are redeposited onto previously demineralized areas (Harris & García-Godoy, 1999). This is an interrupted process, with periods of remineralization and demineralization occurring (Sudjalim, et al., 2006). It is possible to have demineralization and remineralization occur without any loss of tooth mass (Harris & García-Godoy, 1999). However, depending on the state of the oral environment in terms of the prolonged accumulation and retention of bacterial plaque on the enamel surface, the standard of individual oral hygiene and the inherent resistance of that person (Sudjalim, et al., 2006), a lesion can result when the cumulative, negative mineral balance

Structural Changes on Human Dental Enamel Treated

education and patient compliance (Sudjalim, et al., 2006).

**4. Laser technology 4.1 General principles** 

2000).

(Aoki, et al., 2004).

(Stabholz, et al., 2003).

**4.2 Laser technology development** 

and surgery (Sulewski, 2000; Ishikawa et al., 2004).

with Er:YAG, CO2 Lasers and Remineralizing Solution: EDS Analysis 303

The overall management of white spot lesions involves the consideration of methods of preventing desmineralization and also methods of encouraging the remineralization of existing lesions. Preventive measures take precedence, due to the challenging nature of treating patients who do develop significant numbers of white spot lesions. In addition to regular professional oral hygiene visits and the application of appropriate preventive medicaments, successful preventive strategies should involve oral health promotion, patient

The word "laser" is an acronym for light amplification by stimulated emission of radiation. Lasers have their basis in certain theories from the field of quantum mechanics, initially formulated during the early 1900s by the Danish physicist Niels Bohr, among others. Einstein's atomic theories on controlled radiation can be credited as the foundation for laser technology. Einstein's article on the stimulated emission of radiant energy, published in 1917, is acknowledged as the conceptual basis for amplified light (Sulewski,

A beam of light is composed of packets of photons, which are produced by a light bulb or other light sources (Stabholz, et al., 2003). The process of lasing occurs when an excited atom is stimulated to emit a photon before the process occurs spontaneously. Spontaneous emission of a photon by one atom stimulates the release of a subsequent photon and so on

A laser beam implies stimulated emission of radiation and differs from conventional light source. It has a single wavelength (monochromatic) and is collimated (very low divergence), coherent (photons in phase), and intense. The construction of a light source, based on stimulated emission of radiation, requires an active medium, which is a collection of atoms or molecules. The active medium must be excited to emit the photons by stimulated emission; it may be a gas, liquid, or solid material and may be contained in a glass or ceramic tube (Stabholz, et al., 2003). The photon emitted has a specific wavelength that depends on the state of the electron's energy when the photon is released. The characteristics of a laser depend on its wavelength (Aoki, et al., 2004). When tissue is irradiated, four basic types of laser interaction occur: reflection from tissue, scattering within tissue, absorption by tissue and transmission to the surrounding tissues (Aoki, et al., 2004; Stabholz et al., 2003). Transmission of light passes energy through the tissue without interaction and thus causes no effect or injury. When scattered, light travels in different directions, and energy is absorbed over a greater surface area, producing less intense and less precise thermal effects. Reflection results in little or no absorption and, subsequently, no thermal effect on the tissue. When absorbed by tissue, light energy is converted into thermal energy. A single laser device cannot perform all the required functions because the beam is absorbed or reflected according to its wavelength and the color of the object impacted

The first laser device was created in 1960 by Maiman, and since then, the laser has been used in various areas of medicine, particularly in ophthalmology, otolaryngology, dermatology

exceeds the rate of remineralization over an extended period (Harris & García-Godoy 1999).

The incipient lesion is macroscopically evidenced by the appearance of an area of opacity the so-called white spot lesion. During this stage, the carious process can be arrested or reversed (Harris & García-Godoy, 1999). A white spot lesion is the precursor of frank enamel caries (Sudjalim, et al., 2006). The most important fact is that the surface of the enamel is relatively intact, before any physical cavitation requiring clinical intervention has occurred (Harris & García-Godoy, 1999). The white appearance of early enamel caries is due to an optical phenomenon that is caused by mineral loss in the surface or subsurface enamel. Enamel crystal dissolution begins with subsurface demineralization, creating pores between the enamel rods. The resulting alteration of the refractive index in the affected area is a consequence of both surface roughness and loss of surface shine and of alterations in internal reflection, all resulting in greater visual enamel opacity, as porous enamel scatters more light than sound enamel. The demineralization process may encompass the full thickness of the enamel and some of the dentin before the relatively hypermineralized surface layer is actually lost.

It is generally accepted that the insertion of fixed orthodontic appliances creates stagnation areas for plaque and makes tooth cleaning more difficult. The irregular surfaces of brackets, bands, wires and other attachments also limit naturally occurring self-cleansing mechanisms, such as the movement of the oral musculature and saliva. This process, in turn, encourages a lower plaque pH in the presence of carbohydrates and accelerates the rate of plaque accumulation and plaque maturation (Sudjalim, et al., 2006).

The normal formation of a white spot lesion is usually a slower process, which can take 2 years or more. In other cases, such as seen in the xerostomia that follows head and neck radiation, lesions take at least 6 months to develop (Harris & García-Godoy, 1999). However, in patients under fixed orthodontic treatment, demineralized lesions have the potential to develop within 4 weeks of the initiation of the orthodontic treatment (Gorton & Featherstone, 2003; Staud, et al., 2004).

#### **3.2 Prevention of white spot lesions**

The development of white spot lesions during fixed-appliance orthodontic treatment can be prevented.

The chosen method or methods for prevention vary from patient to patient, depending on individual needs, available methods and the dentist's clinical criteria. However, the patient's motivation plays a very important role to be considered.

The available methods and techniques have focused primarily on patient education and topical fluoride administration, including the use of fluoride toothpaste, mouth rinses and gels, fluoride varnishes, fluoride in orthodontic bonding agents, fluoride in elastomeric modules and ligature ties. More recently, casein phosphopeptide-amorphous calcium phosphate and laser irradiation on the enamel surface have been introduced for preventive purposes (Schmit, 2002; Sudjalim, et al., 2006; Dun, 2007).

The aim of modern dentistry is the early prevention of tooth decay, rather than invasive restorative therapy (Hannig & Hannig, 2010; Cochrane, et al., 2010). However, despite tremendous efforts to promote oral hygiene and fluoridation, the prevention and biomimetic treatment of early caries lesions are still challenges for dental research and public health, particularly for individuals at high risk for developing caries, which is the most widespread oral disease (Hannig & Hannig, 2010).

The overall management of white spot lesions involves the consideration of methods of preventing desmineralization and also methods of encouraging the remineralization of existing lesions. Preventive measures take precedence, due to the challenging nature of treating patients who do develop significant numbers of white spot lesions. In addition to regular professional oral hygiene visits and the application of appropriate preventive medicaments, successful preventive strategies should involve oral health promotion, patient education and patient compliance (Sudjalim, et al., 2006).

#### **4. Laser technology**

302 Oral Health Care – Prosthodontics, Periodontology, Biology, Research and Systemic Conditions

exceeds the rate of remineralization over an extended period (Harris & García-Godoy

The incipient lesion is macroscopically evidenced by the appearance of an area of opacity the so-called white spot lesion. During this stage, the carious process can be arrested or reversed (Harris & García-Godoy, 1999). A white spot lesion is the precursor of frank enamel caries (Sudjalim, et al., 2006). The most important fact is that the surface of the enamel is relatively intact, before any physical cavitation requiring clinical intervention has occurred (Harris & García-Godoy, 1999). The white appearance of early enamel caries is due to an optical phenomenon that is caused by mineral loss in the surface or subsurface enamel. Enamel crystal dissolution begins with subsurface demineralization, creating pores between the enamel rods. The resulting alteration of the refractive index in the affected area is a consequence of both surface roughness and loss of surface shine and of alterations in internal reflection, all resulting in greater visual enamel opacity, as porous enamel scatters more light than sound enamel. The demineralization process may encompass the full thickness of the enamel and some of the dentin before the relatively hypermineralized

It is generally accepted that the insertion of fixed orthodontic appliances creates stagnation areas for plaque and makes tooth cleaning more difficult. The irregular surfaces of brackets, bands, wires and other attachments also limit naturally occurring self-cleansing mechanisms, such as the movement of the oral musculature and saliva. This process, in turn, encourages a lower plaque pH in the presence of carbohydrates and accelerates the rate of

The normal formation of a white spot lesion is usually a slower process, which can take 2 years or more. In other cases, such as seen in the xerostomia that follows head and neck radiation, lesions take at least 6 months to develop (Harris & García-Godoy, 1999). However, in patients under fixed orthodontic treatment, demineralized lesions have the potential to develop within 4 weeks of the initiation of the orthodontic treatment (Gorton &

The development of white spot lesions during fixed-appliance orthodontic treatment can be

The chosen method or methods for prevention vary from patient to patient, depending on individual needs, available methods and the dentist's clinical criteria. However, the patient's

The available methods and techniques have focused primarily on patient education and topical fluoride administration, including the use of fluoride toothpaste, mouth rinses and gels, fluoride varnishes, fluoride in orthodontic bonding agents, fluoride in elastomeric modules and ligature ties. More recently, casein phosphopeptide-amorphous calcium phosphate and laser irradiation on the enamel surface have been introduced for preventive

The aim of modern dentistry is the early prevention of tooth decay, rather than invasive restorative therapy (Hannig & Hannig, 2010; Cochrane, et al., 2010). However, despite tremendous efforts to promote oral hygiene and fluoridation, the prevention and biomimetic treatment of early caries lesions are still challenges for dental research and public health, particularly for individuals at high risk for developing caries, which is the

plaque accumulation and plaque maturation (Sudjalim, et al., 2006).

1999).

surface layer is actually lost.

Featherstone, 2003; Staud, et al., 2004).

**3.2 Prevention of white spot lesions** 

motivation plays a very important role to be considered.

purposes (Schmit, 2002; Sudjalim, et al., 2006; Dun, 2007).

most widespread oral disease (Hannig & Hannig, 2010).

prevented.

#### **4.1 General principles**

The word "laser" is an acronym for light amplification by stimulated emission of radiation. Lasers have their basis in certain theories from the field of quantum mechanics, initially formulated during the early 1900s by the Danish physicist Niels Bohr, among others. Einstein's atomic theories on controlled radiation can be credited as the foundation for laser technology. Einstein's article on the stimulated emission of radiant energy, published in 1917, is acknowledged as the conceptual basis for amplified light (Sulewski, 2000).

A beam of light is composed of packets of photons, which are produced by a light bulb or other light sources (Stabholz, et al., 2003). The process of lasing occurs when an excited atom is stimulated to emit a photon before the process occurs spontaneously. Spontaneous emission of a photon by one atom stimulates the release of a subsequent photon and so on (Aoki, et al., 2004).

A laser beam implies stimulated emission of radiation and differs from conventional light source. It has a single wavelength (monochromatic) and is collimated (very low divergence), coherent (photons in phase), and intense. The construction of a light source, based on stimulated emission of radiation, requires an active medium, which is a collection of atoms or molecules. The active medium must be excited to emit the photons by stimulated emission; it may be a gas, liquid, or solid material and may be contained in a glass or ceramic tube (Stabholz, et al., 2003). The photon emitted has a specific wavelength that depends on the state of the electron's energy when the photon is released. The characteristics of a laser depend on its wavelength (Aoki, et al., 2004). When tissue is irradiated, four basic types of laser interaction occur: reflection from tissue, scattering within tissue, absorption by tissue and transmission to the surrounding tissues (Aoki, et al., 2004; Stabholz et al., 2003). Transmission of light passes energy through the tissue without interaction and thus causes no effect or injury. When scattered, light travels in different directions, and energy is absorbed over a greater surface area, producing less intense and less precise thermal effects. Reflection results in little or no absorption and, subsequently, no thermal effect on the tissue. When absorbed by tissue, light energy is converted into thermal energy. A single laser device cannot perform all the required functions because the beam is absorbed or reflected according to its wavelength and the color of the object impacted (Stabholz, et al., 2003).

#### **4.2 Laser technology development**

The first laser device was created in 1960 by Maiman, and since then, the laser has been used in various areas of medicine, particularly in ophthalmology, otolaryngology, dermatology and surgery (Sulewski, 2000; Ishikawa et al., 2004).

Structural Changes on Human Dental Enamel Treated

(2004), have been permitted (Aoki, et al., 2004).

al., 2007).

Tagliaferro et al., 2007).

**4.4 Er:YAG laser** 

et al., 2004).

(Sulewski, 2000).

1989; Aoki, et al., 2004).

with Er:YAG, CO2 Lasers and Remineralizing Solution: EDS Analysis 305

(Morioka, et al., 1991; Fried, et al., 1996; Featherstone, et al., 1998; Hossain, et al., 2000; Young, et al., 2000; Hsu, et al., 2000; Tisai, et al., 2002; Kato, et al., 2003; Matson, et al., 2002; Apel, et al., 2002, 2004, 2005; Rodrigues, et al., 2004; Westerman, et al., 2002; Nammour, et al., 2005 Cecchini, et al., 2005; Liu, et al., 2006; Fried, et al. 2006; Castelan, et

Furthermore, to achieve additional prevention, special attention has focused on laser irradiation, topical fluorides and remineralizing solution associations, showing very promising results (Hossain, et al., 2002; Delbem, et al., 2003; Chin-Ying, et al., 2004; Tepper et al., 2004; Rodrigues, et al., 2004; Kwon, et al., 2005; Ana, et al., 2006; Westerman, 2006;

In 1975, Zharicov introduced the erbium-doped: yttrium-aluminum-garnet (Er:YAG) laser. The active medium of this laser is a solid crystal of yttrium-aluminum-garnet that is doped with erbium. This type of laser generates light with a wavelength of 2.94 µm (2.940 nm), in the near- and mid-infrared spectral range and close to the border-infrared and midinfrared. Furthermore, it is highly absorbed by water because its wavelength coincides with the large absorption band for water. The absorption coefficient of water for the Er:YAG laser is theoretically 10 times higher than that of the CO2 laser, i.e., 10.6 µm (10.600 nm), and 15.000 to 20.000 times higher than that of Nd:YAG (1.064 nm) (Ishikawa,

The pulsed Er:YAG laser was approved in 1997 by the FDA for hard tissue treatment, such as caries removal and cavity preparation (Sulewski, 2000). Additionally, other intraoral applications, such as soft tissue surgery, sulcular debridement (1999) and osseous surgery

The Er:YAG is perhaps the most versatile of all the types of lasers available on the market today because of its many applications in dentistry for both hard and soft tissues. However, one of its limitations is its limited coagulative ability, compared with other types of lasers

During Er:YAG laser irradiation, laser energy is absorbed selectively by water molecules and hydrous organic components of biological tissues, causing the evaporation of water and organic components and resulting in thermal effects due to the heat generated by this process (photothermal evaporation). Moreover, in hard tissue procedures, water vapor production induces an increase of internal pressure within the tissue, resulting in explosive expansion, called "microexplosion". These dynamic effects cause mechanical tissue collapse, resulting in "thermomechanical" or "photomechanical" ablation. This phenomenon has also been referred to as 'water-mediated explosive ablation' (Hibst & Keller, 1989; Keller & Hibst,

Although this laser was introduced into dentistry for the ablation of dental hard tissue (Hibst & Keller, 1989; Keller & Hibst, 1989), an early report (Kayano, et al., 1989) suggested an increase in acid resistance of the enamel adjacent to the ablated area. Later, several in vitro studies (Morioka, et al., 1991; Fried, et al., 1996; Hossain, et al., 2000; Cecchini, et al., 2005; Castelan, et al., 2007) on smooth dental enamel surfaces reported that Er:YAG irradiation promotes caries prevention as well as morphological enamel changes (Matson, et al., 2002; Cecchini, et al., 2005; Apel et al., 2005;). Furthermore, it was reported that both effects depend on the energy density of the laser, among other parameters, including

In 1964, laser was introduced for use in dentistry by Stern, Sognnaes, and Goldman and by Hornby, Meyer and Goldman (Ishikawa et al., 2004). The first laboratory tests in vitro were carried out by Stern and Sognnaes and were limited to the use of ruby laser (Stern & Sognnaes, 1972). Then, due to technological advances, new lasers, such as argon ion, Nd:YAG, and CO2 lasers, among others, were developed (Parker, 2007a). In time, other laser wavelengths, such as holmium (Ho):YAG and erbium (Er):YAG, were investigated.

Historically, the first lasers to be marketed for intraoral use were generally CO2 lasers, with otorhinolaryngologic clearances authorized by the US Food and Drug Administration (FDA). During the 1970s and 1980s, intraoral use of CO2 lasers was confined primarily to specialists, such as ear-nose-throat (ENT) surgeons, oral surgeons, and some periodontists.

It was not until 1990 that the field of laser dentistry began in earnest in the United States, at least in clinical terms. In May 1990, the FDA approved for intraoral soft tissue surgery a pulsed Nd:YAG laser, developed by Myers and Myers and recognized as the first laser designed specifically for general dentistry.

The use of lasers for therapy has become very common in the medical field, and the use of lasers in dentistry is extensive and covers many procedures, such as intraoral soft tissue surgery, hard tissue applications (e.g., caries removal, inhibition and detection, cavity preparation, etching, bleaching, calculus removal, bone ablation, cartilage reshaping, dentin desensitization, analgesia), composite curing, bracket debonding, allow welding, removal of canal debris, performing pulp capping, pulpotomy, and pulpectomy. Other dental applications include laser diagnostic, holography and biostimulation (Sulewski, et al., 2000; Dederich & Bushick, 2004).

#### **4.3 Laser and caries prevention**

In the 1960s, Stern et al. reported increased enamel acid resistance after ruby laser irradiation (Stern, et al., 1966). Since then, several studies on caries prevention have been published due to the development of several types of lasers, such as CO2, (Stern & Sognnaes, 1972; Featherstone, et al., 1998; Hsu, et al., 2000; Tisai, et al., 2002; Kato, et al., 2003; Klein, et al., 2005; Steiner-Oliveira, et al., 2006), argon (Westerman, et al., 2002; Nammour, et al., 2005), Nd:YAG (Bahar & Tagomori, 1994; Hossain, et al., 2001a), and Diodo (Kato, et al., 2006) and more recently with the group of erbium lasers: Er, Cr:YSGG and Er:YAG (Kayano, et al., 1989; Fried, et al., 1996; Hossain, et al., 2001b; Apel, et al., 2004).

There are various theories to explain the reduced acid solubility of dental enamel after heating. For instance, the water permeability of dental enamel has been observed to be lower after heating. More hydroxide and pyrophosphate, but less carbonate, are also generally found, in comparison with unheated enamel (Apel, et al., 2002).

The most accepted theory regarding the mechanism by which laser irradiation enhances enamel acid resistance is the reduction of bound carbonate, when the enamel surface is heated to the range of 100–400°C (Holcom & Young, 1980; Fowler & Kuboda, 1986; Liu & Hsu, 2007). Nevertheless, the modification of organic matter has been reported as one of the mechanisms in laser-induced caries prevention (the organic blocking theory) (Ying, et al., 2004).

In laser therapy, several factors related to exposure need to be considered: the wavelength and energy density of the laser, the irradiation time, the focal distance, and water cooling (Morioka, et al., 1991; Fried, et al., 1996; Featherstone, et al., 1998; Hossain, et al., 2000; Young, et al., 2000; Hsu, et al., 2000; Tisai, et al., 2002; Kato, et al., 2003; Matson, et al., 2002; Apel, et al., 2002, 2004, 2005; Rodrigues, et al., 2004; Westerman, et al., 2002; Nammour, et al., 2005 Cecchini, et al., 2005; Liu, et al., 2006; Fried, et al. 2006; Castelan, et al., 2007).

Furthermore, to achieve additional prevention, special attention has focused on laser irradiation, topical fluorides and remineralizing solution associations, showing very promising results (Hossain, et al., 2002; Delbem, et al., 2003; Chin-Ying, et al., 2004; Tepper et al., 2004; Rodrigues, et al., 2004; Kwon, et al., 2005; Ana, et al., 2006; Westerman, 2006; Tagliaferro et al., 2007).

#### **4.4 Er:YAG laser**

304 Oral Health Care – Prosthodontics, Periodontology, Biology, Research and Systemic Conditions

In 1964, laser was introduced for use in dentistry by Stern, Sognnaes, and Goldman and by Hornby, Meyer and Goldman (Ishikawa et al., 2004). The first laboratory tests in vitro were carried out by Stern and Sognnaes and were limited to the use of ruby laser (Stern & Sognnaes, 1972). Then, due to technological advances, new lasers, such as argon ion, Nd:YAG, and CO2 lasers, among others, were developed (Parker, 2007a). In time, other laser wavelengths, such as holmium (Ho):YAG and erbium (Er):YAG, were

Historically, the first lasers to be marketed for intraoral use were generally CO2 lasers, with otorhinolaryngologic clearances authorized by the US Food and Drug Administration (FDA). During the 1970s and 1980s, intraoral use of CO2 lasers was confined primarily to specialists, such as ear-nose-throat (ENT) surgeons, oral surgeons, and some

It was not until 1990 that the field of laser dentistry began in earnest in the United States, at least in clinical terms. In May 1990, the FDA approved for intraoral soft tissue surgery a pulsed Nd:YAG laser, developed by Myers and Myers and recognized as the first laser

The use of lasers for therapy has become very common in the medical field, and the use of lasers in dentistry is extensive and covers many procedures, such as intraoral soft tissue surgery, hard tissue applications (e.g., caries removal, inhibition and detection, cavity preparation, etching, bleaching, calculus removal, bone ablation, cartilage reshaping, dentin desensitization, analgesia), composite curing, bracket debonding, allow welding, removal of canal debris, performing pulp capping, pulpotomy, and pulpectomy. Other dental applications include laser diagnostic, holography and biostimulation (Sulewski, et al., 2000;

In the 1960s, Stern et al. reported increased enamel acid resistance after ruby laser irradiation (Stern, et al., 1966). Since then, several studies on caries prevention have been published due to the development of several types of lasers, such as CO2, (Stern & Sognnaes, 1972; Featherstone, et al., 1998; Hsu, et al., 2000; Tisai, et al., 2002; Kato, et al., 2003; Klein, et al., 2005; Steiner-Oliveira, et al., 2006), argon (Westerman, et al., 2002; Nammour, et al., 2005), Nd:YAG (Bahar & Tagomori, 1994; Hossain, et al., 2001a), and Diodo (Kato, et al., 2006) and more recently with the group of erbium lasers: Er, Cr:YSGG and Er:YAG (Kayano,

There are various theories to explain the reduced acid solubility of dental enamel after heating. For instance, the water permeability of dental enamel has been observed to be lower after heating. More hydroxide and pyrophosphate, but less carbonate, are also

The most accepted theory regarding the mechanism by which laser irradiation enhances enamel acid resistance is the reduction of bound carbonate, when the enamel surface is heated to the range of 100–400°C (Holcom & Young, 1980; Fowler & Kuboda, 1986; Liu & Hsu, 2007). Nevertheless, the modification of organic matter has been reported as one of the mechanisms in laser-induced caries prevention (the organic blocking theory) (Ying, et al.,

In laser therapy, several factors related to exposure need to be considered: the wavelength and energy density of the laser, the irradiation time, the focal distance, and water cooling

et al., 1989; Fried, et al., 1996; Hossain, et al., 2001b; Apel, et al., 2004).

generally found, in comparison with unheated enamel (Apel, et al., 2002).

investigated.

periodontists.

designed specifically for general dentistry.

Dederich & Bushick, 2004).

2004).

**4.3 Laser and caries prevention** 

In 1975, Zharicov introduced the erbium-doped: yttrium-aluminum-garnet (Er:YAG) laser. The active medium of this laser is a solid crystal of yttrium-aluminum-garnet that is doped with erbium. This type of laser generates light with a wavelength of 2.94 µm (2.940 nm), in the near- and mid-infrared spectral range and close to the border-infrared and midinfrared. Furthermore, it is highly absorbed by water because its wavelength coincides with the large absorption band for water. The absorption coefficient of water for the Er:YAG laser is theoretically 10 times higher than that of the CO2 laser, i.e., 10.6 µm (10.600 nm), and 15.000 to 20.000 times higher than that of Nd:YAG (1.064 nm) (Ishikawa, et al., 2004).

The pulsed Er:YAG laser was approved in 1997 by the FDA for hard tissue treatment, such as caries removal and cavity preparation (Sulewski, 2000). Additionally, other intraoral applications, such as soft tissue surgery, sulcular debridement (1999) and osseous surgery (2004), have been permitted (Aoki, et al., 2004).

The Er:YAG is perhaps the most versatile of all the types of lasers available on the market today because of its many applications in dentistry for both hard and soft tissues. However, one of its limitations is its limited coagulative ability, compared with other types of lasers (Sulewski, 2000).

During Er:YAG laser irradiation, laser energy is absorbed selectively by water molecules and hydrous organic components of biological tissues, causing the evaporation of water and organic components and resulting in thermal effects due to the heat generated by this process (photothermal evaporation). Moreover, in hard tissue procedures, water vapor production induces an increase of internal pressure within the tissue, resulting in explosive expansion, called "microexplosion". These dynamic effects cause mechanical tissue collapse, resulting in "thermomechanical" or "photomechanical" ablation. This phenomenon has also been referred to as 'water-mediated explosive ablation' (Hibst & Keller, 1989; Keller & Hibst, 1989; Aoki, et al., 2004).

Although this laser was introduced into dentistry for the ablation of dental hard tissue (Hibst & Keller, 1989; Keller & Hibst, 1989), an early report (Kayano, et al., 1989) suggested an increase in acid resistance of the enamel adjacent to the ablated area. Later, several in vitro studies (Morioka, et al., 1991; Fried, et al., 1996; Hossain, et al., 2000; Cecchini, et al., 2005; Castelan, et al., 2007) on smooth dental enamel surfaces reported that Er:YAG irradiation promotes caries prevention as well as morphological enamel changes (Matson, et al., 2002; Cecchini, et al., 2005; Apel et al., 2005;). Furthermore, it was reported that both effects depend on the energy density of the laser, among other parameters, including

Structural Changes on Human Dental Enamel Treated

**5.1 X-ray production and fluorescence yield** 

energy.

**5.2 Interaction volume** 

material and the incidence angle of the beam.

several micrometers, depending on its density.

in Fig. 1.

that help with understanding and interpreting the results.

with Er:YAG, CO2 Lasers and Remineralizing Solution: EDS Analysis 307

technique that we have found are important to setting the analysis parameters properly and

When the incident electron beam reaches the sample, one phenomenon that occurs is that one electron of the inner shells of an atom is excited and ejected from the atom, leaving an electron hole. Another electron from an outer, higher energy shell fills the hole and in the process an X-ray is produced. As the energy of the X-ray is characteristic of the electronic structure of each element and of the differences in energy from one shell to another, this allows knowing from which element the X-ray came from by measuring its

X-ray production is one of several de-excitation processes of an ionized atom. Therefore, it is important to have an idea of the amount of generated X-ray for each atom. The fluorescence

> # #

<sup>=</sup> −

The fluorescence yield is favored for high atomic number atoms. For example, the ωK for carbon is approximately 0.005, while for germanium, it is approximately 0.5 and near unity for the heaviest atoms. The impact of this number on the analysis of biological samples is obvious: it takes many more beam electrons to produce a significant amount of X-rays from carbon (C), oxygen (O) or nitrogen (N) atoms. In practice, this fact means that a longer

Although it is said that SEM and coupled EDS are surface analytical techniques, this statement is not completely true. Due to the energy of their beam electrons, they are capable of penetrating a sample, interacting with its atoms and therefore generating signals (backscattered electrons, secondary electrons, characteristic X-rays, etc.). The space underneath the sample surface, where these signals are generated, is called the interaction volume (Goldstein, et al., 2003). The shape of the interaction volume varies from a hemisphere, for high atomic number atoms, to a pear, for low atomic number atoms, as seen

The dimensions and shape of the interaction volume depend on several factors, such as the energy of the electron beam, the average atomic number of the sample, the density of the

The energy of the beam has a strong influence on the size of the interaction volume. For example, for iron, the interaction volume size ranges from 0.5 µm at 10 keV to 2 µm at 30 keV. This effect is much more pronounced in low atomic number materials; the interaction volume at 20 keV in a low atomic number target, such as a biopolymer, can be as large as

The next factor affecting the interaction volume is the atomic number Z. The larger the atom is, the higher the probability of interaction with the electron beam will be. Therefore, as Z increases, the interaction volume decreases. For example, at 20 keV, the interaction volume

for carbon is approximately 8 µm, while for uranium, it is approximately 0.4 µm.

*K photons produced K shell ionizations*

yield w for the production of K shell radiation is given by the following equation:

*<sup>K</sup>*

analysis time is required to obtain an adequate signal-to-noise ratio.

ω

irradiation time, focal distance, and water cooling (Morioka, et al., 1991; Fried, et al., 1996; Hossain, et al., 2000; Young, et al., 2000; Matson, et al., 2002; Apel, et al; 2002, 2004, 2005; Cecchini, et al., 2005; Liu, et al., 2006; Castelan, et al., 2007).

#### **4.5 CO2 laser**

In 1964, the CO2 laser was developed at Bell Laboratories in the United States (Parker, 2007a). The active medium of CO2 laser is a gas, and it emits infrared light at different wavelengths (9,300, 9,600, 10,300 and 10,600 nm) (Aoki, et al., 2004; Ishikawa, et al., 2004; Parker, 2007b). The 10,600 nm CO2 laser is the most commercially available, and it is used as both a pulsed- and a continuous-wave laser (Rodrigues, et al., 2004). This laser is readily absorbed by water and therefore is very effective for surgery on soft tissues, which have high water content. The primary advantage of CO2 laser surgery over the scalpel is its strong hemostatic and bactericidal effects. Very little wound contraction and minimal scarring are other advantages of laser surgery, especially for the CO2 laser. However, the CO2 laser is also highly absorbed by the principal mineral components of hard tissue, especially the phosphate ions (– PO4) in carbonated hydroxyapatite. The energy applied is readily absorbed in hard tissues but causes instantaneous heat accumulation in the irradiated inorganic components, resulting in carbonization of the organic components and melting of the inorganic components, instead of the water-mediated physical collapse of hard tissues observed in Er:YAG laser irradiation (Aoki, et al., 2004). The caries-preventive effect produced on the enamel surface due to CO2 laser irradiation was reported by Stern et al. (Stern, et al., 1972). Subsequently, several studies, both in vitro (Featherstone, et al. 1998; Kantorowitz, et al., 1998; Hsu, et al., 2000; Tsai, et al., 2002) and in vivo (Kato, et al., 2003), have shown increases in enamel acid resistance.

#### **5. General-scope energy dispersive spectroscopy**

Energy dispersive spectroscopy (EDS) is an analytical technique that allows the detection of the elements present in the studied material. It is very versatile and can be used with any type of solid sample, from metals and ceramics to biological tissues. It is usually coupled with an electron microscope to observe simultaneously the exact area of interest from which the signal will be collected.

One of the main advantages of EDS is its ability to detect almost all of the elements of the periodic table simultaneously and to quantify the amount of each of those elements present in a sample. Additionally, it is a very attractive technique because of the small amount of time that it takes to analyze a sample, which is typically on the order of minutes. However, when element mapping is needed, the measurements can take as long as several hours, depending on the material and the concentration of the elements of interest.

The main disadvantage of EDS is its inability to detect hydrogen (H), helium (He) and lithium (Li) due to the protecting window used in front of the detector that absorbs lowenergy X-rays. This is an important disadvantage, especially for biological samples because many organic compounds and biomaterials are principally composed of carbon (C), oxygen (O) and hydrogen (H) (Williams, et al., 1996).

The main goal of this section is to show the way we use EDS coupled with a scanning electron microscope (SEM) in our research, which involves the chemical characterization of human teeth. For that purpose, we will begin with some fundamental aspects of the technique that we have found are important to setting the analysis parameters properly and that help with understanding and interpreting the results.

#### **5.1 X-ray production and fluorescence yield**

306 Oral Health Care – Prosthodontics, Periodontology, Biology, Research and Systemic Conditions

irradiation time, focal distance, and water cooling (Morioka, et al., 1991; Fried, et al., 1996; Hossain, et al., 2000; Young, et al., 2000; Matson, et al., 2002; Apel, et al; 2002, 2004, 2005;

In 1964, the CO2 laser was developed at Bell Laboratories in the United States (Parker, 2007a). The active medium of CO2 laser is a gas, and it emits infrared light at different wavelengths (9,300, 9,600, 10,300 and 10,600 nm) (Aoki, et al., 2004; Ishikawa, et al., 2004; Parker, 2007b). The 10,600 nm CO2 laser is the most commercially available, and it is used as both a pulsed- and a continuous-wave laser (Rodrigues, et al., 2004). This laser is readily absorbed by water and therefore is very effective for surgery on soft tissues, which have high water content. The primary advantage of CO2 laser surgery over the scalpel is its strong hemostatic and bactericidal effects. Very little wound contraction and minimal scarring are other advantages of laser surgery, especially for the CO2 laser. However, the CO2 laser is also highly absorbed by the principal mineral components of hard tissue, especially the phosphate ions (– PO4) in carbonated hydroxyapatite. The energy applied is readily absorbed in hard tissues but causes instantaneous heat accumulation in the irradiated inorganic components, resulting in carbonization of the organic components and melting of the inorganic components, instead of the water-mediated physical collapse of hard tissues observed in Er:YAG laser irradiation (Aoki, et al., 2004). The caries-preventive effect produced on the enamel surface due to CO2 laser irradiation was reported by Stern et al. (Stern, et al., 1972). Subsequently, several studies, both in vitro (Featherstone, et al. 1998; Kantorowitz, et al., 1998; Hsu, et al., 2000; Tsai, et al., 2002) and in vivo (Kato, et al., 2003),

Energy dispersive spectroscopy (EDS) is an analytical technique that allows the detection of the elements present in the studied material. It is very versatile and can be used with any type of solid sample, from metals and ceramics to biological tissues. It is usually coupled with an electron microscope to observe simultaneously the exact area of interest from which

One of the main advantages of EDS is its ability to detect almost all of the elements of the periodic table simultaneously and to quantify the amount of each of those elements present in a sample. Additionally, it is a very attractive technique because of the small amount of time that it takes to analyze a sample, which is typically on the order of minutes. However, when element mapping is needed, the measurements can take as long as several hours,

The main disadvantage of EDS is its inability to detect hydrogen (H), helium (He) and lithium (Li) due to the protecting window used in front of the detector that absorbs lowenergy X-rays. This is an important disadvantage, especially for biological samples because many organic compounds and biomaterials are principally composed of carbon (C), oxygen

The main goal of this section is to show the way we use EDS coupled with a scanning electron microscope (SEM) in our research, which involves the chemical characterization of human teeth. For that purpose, we will begin with some fundamental aspects of the

depending on the material and the concentration of the elements of interest.

Cecchini, et al., 2005; Liu, et al., 2006; Castelan, et al., 2007).

have shown increases in enamel acid resistance.

(O) and hydrogen (H) (Williams, et al., 1996).

the signal will be collected.

**5. General-scope energy dispersive spectroscopy** 

**4.5 CO2 laser** 

When the incident electron beam reaches the sample, one phenomenon that occurs is that one electron of the inner shells of an atom is excited and ejected from the atom, leaving an electron hole. Another electron from an outer, higher energy shell fills the hole and in the process an X-ray is produced. As the energy of the X-ray is characteristic of the electronic structure of each element and of the differences in energy from one shell to another, this allows knowing from which element the X-ray came from by measuring its energy.

X-ray production is one of several de-excitation processes of an ionized atom. Therefore, it is important to have an idea of the amount of generated X-ray for each atom. The fluorescence yield w for the production of K shell radiation is given by the following equation:

$$a\_{\mathbb{K}} = \frac{\#\mathbb{K}\text{ photons produced}}{\#\mathbb{K}-\text{shell ionization}}$$

The fluorescence yield is favored for high atomic number atoms. For example, the ωK for carbon is approximately 0.005, while for germanium, it is approximately 0.5 and near unity for the heaviest atoms. The impact of this number on the analysis of biological samples is obvious: it takes many more beam electrons to produce a significant amount of X-rays from carbon (C), oxygen (O) or nitrogen (N) atoms. In practice, this fact means that a longer analysis time is required to obtain an adequate signal-to-noise ratio.

#### **5.2 Interaction volume**

Although it is said that SEM and coupled EDS are surface analytical techniques, this statement is not completely true. Due to the energy of their beam electrons, they are capable of penetrating a sample, interacting with its atoms and therefore generating signals (backscattered electrons, secondary electrons, characteristic X-rays, etc.). The space underneath the sample surface, where these signals are generated, is called the interaction volume (Goldstein, et al., 2003). The shape of the interaction volume varies from a hemisphere, for high atomic number atoms, to a pear, for low atomic number atoms, as seen in Fig. 1.

The dimensions and shape of the interaction volume depend on several factors, such as the energy of the electron beam, the average atomic number of the sample, the density of the material and the incidence angle of the beam.

The energy of the beam has a strong influence on the size of the interaction volume. For example, for iron, the interaction volume size ranges from 0.5 µm at 10 keV to 2 µm at 30 keV. This effect is much more pronounced in low atomic number materials; the interaction volume at 20 keV in a low atomic number target, such as a biopolymer, can be as large as several micrometers, depending on its density.

The next factor affecting the interaction volume is the atomic number Z. The larger the atom is, the higher the probability of interaction with the electron beam will be. Therefore, as Z increases, the interaction volume decreases. For example, at 20 keV, the interaction volume for carbon is approximately 8 µm, while for uranium, it is approximately 0.4 µm.

Structural Changes on Human Dental Enamel Treated

known as the ZAF correction.

called a semiquantitative analysis.

**6. Experimental design** 

signed an informed consent.

**6.1 Tooth selection** 

concentration of certain elements is less than 5%.

element composition to its corresponding atomic number.

with Er:YAG, CO2 Lasers and Remineralizing Solution: EDS Analysis 309

In practice, it is very difficult to meet all the requirements for a true quantitative analysis for several reasons: our samples are not always flat and free of surface defects, and we do not have a reference standard for each type of sample used (metallic, polymeric, biological, etc.). In such cases, the peaks from the elements in the specimen are compared with the peak of a pure element, usually copper. Some corrections should be made to have reliable results: an atomic number correction, accounting for the fraction of backscattered electrons by the sample within the interaction volume (the Z factor), a correction for the absorption of X-rays inside the sample (the A factor), and a correction for secondary X-ray fluorescence in the sample (the F factor). The most common procedure to take into account these factors is

In the case of a true quantitative analysis, the expected error is approximately 2% for major concentrations. When using a pure reference element, the error should be expected to be 4- 5%. For elements with concentrations of less than 5% the relative error would be approximately 10%. This is why, when using a pure reference element, the process is often

In dental research, due to the inherent changes in morphology and composition of teeth from human to human and from tooth to tooth, it is virtually impossible to carry out a true quantitative analysis. However, a semiquantitative analysis is possible if we are careful during the analysis. The setup parameters of the microscope must always be the same (accelerating voltage, spot size, working distance, etc.). Since we deal with low atomic numbers (mainly O, Ca and P) the spectrum acquisition time should be long in order to have a good signal-to-noise ratio with well-defined peaks and a high number of counts. Calibration with the reference element should be performed every day or even every several hours to account for changes in the electronics of the system due to changes in the room temperature, vacuum, etc. Even with these precautions, as stated previously, we should consider a relative error in the calculations of approximately 10% or more if the

Usually, in the revised literature, people working with teeth have tended to report the concentrations of elements using wt.%, perhaps as a convention. However, we have proposed the use of atomic percentage (at.%) instead, because it is more convenient to consider the difference in the number of atoms, rather than their weight. In this way, we can better correlate any changes in tooth composition directly with the molecular or atomic structure. Therefore, all of our results for tooth composition are presented in atomic percentages. Of course, one can change from one percentage to the other by relating each

The study protocol was reviewed and approved by the Research and Ethics Committee at the Autonomous University of the State of Mexico. All subjects enrolled in this research

A total of 48 premolar teeth, extracted for orthodontic reasons, were stored in 0.1% (wt. /vol) thymol solution at 4°C, until the experiment began. The teeth were selected according to the following criteria: intact buccal enamel surfaces without developmental defects,

Fig. 1. Interaction volume from samples with different average atomic numbers

In dental research, it is very important to take into account these effects to avoid mistakes in the interpretation of the results. For example, during investigations in which the surface of the teeth are treated and low depths need to be studied, we recommend working with lowbeam energy; otherwise, the volume underneath the treated surface will be analyzed together with the space of interest. However, as we decrease the beam energy, the number of generated X-rays also decreases. Thus, care should be taken when choosing the analysis parameters.

#### **5.3 Qualitative analysis**

EDS allows us to determine qualitatively the elements present in the specimen. This process is undertaken by analyzing the EDS spectrum and assigning an element to each peak on that spectrum. Today, modern equipment can perform this assignment automatically, although further analysis, done by the researcher, is necessary because many peaks from different elements overlap with the same energies. This fact is most important when analyzing samples, the composition of which is completely unknown.

#### **5.4 Quantitative and semiquantitative analysis**

In addition to qualitative analysis, EDS is widely used because of its ability to measure the concentrations of all elements present in samples (except for H, He and Li).. This process is undertaken by a series of measurements, for which the peak intensity from every element is compared with the peak intensity from a reference standard. The minimum detection limit of an EDS analyzer is approximately 0.1% for elements with Z > 10 and approximately 1.0 wt. % (weight percentage) for lighter elements (Brundle, et al., 1992).

To perform a true quantitative analysis, several issues must be taken into account. First, the sample and the reference must be flat, such that the surface imperfections do not interfere with the generated X-rays. Second, all the analysis parameters (e.g., accelerating voltage, spot size, time of analysis, etc.) must be the same. Additionally, the reference sample must contain the same elements as the studied specimen.

Electron beam

Fig. 1. Interaction volume from samples with different average atomic numbers

samples, the composition of which is completely unknown.

wt. % (weight percentage) for lighter elements (Brundle, et al., 1992).

**5.4 Quantitative and semiquantitative analysis** 

contain the same elements as the studied specimen.

parameters.

**5.3 Qualitative analysis** 

In dental research, it is very important to take into account these effects to avoid mistakes in the interpretation of the results. For example, during investigations in which the surface of the teeth are treated and low depths need to be studied, we recommend working with lowbeam energy; otherwise, the volume underneath the treated surface will be analyzed together with the space of interest. However, as we decrease the beam energy, the number of generated X-rays also decreases. Thus, care should be taken when choosing the analysis

High atomic number Low atomic number

Interaction volume

EDS allows us to determine qualitatively the elements present in the specimen. This process is undertaken by analyzing the EDS spectrum and assigning an element to each peak on that spectrum. Today, modern equipment can perform this assignment automatically, although further analysis, done by the researcher, is necessary because many peaks from different elements overlap with the same energies. This fact is most important when analyzing

In addition to qualitative analysis, EDS is widely used because of its ability to measure the concentrations of all elements present in samples (except for H, He and Li).. This process is undertaken by a series of measurements, for which the peak intensity from every element is compared with the peak intensity from a reference standard. The minimum detection limit of an EDS analyzer is approximately 0.1% for elements with Z > 10 and approximately 1.0

To perform a true quantitative analysis, several issues must be taken into account. First, the sample and the reference must be flat, such that the surface imperfections do not interfere with the generated X-rays. Second, all the analysis parameters (e.g., accelerating voltage, spot size, time of analysis, etc.) must be the same. Additionally, the reference sample must In practice, it is very difficult to meet all the requirements for a true quantitative analysis for several reasons: our samples are not always flat and free of surface defects, and we do not have a reference standard for each type of sample used (metallic, polymeric, biological, etc.). In such cases, the peaks from the elements in the specimen are compared with the peak of a pure element, usually copper. Some corrections should be made to have reliable results: an atomic number correction, accounting for the fraction of backscattered electrons by the sample within the interaction volume (the Z factor), a correction for the absorption of X-rays inside the sample (the A factor), and a correction for secondary X-ray fluorescence in the sample (the F factor). The most common procedure to take into account these factors is known as the ZAF correction.

In the case of a true quantitative analysis, the expected error is approximately 2% for major concentrations. When using a pure reference element, the error should be expected to be 4- 5%. For elements with concentrations of less than 5% the relative error would be approximately 10%. This is why, when using a pure reference element, the process is often called a semiquantitative analysis.

In dental research, due to the inherent changes in morphology and composition of teeth from human to human and from tooth to tooth, it is virtually impossible to carry out a true quantitative analysis. However, a semiquantitative analysis is possible if we are careful during the analysis. The setup parameters of the microscope must always be the same (accelerating voltage, spot size, working distance, etc.). Since we deal with low atomic numbers (mainly O, Ca and P) the spectrum acquisition time should be long in order to have a good signal-to-noise ratio with well-defined peaks and a high number of counts. Calibration with the reference element should be performed every day or even every several hours to account for changes in the electronics of the system due to changes in the room temperature, vacuum, etc. Even with these precautions, as stated previously, we should consider a relative error in the calculations of approximately 10% or more if the concentration of certain elements is less than 5%.

Usually, in the revised literature, people working with teeth have tended to report the concentrations of elements using wt.%, perhaps as a convention. However, we have proposed the use of atomic percentage (at.%) instead, because it is more convenient to consider the difference in the number of atoms, rather than their weight. In this way, we can better correlate any changes in tooth composition directly with the molecular or atomic structure. Therefore, all of our results for tooth composition are presented in atomic percentages. Of course, one can change from one percentage to the other by relating each element composition to its corresponding atomic number.

#### **6. Experimental design**

The study protocol was reviewed and approved by the Research and Ethics Committee at the Autonomous University of the State of Mexico. All subjects enrolled in this research signed an informed consent.

#### **6.1 Tooth selection**

A total of 48 premolar teeth, extracted for orthodontic reasons, were stored in 0.1% (wt. /vol) thymol solution at 4°C, until the experiment began. The teeth were selected according to the following criteria: intact buccal enamel surfaces without developmental defects,

Structural Changes on Human Dental Enamel Treated

**6.4 pH cycling** 

over 9 days.

**6.5 SEM and EDS** 

United Kingdom).

**7. Results** 

Groups III and IV.

element.

**6.6 Statistical analysis** 

Whitney tests at a *p* ≤ 0.05 level of significance.

3d), rough areas, craters and cracks were observed.

with Er:YAG, CO2 Lasers and Remineralizing Solution: EDS Analysis 311

After laser irradiation under specific conditions, a pH-cycling model of ten Cate and Duijister, modified by Featherstone (Featherstone, et al., 1998), was used to produce carious lesions, with a demineralization and remineralization period alternating daily

At the conclusion of the pH-cycling process, each tooth was rinsed with deionized water. Finally, the teeth were dried at room temperature and attached to a testing ring, using adhesive carbon paper (SPI Supplies, USA) to be observed by scanning electron microscopy (JEOL, JSM-6510LV, Japan). The atomic percentages (at.%) of calcium (Ca), phosphorus (P), carbon (C) and oxygen (O) on the enamel surface adjacent to the bracket were evaluated by energy dispersive spectroscopy (EDS) (Oxford Instrument, 7582,

All data were analyzed using the SPSS 13.0 statistical package for Windows (SPSS Inc., Chicago, IL, USA). The measurements were analyzed using the Kruskal-Wallis and Mann-

The most significant images obtained for each group are shown. The control group (not irradiated) displayed open enamel prisms (Fig. 3a). In the irradiated samples (Figs. 3b, 3c,

The experimental data obtained by EDS for all groups regarding the percentages of Ca, P, C and O are displayed in Table 1. A similar content for Ca was observed in all groups; however, additional variations in the content of other elements, especially C, were found in

Groups n C O P Ca

Group I 12 23.2 A ± 3.5 52.6 A ± 3.2 10.1 A ± 0.9 14.1 A ± 2.0

Group II 12 23.4 A ± 5.4 53.5 A ± 5.1 9.4 A ± 1.1 13.7 A ± 1.7

Group III 12 16.3 B ± 4.9 58.6 B ± 5.2 10.6 A ± 1.2 14.6 A ± 2.6

Group IV 12 14.5 C ± 6.5 57.3 A ± 6.7 11.5 B ± 1.5 16.7 A ± 3.9 **\***Groups with different letters are significantly different (p≤0.05), based on statistical analysis by

Table 1. Mean Values and Standard Deviations of Atomic Percentages for Each Element

restorations or fluorosis, not subjected to any pretreatment chemical agents, such as hydrogen peroxide, no cracks and no caries, according to the DIAGNOdent criteria (DIAGNOdent pen, KaVo, Biderach, Germany).

#### **6.2 Sample preparation**

All selected teeth were cleaned with a brush and deionized water; subsequently, they were dried with compressed, oil-free air. In the middle third of each root, a mesio-distal perforation was made, and then a fixture of stainless wire was introduced to attach each sample with self-curing acrylic to the top of a polyethylene container. For etching, a 35 percent phosphoric acid gel (Ultra-Etch; Ultradent, UT, USA) was used (15 sec). Then, the teeth were rinsed and dried again, as previously described. On the buccal surface, an orthodontic bracket (slot 0.018 inch standard edgewise premolar bracket, Ormco, CA, USA) was bonded to the enamel with a composite resin (Transbond XT cure, 3 M Unitek, CA, USA, Lot), following the manufacturer's instructions. The position of the orthodontic bracket was parallel to the longitudinal axis of the tooth, at a height of 4.0 mm, using bracket height gauges (Ortho™ Ormco, California, USA)..

#### **6.3 Treatment of the enamel surface**

The samples were randomly divided into four groups (n=12): Group 1 no laser irradiation (control group); Group 2 was treated with CO2 laser; Group 3 was irradiated with Er:YAG laser; and Group 4 was treated with Er:YAG + remineralizing solution (Fig. 2). Each sample was irradiated twice during a time period of 18 sec.

Fig. 2. Experimental design

#### **6.4 pH cycling**

310 Oral Health Care – Prosthodontics, Periodontology, Biology, Research and Systemic Conditions

restorations or fluorosis, not subjected to any pretreatment chemical agents, such as hydrogen peroxide, no cracks and no caries, according to the DIAGNOdent criteria

All selected teeth were cleaned with a brush and deionized water; subsequently, they were dried with compressed, oil-free air. In the middle third of each root, a mesio-distal perforation was made, and then a fixture of stainless wire was introduced to attach each sample with self-curing acrylic to the top of a polyethylene container. For etching, a 35 percent phosphoric acid gel (Ultra-Etch; Ultradent, UT, USA) was used (15 sec). Then, the teeth were rinsed and dried again, as previously described. On the buccal surface, an orthodontic bracket (slot 0.018 inch standard edgewise premolar bracket, Ormco, CA, USA) was bonded to the enamel with a composite resin (Transbond XT cure, 3 M Unitek, CA, USA, Lot), following the manufacturer's instructions. The position of the orthodontic bracket was parallel to the longitudinal axis of the tooth, at a height of 4.0 mm, using bracket

The samples were randomly divided into four groups (n=12): Group 1 no laser irradiation (control group); Group 2 was treated with CO2 laser; Group 3 was irradiated with Er:YAG laser; and Group 4 was treated with Er:YAG + remineralizing solution (Fig. 2). Each sample

(DIAGNOdent pen, KaVo, Biderach, Germany).

height gauges (Ortho™ Ormco, California, USA)..

was irradiated twice during a time period of 18 sec.

**6.3 Treatment of the enamel surface** 

Fig. 2. Experimental design

**6.2 Sample preparation** 

After laser irradiation under specific conditions, a pH-cycling model of ten Cate and Duijister, modified by Featherstone (Featherstone, et al., 1998), was used to produce carious lesions, with a demineralization and remineralization period alternating daily over 9 days.

#### **6.5 SEM and EDS**

At the conclusion of the pH-cycling process, each tooth was rinsed with deionized water. Finally, the teeth were dried at room temperature and attached to a testing ring, using adhesive carbon paper (SPI Supplies, USA) to be observed by scanning electron microscopy (JEOL, JSM-6510LV, Japan). The atomic percentages (at.%) of calcium (Ca), phosphorus (P), carbon (C) and oxygen (O) on the enamel surface adjacent to the bracket were evaluated by energy dispersive spectroscopy (EDS) (Oxford Instrument, 7582, United Kingdom).

#### **6.6 Statistical analysis**

All data were analyzed using the SPSS 13.0 statistical package for Windows (SPSS Inc., Chicago, IL, USA). The measurements were analyzed using the Kruskal-Wallis and Mann-Whitney tests at a *p* ≤ 0.05 level of significance.

#### **7. Results**

The most significant images obtained for each group are shown. The control group (not irradiated) displayed open enamel prisms (Fig. 3a). In the irradiated samples (Figs. 3b, 3c, 3d), rough areas, craters and cracks were observed.

The experimental data obtained by EDS for all groups regarding the percentages of Ca, P, C and O are displayed in Table 1. A similar content for Ca was observed in all groups; however, additional variations in the content of other elements, especially C, were found in Groups III and IV.


**\***Groups with different letters are significantly different (p≤0.05), based on statistical analysis by element.

Table 1. Mean Values and Standard Deviations of Atomic Percentages for Each Element

Structural Changes on Human Dental Enamel Treated

prevention. *Laser Physics,* 16, 5, 865-75.

therapy. *Periodontology* 2000, 36, 59-97.

vitro. *Lasers in Surgery and Medicine*, 30, 5, 337-41.

use for caries prevention. *Caries Research*, 39, 65-70.

**8. Conclusion** 

**9. Acknowledgment** 

712. e 7.

2, 85-90.

USA, 120-33

*Stomatologica*, 45, 5, 1 97-204.

**10. References** 

with Er:YAG, CO2 Lasers and Remineralizing Solution: EDS Analysis 313

The treatment conditions used on dental enamel surfaces for Groups II and IV likely induced changes in the structure of these biological tissues, which could interfere with the development of early lesions of dental caries. However, additional studies are required.

Ana, P.A., Bachmann, L. & Zezell, D.M. (2006). Lasers effects on enamel for caries

Aoki, A., Sasaki, K.M., Watanabe, H. & Ishikawa I. (2004). Lasers in nonsurgical periodontal

Apel, C., Meister, J., Schmitt, N., Graber, H.G. & Gutknecht, N. (2002). Calcium solubility of

Apel, C., Birker, L., Meister, J., Weiss, C. & Gutknecht, N. (2004). The caries-preventive

Apel, C., Meister, J., Gotz, H., Duschner, H. & Gutknecht, N. (2005). Structural changes in

Bahar, A. & Tagomori, S. (1994). The effect of normal pulsed Nd-YAG laser irradiation on

Behnan, S.M., Arruda, A.O., González-Cabezas, C., Sohn, W. & Peters, M.C. (2010).In-vitro

Brundle, C. R., Evans, C. A. & Wilson S. (1992). *Encycopedia of Materials Characterization:* 

Caltabiano, C., Leonardi, R., Martinez, G., Viscuso, O., Romero M. & Caltabiano R. (1996).

Castellan, C.S., Luiz, A.C., Bezinelli, L.M., Lopes, R.M.G. Mendes F.M., Eduardo C. de P. &

Cecchini, R.C.M., Zezell, D.M., de Oliveira, E., de Freitas, P.M. & Eduardo, C de P. (2005).

spectrometry analysis. *Lasers in Surgery and Medicine*, 37, 5, 366-72.

a pilot study. Photomedicine and Laser Surgery, 22, 4, 312-17.

pits and fissures in human teeth. *Caries Research,* 28, 460-467.

dental enamel following sub-ablative Er:YAG and Er:YSGG laser irradiation in

potential of subablative Er:YAG and Er:YSGG laser radiation in an intraoral model:

human dental enamel after subablative erbium laser irradiation and its potential

evaluation of various treatments to prevent demineralization next to orthodontic brackets. *American Journal Orthodontics and Dentofacial Orthopedics*, 138, 6, 712. e 1-

*Surfaces, Interfaces and Thin films*. Butterworth-Heinemann, ISBN 0-7506-9168-9,

"Carious" and "noncarious" lesions of the hard dental tissues. Ultraestructural (SEM) and microanalytical (EDS) analyses of teeth the 3rd century B.C. *Minerva* 

De Freitas P.M. (2007). In vitro evaluation of enamel demineralization after Er:YAG and Nd:YAG laser irradiation on primary teeth. *Photomedicine and Laser Surgery*, 25,

Effect of Er:YAG laser on enamel acid resistance: Morphological and atomic

This project was financed by Universidad Autónoma del Estado de México.

Fig. 3. Representative SEM micrographs of samples from the control group (a) and from experimental groups (b,c,d), showing the typical pattern of a non-irradiated enamel surface with exposed prisms (a), craters and melting produced by CO2 laser irradiation (b) and craters produced by Er:YAG laser irradiation and evident demineralization due to a pH cycling process (c); also, craters and less demineralization are observed in Group IV (d). Original magnification x 200; scale bar =100 µm

#### **8. Conclusion**

312 Oral Health Care – Prosthodontics, Periodontology, Biology, Research and Systemic Conditions

Fig. 3. Representative SEM micrographs of samples from the control group (a) and from experimental groups (b,c,d), showing the typical pattern of a non-irradiated enamel surface with exposed prisms (a), craters and melting produced by CO2 laser irradiation (b) and craters produced by Er:YAG laser irradiation and evident demineralization due to a pH cycling process (c); also, craters and less demineralization are observed in Group IV (d).

Original magnification x 200; scale bar =100 µm

The treatment conditions used on dental enamel surfaces for Groups II and IV likely induced changes in the structure of these biological tissues, which could interfere with the development of early lesions of dental caries. However, additional studies are required.

#### **9. Acknowledgment**

This project was financed by Universidad Autónoma del Estado de México.

#### **10. References**


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**20** 

*Australia* 

**Indigenous Australians and Oral Health** 

*Australian Research Centre for Population Oral Health, University of Adelaide* 

Indigenous disadvantage is an ongoing problem in Australia. In terms of health, the situation is critical. Indigenous Australians 1 experience higher rates of chronic disease, the persistence of serious ear and eye infections amongst young children, and often poor access to primary health care facilities (Aboriginal and Torres Strait Islander Social Justice Commissioner, 2005). In the area of oral health, there is also a wide disparity between Indigenous and non-Indigenous Australians. Unfortunately available data on the oral health of Indigenous people is limited, making it all the more difficult to make progress towards eliminating this discrepancy. The reasons for the gap are many, but include the fact that culturally appropriate and timely dental care are often inaccessible, as are appropriate resources on how to maintain good oral health, particularly for those residing in rural and remote areas. Differing understandings of health, as well as the division between medicine and dentistry that has traditionally been so strong in Australia, do nothing to help the situation. Reducing the disparities in oral health between Indigenous and non-Indigenous groups is an immense task that will require a dedicated and coordinated approach – it will depend on improved access to dental care as well as a more holistic approach to oral health,

In the past, Indigenous Australians enjoyed better oral health than non-Indigenous people Harford et al., 2003). Dental decay and periodontal disease were uncommon in rural and remote Indigenous communities up until recently. Caries was, throughout the 19th and early 20th centuries, regarded as a disease of affluence in Australia – but has now become an 'indicator of deprivation' (Williams et al., 2011). As foods rich in fermentable carbohydrates became more common in rural and remote areas, so did dental decay (Harford et al., 2003). While oral health risk factors are the same for all Australians, many Indigenous people do not enjoy the same access to protection from dental decay afforded by fluoridated water,

This chapter will begin with an overview of the general situation of Indigenous health and disadvantage in Australia, including a discussion of the Close the Gap campaign, and will also delve briefly into Indigenous understandings of health to provide some cultural context. We will then move on specifically to the topic of oral health amongst the

1 The term 'Indigenous Australians' includes Aboriginal people from across Australia as well as Torres Strait Islanders – the Torres Strait Islands are located between the tip of Cape York, the northernmost

**1. Introduction** 

including preventive measures.

toothpaste, or easy access to dental care.

point of the state of Queensland, and Papua New Guinea

Madeline Shearer and Lisa Jamieson


### **Indigenous Australians and Oral Health**

Madeline Shearer and Lisa Jamieson

*Australian Research Centre for Population Oral Health, University of Adelaide Australia* 

#### **1. Introduction**

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Westerman, G.H., Hicks, M.J., Flaitz, C.M, Powell, G.L. & Hicks J. (2002). Enamel caries

Ying, D., Chuah, G.K. & Hsu, C.Y.S. (2004). Effect of Er:YAG laser and organic matrix on porosity changes in human enamel. *Journal of Dentistry*, 32, 1, 41-46. Young, D.A., Fried, D. & Featherstone, J.D.B. Treating occlusal pit and fissure surfaces by IR

comparison. *Journal of Clinical Laser Medicine & Surgery*, 20, 5, 257-62. Westerman, G.H., Flaitz, C.M., Powell, G.L., Hicks, M.J., &. (2006). In vitro caries formation

solution treatment *Journal American Dental Association*, 137, 5, 638-44. Williams, D. B. & Carter C. Barry. (1996). *Transmission Electron Microscopy*. Plenum Press.

ISBN 0-306-45324-X, New York, 589-617.

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initiation and progression after argón laser irradiation: in vitro argon laser systems

in primary tooth enamel - Role of argon laser irradiation and remineralizing

laser irradiation. (2000). In: Featherstone, J. D. B., Rechmann, P., Fried, D., J., *editors.* 

Indigenous disadvantage is an ongoing problem in Australia. In terms of health, the situation is critical. Indigenous Australians 1 experience higher rates of chronic disease, the persistence of serious ear and eye infections amongst young children, and often poor access to primary health care facilities (Aboriginal and Torres Strait Islander Social Justice Commissioner, 2005). In the area of oral health, there is also a wide disparity between Indigenous and non-Indigenous Australians. Unfortunately available data on the oral health of Indigenous people is limited, making it all the more difficult to make progress towards eliminating this discrepancy. The reasons for the gap are many, but include the fact that culturally appropriate and timely dental care are often inaccessible, as are appropriate resources on how to maintain good oral health, particularly for those residing in rural and remote areas. Differing understandings of health, as well as the division between medicine and dentistry that has traditionally been so strong in Australia, do nothing to help the situation. Reducing the disparities in oral health between Indigenous and non-Indigenous groups is an immense task that will require a dedicated and coordinated approach – it will depend on improved access to dental care as well as a more holistic approach to oral health, including preventive measures.

In the past, Indigenous Australians enjoyed better oral health than non-Indigenous people Harford et al., 2003). Dental decay and periodontal disease were uncommon in rural and remote Indigenous communities up until recently. Caries was, throughout the 19th and early 20th centuries, regarded as a disease of affluence in Australia – but has now become an 'indicator of deprivation' (Williams et al., 2011). As foods rich in fermentable carbohydrates became more common in rural and remote areas, so did dental decay (Harford et al., 2003). While oral health risk factors are the same for all Australians, many Indigenous people do not enjoy the same access to protection from dental decay afforded by fluoridated water, toothpaste, or easy access to dental care.

This chapter will begin with an overview of the general situation of Indigenous health and disadvantage in Australia, including a discussion of the Close the Gap campaign, and will also delve briefly into Indigenous understandings of health to provide some cultural context. We will then move on specifically to the topic of oral health amongst the

<sup>1</sup> The term 'Indigenous Australians' includes Aboriginal people from across Australia as well as Torres Strait Islanders – the Torres Strait Islands are located between the tip of Cape York, the northernmost point of the state of Queensland, and Papua New Guinea

Indigenous Australians and Oral Health 321

As we see in so many areas concerning Indigenous Australians, there is a lack of data regarding Indigenous understandings of health too, particularly those living in urban areas. We do know, however, that for the most part Indigenous Australians share a holistic understanding of the concept of health, with physical, mental, social, cultural and spiritual health all playing an important part (Commonwealth of Australia, 2007). The Standing Committee on Family and Community Affairs notes that Aboriginal society has 'no word, term or expression for 'health' as it is understood in Western society…The nearest translation in an Aboriginal context would probably be a term such as 'life is health is life'' (National Aboriginal Health Strategy Working Party, cited in Commonwealth of Australia, 2000: vii). As the Committee acknowledges, health disparities between Indigenous and non-Indigenous Australians can in part be attributed to the lack of culturally-appropriate access to health care for Indigenous people - many of the difficulties can be explained by these differing views of health, how to define it, and which services are necessary (Commonwealth of Australia, 2000). This approach differs from Western medicine which tends to separate body, mind and society – but this is not to say that the two approaches are mutually exclusive. It is also important to emphasise the variety of beliefs that occurs between the people of different parts of Australia (Maher, 1999). Health, from an Indigenous

everything important in a person's life, including land, environment, physical body, community, relationships and law. Health is the social, emotional, and cultural well-being of the whole community and the concept is thus linked to the sense of being Indigenous

(Queensland Aboriginal and Islander Health Forum, cited in Burns et al., 2010).

The National Indigenous Health Equality Campaign was developed in March of 2006, and the following year launched the name *Close the Gap* for its public awareness campaign. This came in the wake of 2005's Social Justice Report which called for state and national governments to commit to achieving equality for Indigenous people in health and life expectancy within 25 years. To demonstrate the major problem areas for Indigenous disadvantage, the Council of Australian Governments (COAG) set six targets over 2007– 2008 towards 'Closing the Gap': it chose to focus on reducing the disparities in life expectancy, young child mortality, reading, writing and numeracy, employment, early childhood education, and secondary school completion (Steering Committee for the Review of Government Service Provision, 2009), so it is clear that health disparities occur within a

The campaign has brought together many health organisations (both Indigenous and non-Indigenous), including the Indigenous Dentists' Association Australia, as well as human rights groups. Probably the strongest messages conveyed to the public through this campaign include the fact that Indigenous Australians will die up to 17 years earlier than other Australians, and that access to basic health care facilities continues to be very limited (Oxfam Australia, 2010). We are seeing an increased commitment now, with the Federal government signing the Close the Gap Statement of Intent in March 2008, COAG's commitment, and the announcement in late 2008 that the Australian Government would commit the unprecedented sum of AU\$1.6 billion towards improving Indigenous health (Oxfam Australia, 2010). This is of course a welcome response, but the National Partnership

Agreement makes no mention of oral health, an area that often seems to go ignored.

**2.3 Indigenous understandings of health** 

perspective, is a concept that incorporates:

**2.4 The Close the Gap campaign** 

context of general inequality.

Indigenous community, including a discussion of the relevant social determinants. Three indicators will be used to assess the levels of Indigenous oral health in comparison to that of non-Indigenous Australians: caries, periodontal disease, and tooth loss. We will provide a brief summary of some of the barriers to attaining better standards of oral health, particularly in remote communities. Finally, we discuss what additional measures might be required if we are to make progress.

#### **2. Closing the Gap: Indigenous disadvantage and health in Australia**

In 2000, Commonwealth Minister for Health Dr Michael Wooldridge stated that Australia's 'single most spectacular failure as a nation has been in the area of Aboriginal and Torres Strait Islander health' (Jupp 2001). Such an acknowledgement in itself indicates progress. While the *National Aboriginal Health Strategy* received support from ministers back in 1990, it was never implemented fully (Thomson, 2003). Not until the mid-nineties did the government's involvement in Indigenous health even begin 'to approach the level required to address the persisting health disadvantages experienced by Indigenous people' (Thomson, 2003). As time goes by the issue of Indigenous health is receiving much more attention in politics, the media and the national collective consciousness. This section will first give a brief overview of the current situation of Indigenous health, and will then discuss the social determinants of Indigenous health in Australia. A quick introduction to Indigenous understandings of health will then be followed by a summary of the Close the Gap campaign.

#### **2.1 The situation today**

In terms of general health, Indigenous Australians suffer a significantly greater burden of disease than non-Indigenous people, yet they nonetheless have less access to health care than the rest of the population (AIHW, 2011). The Australian Indigenous population is a classic example of a non-Western society being highly susceptible to diabetes upon the introduction of a Western lifestyle (Irvine et al., 2003). They are often diagnosed later, are less likely to receive proper treatment, and are consequently more likely to die from cancer than non-Indigenous Australians (Thomson et al., 2010). Other conditions that impact on Indigenous people's greater burden of disease include kidney and respiratory diseases, rheumatic heart disease, and ear and hearing problems, while inadequate nutrition, alcohol consumption, smoking and the use of other drugs constitute the major risk factors impacting on the quality of life of Indigenous Australians (AIHW, 2011).

#### **2.2 Social determinants**

The current health status of Indigenous Australians is linked very closely to the social inequalities that many face (Thomson et al., 2010). These social inequalities are rooted in the experience of 'a history of conflict and dispossession, loss of traditional roles, failed assimilation and passive welfare' (Banks, 2007: 8) shared by many Indigenous groups around the world. The fact that such discrepancies in health status continue to this day, and that they are so overwhelming, is largely attributable to the social determinants of health – current structural and social circumstances (Thomson et al., 2010). Social determinants of Indigenous health include socioeconomic position (incorporating educational attainment, income, and employment), housing, transport (Carson et al., 2007) and racism.

Indigenous community, including a discussion of the relevant social determinants. Three indicators will be used to assess the levels of Indigenous oral health in comparison to that of non-Indigenous Australians: caries, periodontal disease, and tooth loss. We will provide a brief summary of some of the barriers to attaining better standards of oral health, particularly in remote communities. Finally, we discuss what additional measures might be

In 2000, Commonwealth Minister for Health Dr Michael Wooldridge stated that Australia's 'single most spectacular failure as a nation has been in the area of Aboriginal and Torres Strait Islander health' (Jupp 2001). Such an acknowledgement in itself indicates progress. While the *National Aboriginal Health Strategy* received support from ministers back in 1990, it was never implemented fully (Thomson, 2003). Not until the mid-nineties did the government's involvement in Indigenous health even begin 'to approach the level required to address the persisting health disadvantages experienced by Indigenous people' (Thomson, 2003). As time goes by the issue of Indigenous health is receiving much more attention in politics, the media and the national collective consciousness. This section will first give a brief overview of the current situation of Indigenous health, and will then discuss the social determinants of Indigenous health in Australia. A quick introduction to Indigenous understandings of health will then be followed by a summary of the Close the

In terms of general health, Indigenous Australians suffer a significantly greater burden of disease than non-Indigenous people, yet they nonetheless have less access to health care than the rest of the population (AIHW, 2011). The Australian Indigenous population is a classic example of a non-Western society being highly susceptible to diabetes upon the introduction of a Western lifestyle (Irvine et al., 2003). They are often diagnosed later, are less likely to receive proper treatment, and are consequently more likely to die from cancer than non-Indigenous Australians (Thomson et al., 2010). Other conditions that impact on Indigenous people's greater burden of disease include kidney and respiratory diseases, rheumatic heart disease, and ear and hearing problems, while inadequate nutrition, alcohol consumption, smoking and the use of other drugs constitute the major risk factors impacting

The current health status of Indigenous Australians is linked very closely to the social inequalities that many face (Thomson et al., 2010). These social inequalities are rooted in the experience of 'a history of conflict and dispossession, loss of traditional roles, failed assimilation and passive welfare' (Banks, 2007: 8) shared by many Indigenous groups around the world. The fact that such discrepancies in health status continue to this day, and that they are so overwhelming, is largely attributable to the social determinants of health – current structural and social circumstances (Thomson et al., 2010). Social determinants of Indigenous health include socioeconomic position (incorporating educational attainment,

income, and employment), housing, transport (Carson et al., 2007) and racism.

on the quality of life of Indigenous Australians (AIHW, 2011).

**2. Closing the Gap: Indigenous disadvantage and health in Australia** 

required if we are to make progress.

Gap campaign.

**2.1 The situation today** 

**2.2 Social determinants** 

#### **2.3 Indigenous understandings of health**

As we see in so many areas concerning Indigenous Australians, there is a lack of data regarding Indigenous understandings of health too, particularly those living in urban areas. We do know, however, that for the most part Indigenous Australians share a holistic understanding of the concept of health, with physical, mental, social, cultural and spiritual health all playing an important part (Commonwealth of Australia, 2007). The Standing Committee on Family and Community Affairs notes that Aboriginal society has 'no word, term or expression for 'health' as it is understood in Western society…The nearest translation in an Aboriginal context would probably be a term such as 'life is health is life'' (National Aboriginal Health Strategy Working Party, cited in Commonwealth of Australia, 2000: vii). As the Committee acknowledges, health disparities between Indigenous and non-Indigenous Australians can in part be attributed to the lack of culturally-appropriate access to health care for Indigenous people - many of the difficulties can be explained by these differing views of health, how to define it, and which services are necessary (Commonwealth of Australia, 2000). This approach differs from Western medicine which tends to separate body, mind and society – but this is not to say that the two approaches are mutually exclusive. It is also important to emphasise the variety of beliefs that occurs between the people of different parts of Australia (Maher, 1999). Health, from an Indigenous

perspective, is a concept that incorporates: everything important in a person's life, including land, environment, physical body, community, relationships and law. Health is the social, emotional, and cultural well-being of the whole community and the concept is thus linked to the sense of being Indigenous (Queensland Aboriginal and Islander Health Forum, cited in Burns et al., 2010).

#### **2.4 The Close the Gap campaign**

The National Indigenous Health Equality Campaign was developed in March of 2006, and the following year launched the name *Close the Gap* for its public awareness campaign. This came in the wake of 2005's Social Justice Report which called for state and national governments to commit to achieving equality for Indigenous people in health and life expectancy within 25 years. To demonstrate the major problem areas for Indigenous disadvantage, the Council of Australian Governments (COAG) set six targets over 2007– 2008 towards 'Closing the Gap': it chose to focus on reducing the disparities in life expectancy, young child mortality, reading, writing and numeracy, employment, early childhood education, and secondary school completion (Steering Committee for the Review of Government Service Provision, 2009), so it is clear that health disparities occur within a context of general inequality.

The campaign has brought together many health organisations (both Indigenous and non-Indigenous), including the Indigenous Dentists' Association Australia, as well as human rights groups. Probably the strongest messages conveyed to the public through this campaign include the fact that Indigenous Australians will die up to 17 years earlier than other Australians, and that access to basic health care facilities continues to be very limited (Oxfam Australia, 2010). We are seeing an increased commitment now, with the Federal government signing the Close the Gap Statement of Intent in March 2008, COAG's commitment, and the announcement in late 2008 that the Australian Government would commit the unprecedented sum of AU\$1.6 billion towards improving Indigenous health (Oxfam Australia, 2010). This is of course a welcome response, but the National Partnership Agreement makes no mention of oral health, an area that often seems to go ignored.

Indigenous Australians and Oral Health 323

Caries, periodontal diseases and tooth loss all provide visible, quantifiable evidence of oral ill-health, but the experience of pain, oral functioning and quality of life are also very important. People's experience of food avoidance because of dental problems, perceptions of their oral health, and experience of toothache provide additional insights into the oral health of Australians. The *National Survey of Adult Oral Health* (NSAOH) included qualitative

Poor oral health can cause people to avoid certain foods, which may limit a person's enjoyment of food and their ability to maintain a balanced diet (Slade et al., 2007). Indigenous adults were twice as likely as non-Indigenous adults to report avoiding foods due to oral health problems, with the highest difference in those aged 35-54 years (49% of

In responses to the *NSAOH*, Indigenous people were 1.5 times more likely than non-Indigenous people to rate their oral health as 'fair' or 'poor' (the two lowest measures) (Slade et al., 2007). Indigenous adults aged 35-54 years were twice as likely as their non-

Toothache can be caused by dental diseases, related infections, broken teeth, or nerve sensitivity (largely due to contact with hot or cold food or drinks). Toothache ranges from a short-term mild sensation to persistent, disabling pain. Data on the frequency of toothache collected in the *NSAOH* identified that Indigenous people were 1.8 times more likely than non-Indigenous people to report toothache in the previous year (27% compared with 15%) (Slade et al., 2007). The largest difference was seen for those aged 35-54 years: 39% of

This section will discuss the current state of Indigenous oral health in comparison to that of non-Indigenous Australians using three main indicators: caries, periodontal disease, and tooth loss. It will also consider other conditions resulting from poor oral health. Caries and periodontal disease are both easily preventable, as well as being curable within the initial stages. We will then move on to present information on some of the barriers to good oral

Dental caries (cavities or tooth decay) is caused by acid-producing bacteria that exist in the oral environment. These bacteria proliferate in the presence of sweet and sticky foods (Harford et al., 2003). In the early stages dental caries can be completely reversed, but when left untreated it may cause irreversible damage such as cavitation of tooth enamel. Small cavitations do not generally produce ongoing pain and require small restorations (fillings). Larger carious lesions, however, can completely undermine the structural integrity of the tooth. These often require substantial restorative treatment or extraction, particularly if the lesions extend to the dental pulp, resulting in pulpal infection, pulpal inflammation and pain. Pulpal inflammation is one of the most common reasons for attendance at the dentist (Williams et al., 2011). It can be reversible up until the carious lesion reaches the pulp, but once it does it is more likely to be irreversible (Abbott & Yu, 2007). The treatment protocol for long-standing irreversible pulpal inflammation is root canal therapy or extraction (Yeng et al., 2007). Long-standing pulpal inflammation will result in pulp necrosis. As pulp necrosis causes loss of the tooth's sensory apparatus, the dental pain associated with the initial inflammation completely subsides. Many patients at this point will assume the

Indigenous people and 15% of non-Indigenous people reported toothache.

**3.1 Experience of oral health impairment** 

questions to assess the experience of oral health impairment.

Indigenous people and 17% of non-Indigenous people).

Indigenous counterparts to provide this rating.

health for Indigenous communities across Australia.

**4. Caries** 

#### **3. Indigenous oral health**

The World Health Organisation defines oral health as 'being free of chronic mouth and facial pain, oral and throat cancer, oral sores, birth defects such as cleft lip and palate, periodontal disease, tooth decay and tooth loss, and other diseases and disorders that affect the mouth and oral cavity' (WHO, 2007). Following on from this, another definition emphasises the fact that a satisfactory standard of oral health will allow an individual to 'eat, speak and socialise without active disease, discomfort, or embarrassment and which *contributes to general wellbeing*' (Dental and Ophthalmic Services Division, 2005, emphasis added). The body of evidence linking oral health to other conditions only continues to grow (Guynup, 2006), demonstrating the importance of oral health as an important public health issue. Unsurprisingly, tooth loss and pain will often restrict eating and can result in weaker nutritional intake, which in turn can be associated with anaemia and gastrointestinal disturbances. Infection and tooth loss often result from poor oral health, and in addition to causing pain they can impede speaking and therefore have an impact on social interaction (Mason et al., 2006). More complex relationships link oral infection to systemic disease, for example arteriosclerosis, cardiovascular disease (Ylöstalo et al., 2006), diabetes (Taylor, Bornakke, 2008), stroke (Joshipura 2003), pre-term and low birth weight babies (Xiong et al., 2006), pulmonary diseases, and disorders such as otitis media and delayed growth and development. Likewise, recent studies have found associations between diseases like arthritis, diabetes, HIV and osteoporosis, and oral, dental and craniofacial diseases and disorders (Slavkin, 2000).

The ramifications of poor oral health can be immense, and are felt much more by Indigenous Australians than non-Indigenous people - Indigenous people have more caries, periodontal disease, and tooth loss than other Australians and, given that problems are more likely to go untreated, are also more likely to have teeth removed (Williams et al., 2011). It is important to note that it is likely that levels of oral disease amongst Indigenous Australians are in fact under-reported (Bazen et al., 2007b).

Many oral health problems suffered by Indigenous Australians share risk factor characteristics with wider general health problems. This means that while a great deal of work needs to be done, we can choose to see this as an opportunity to create positive change – efforts to encourage healthy eating, for example, are likely to have a positive impact not just on the oral health of the community but could also lead to reduced incidence of heart disease, obesity, and anaemia. An oral health campaign around links with drinking alcohol and smoking could have ramifications not just on oral health, but rates of lung cancer and emphysema. Such associations mean that the potential benefits of improvements in Indigenous oral health could extend to have numerous other health benefits, and as we learn more about these links our capacity to improve the situation will only increase. Improved information and understanding of oral health and dental care for this group is absolutely essential for the development and implementation of informed, effective public health policy.

There are numerous challenges arising from the lack of data on Indigenous health, particularly oral health. A large proportion of the available information focuses on specific communities or regions rather than giving an overall picture of the national situation. With wide variations in study design, it is not possible to accurately compare statistics taken in the past to those acquired more recently - before a complete understanding of the oral health status of Indigenous Australians can be attained, there is a great need for further epidemiological information (Williams et al., 2011).

The World Health Organisation defines oral health as 'being free of chronic mouth and facial pain, oral and throat cancer, oral sores, birth defects such as cleft lip and palate, periodontal disease, tooth decay and tooth loss, and other diseases and disorders that affect the mouth and oral cavity' (WHO, 2007). Following on from this, another definition emphasises the fact that a satisfactory standard of oral health will allow an individual to 'eat, speak and socialise without active disease, discomfort, or embarrassment and which *contributes to general wellbeing*' (Dental and Ophthalmic Services Division, 2005, emphasis added). The body of evidence linking oral health to other conditions only continues to grow (Guynup, 2006), demonstrating the importance of oral health as an important public health issue. Unsurprisingly, tooth loss and pain will often restrict eating and can result in weaker nutritional intake, which in turn can be associated with anaemia and gastrointestinal disturbances. Infection and tooth loss often result from poor oral health, and in addition to causing pain they can impede speaking and therefore have an impact on social interaction (Mason et al., 2006). More complex relationships link oral infection to systemic disease, for example arteriosclerosis, cardiovascular disease (Ylöstalo et al., 2006), diabetes (Taylor, Bornakke, 2008), stroke (Joshipura 2003), pre-term and low birth weight babies (Xiong et al., 2006), pulmonary diseases, and disorders such as otitis media and delayed growth and development. Likewise, recent studies have found associations between diseases like arthritis, diabetes, HIV and osteoporosis, and oral, dental and craniofacial diseases and

The ramifications of poor oral health can be immense, and are felt much more by Indigenous Australians than non-Indigenous people - Indigenous people have more caries, periodontal disease, and tooth loss than other Australians and, given that problems are more likely to go untreated, are also more likely to have teeth removed (Williams et al., 2011). It is important to note that it is likely that levels of oral disease amongst Indigenous Australians are in fact

Many oral health problems suffered by Indigenous Australians share risk factor characteristics with wider general health problems. This means that while a great deal of work needs to be done, we can choose to see this as an opportunity to create positive change – efforts to encourage healthy eating, for example, are likely to have a positive impact not just on the oral health of the community but could also lead to reduced incidence of heart disease, obesity, and anaemia. An oral health campaign around links with drinking alcohol and smoking could have ramifications not just on oral health, but rates of lung cancer and emphysema. Such associations mean that the potential benefits of improvements in Indigenous oral health could extend to have numerous other health benefits, and as we learn more about these links our capacity to improve the situation will only increase. Improved information and understanding of oral health and dental care for this group is absolutely essential for the development and implementation of informed, effective public health policy. There are numerous challenges arising from the lack of data on Indigenous health, particularly oral health. A large proportion of the available information focuses on specific communities or regions rather than giving an overall picture of the national situation. With wide variations in study design, it is not possible to accurately compare statistics taken in the past to those acquired more recently - before a complete understanding of the oral health status of Indigenous Australians can be attained, there is a great need for further

**3. Indigenous oral health** 

disorders (Slavkin, 2000).

under-reported (Bazen et al., 2007b).

epidemiological information (Williams et al., 2011).

#### **3.1 Experience of oral health impairment**

Caries, periodontal diseases and tooth loss all provide visible, quantifiable evidence of oral ill-health, but the experience of pain, oral functioning and quality of life are also very important. People's experience of food avoidance because of dental problems, perceptions of their oral health, and experience of toothache provide additional insights into the oral health of Australians. The *National Survey of Adult Oral Health* (NSAOH) included qualitative questions to assess the experience of oral health impairment.

Poor oral health can cause people to avoid certain foods, which may limit a person's enjoyment of food and their ability to maintain a balanced diet (Slade et al., 2007). Indigenous adults were twice as likely as non-Indigenous adults to report avoiding foods due to oral health problems, with the highest difference in those aged 35-54 years (49% of Indigenous people and 17% of non-Indigenous people).

In responses to the *NSAOH*, Indigenous people were 1.5 times more likely than non-Indigenous people to rate their oral health as 'fair' or 'poor' (the two lowest measures) (Slade et al., 2007). Indigenous adults aged 35-54 years were twice as likely as their non-Indigenous counterparts to provide this rating.

Toothache can be caused by dental diseases, related infections, broken teeth, or nerve sensitivity (largely due to contact with hot or cold food or drinks). Toothache ranges from a short-term mild sensation to persistent, disabling pain. Data on the frequency of toothache collected in the *NSAOH* identified that Indigenous people were 1.8 times more likely than non-Indigenous people to report toothache in the previous year (27% compared with 15%) (Slade et al., 2007). The largest difference was seen for those aged 35-54 years: 39% of Indigenous people and 15% of non-Indigenous people reported toothache.

This section will discuss the current state of Indigenous oral health in comparison to that of non-Indigenous Australians using three main indicators: caries, periodontal disease, and tooth loss. It will also consider other conditions resulting from poor oral health. Caries and periodontal disease are both easily preventable, as well as being curable within the initial stages. We will then move on to present information on some of the barriers to good oral health for Indigenous communities across Australia.

#### **4. Caries**

Dental caries (cavities or tooth decay) is caused by acid-producing bacteria that exist in the oral environment. These bacteria proliferate in the presence of sweet and sticky foods (Harford et al., 2003). In the early stages dental caries can be completely reversed, but when left untreated it may cause irreversible damage such as cavitation of tooth enamel. Small cavitations do not generally produce ongoing pain and require small restorations (fillings). Larger carious lesions, however, can completely undermine the structural integrity of the tooth. These often require substantial restorative treatment or extraction, particularly if the lesions extend to the dental pulp, resulting in pulpal infection, pulpal inflammation and pain. Pulpal inflammation is one of the most common reasons for attendance at the dentist (Williams et al., 2011). It can be reversible up until the carious lesion reaches the pulp, but once it does it is more likely to be irreversible (Abbott & Yu, 2007). The treatment protocol for long-standing irreversible pulpal inflammation is root canal therapy or extraction (Yeng et al., 2007). Long-standing pulpal inflammation will result in pulp necrosis. As pulp necrosis causes loss of the tooth's sensory apparatus, the dental pain associated with the initial inflammation completely subsides. Many patients at this point will assume the

Indigenous Australians and Oral Health 325

Indigenous children experience more caries that non-Indigenous children in their deciduous teeth (Jamieson et al., 2007). According to the *Child Dental Health Survey* conducted in 1999, the mean number of decayed, missing, and filled deciduous teeth (dmft) in Indigenous children aged 4–10 years who attended a school dental service clinic was significantly higher than for their non-Indigenous counterparts in NSW, SA and the NT (Armfield et al., 2003). The highest dmft scores were for Indigenous six-year-olds, who experienced 2.4 times

Four-year-old Indigenous children had more than three times the dental disease experience of their non-Indigenous counterparts. The highest numbers of missing teeth occurred in five-year-old Indigenous children, with a level more than five times that of non-Indigenous five-year-olds. The highest number of filled teeth occurred in eight-year-old Indigenous children. Taken together, the dmft scores indicated much poorer oral health in the deciduous dentition of Indigenous children aged 4-10 years than of their non-Indigenous

Poorer oral health for Indigenous children continues among those with permanent teeth: the DMFT2 was 1.5 times greater for Indigenous children aged 6-15 years than for their non-Indigenous counterparts, with higher DMFTs for each increasing age group. Indigenous children had higher numbers of permanent teeth with untreated decay, with those aged 15 years having almost three times the average number of their non-Indigenous counterparts. Numbers of filled teeth were similarly higher for Indigenous children, with six- year-old Indigenous children experiencing twice the number of filled teeth than non-Indigenous six-

Age (years) Indigenous Non-Indigenous 6 8 3 7 14 10 8 24 14 9 29 17 10 38 21 11 37 25 12 45 29 13 46 31 14 59 39 15 62 58 16 67 59 17 73 61 Note: 1 Data are for 12-month periods: NSW from 2000; SA from 2003; and the NT from 2002

2 Where children had more than one examination, information from the first examination has

Table 1. Proportions (%) of children aged 6-17 years with DMFT>0, by Indigenous status and age, New South Wales (NSW), South Australia (SA) and the Northern Territory (NT),

2 The numbers of missing permanent teeth of children aged 6-15 years were negligible

**4.1 Caries among Indigenous children** 

the dmft of non-Indigenous children of that age.

year-olds.

been used

Source: Jamieson, Armfield & Roberts-Thomson, 2007

2000-2003

counterparts, with the largest differences in the younger age groups.

problem has improved or healed itself, but infection of the dental pulp may continue to spread through the apex of the pulp canal/s into the supporting structures, causing periapical periodontitis (Abbott & Yu, 2007). This may result in severe pain and often systemic effects (e.g. fever). Patients with periapical periodontitis require root canal treatment or extraction. If the tooth is to be restored, the remaining decay usually requires substantial extra coronal restoration (i.e. crowns). Both the root canal therapy and the crown are expensive, and this type of treatment from a private practitioner may cost more than one thousand Australian dollars. If specialists are performing the treatment it will likely be more.

Such costs present an insurmountable barrier to many patients, particularly the socially and financially disadvantaged. If the patient is treated in the public sector, whilst the cost is substantially less, the waiting lists are large in some jurisdictions and treatment options are usually restricted by policy. As extractions tend to cost a few hundred dollars in the private sector and tens of dollars in the public sector, it is no surprise that many disadvantaged patients (including Indigenous Australians) opt for extraction, rather than other treatments. Most public dental providers in Australia do not offer root canals or crowns. Whilst extraction may provide quick relief of pain, there are long-term consequences that may need to be addressed later on. For instance, masticatory efficiency diminishes as teeth are lost. If a patient has many extractions they may require dentures. In the private sector dentures may cost upwards of a thousand dollars. In the public sector they cost hundreds of dollars, but there may be a further waiting list. For instance, in 2010, South Australia had approximately a two-year waiting list for treatment in the public dental sector. The waiting list for dentures, however, was about four years.

Caries is a major health concern and if not prevented may have painful and difficult consequences. Regardless of the extent of the disease and the required treatment modality, all of the options will have life-long consequences and require maintenance/treatment even if a tooth is lost. As such, increased policy and interventions aimed at the prevention of dental caries would be cost-beneficial.

Caries experience is measured by the Decayed Missing and Filled Teeth (DMFT) index for permanent (adult) teeth or by the dmft index for deciduous (juvenile) teeth. Both indices measure how many teeth (T/t) are decayed (D/d), missing due to caries (M/s) or filled due to caries (F/f). Neither index differentiates between a tooth with minor problems and one with major problems, nor do they provide a direct indication of the discomfort or dysfunction experienced.

To get a more accurate picture of decay, another index, the Decayed Missing and Filled Surfaces (DMFS) is used. By measuring the number of decayed/missing/filled surfaces on each tooth, rather than the tooth as a whole, the DMFS provides more detail about an individual's caries experience. It is also important to note that the DMFT/dmft and DMFS/dmfs indices are cumulative: once a tooth has experienced caries it is permanently recorded by the index. As a result, these indices provide information about caries experience over a lifetime and cannot account for changes in risk factors or active disease levels.

It should also be noted that these indices do not measure the effect of caries experience on quality of life, which can be significant. It is important to understand this relationship, and so several instruments have been developed to measure the effect oral health has on quality of life. The Oral Health Impact Profile (OHIP) is one such index (Slade & Spencer, 1994). The shortened version, OHIP-14, contains fourteen questions that address the effect of oral health on a subject's life, for instance, recent pain levels or disruptions to sleep.

problem has improved or healed itself, but infection of the dental pulp may continue to spread through the apex of the pulp canal/s into the supporting structures, causing periapical periodontitis (Abbott & Yu, 2007). This may result in severe pain and often systemic effects (e.g. fever). Patients with periapical periodontitis require root canal treatment or extraction. If the tooth is to be restored, the remaining decay usually requires substantial extra coronal restoration (i.e. crowns). Both the root canal therapy and the crown are expensive, and this type of treatment from a private practitioner may cost more than one thousand Australian dollars. If specialists are performing the treatment it will likely be

Such costs present an insurmountable barrier to many patients, particularly the socially and financially disadvantaged. If the patient is treated in the public sector, whilst the cost is substantially less, the waiting lists are large in some jurisdictions and treatment options are usually restricted by policy. As extractions tend to cost a few hundred dollars in the private sector and tens of dollars in the public sector, it is no surprise that many disadvantaged patients (including Indigenous Australians) opt for extraction, rather than other treatments. Most public dental providers in Australia do not offer root canals or crowns. Whilst extraction may provide quick relief of pain, there are long-term consequences that may need to be addressed later on. For instance, masticatory efficiency diminishes as teeth are lost. If a patient has many extractions they may require dentures. In the private sector dentures may cost upwards of a thousand dollars. In the public sector they cost hundreds of dollars, but there may be a further waiting list. For instance, in 2010, South Australia had approximately a two-year waiting list for treatment in the public dental sector. The waiting list for

Caries is a major health concern and if not prevented may have painful and difficult consequences. Regardless of the extent of the disease and the required treatment modality, all of the options will have life-long consequences and require maintenance/treatment even if a tooth is lost. As such, increased policy and interventions aimed at the prevention of

Caries experience is measured by the Decayed Missing and Filled Teeth (DMFT) index for permanent (adult) teeth or by the dmft index for deciduous (juvenile) teeth. Both indices measure how many teeth (T/t) are decayed (D/d), missing due to caries (M/s) or filled due to caries (F/f). Neither index differentiates between a tooth with minor problems and one with major problems, nor do they provide a direct indication of the discomfort or

To get a more accurate picture of decay, another index, the Decayed Missing and Filled Surfaces (DMFS) is used. By measuring the number of decayed/missing/filled surfaces on each tooth, rather than the tooth as a whole, the DMFS provides more detail about an individual's caries experience. It is also important to note that the DMFT/dmft and DMFS/dmfs indices are cumulative: once a tooth has experienced caries it is permanently recorded by the index. As a result, these indices provide information about caries experience

It should also be noted that these indices do not measure the effect of caries experience on quality of life, which can be significant. It is important to understand this relationship, and so several instruments have been developed to measure the effect oral health has on quality of life. The Oral Health Impact Profile (OHIP) is one such index (Slade & Spencer, 1994). The shortened version, OHIP-14, contains fourteen questions that address the effect of oral

over a lifetime and cannot account for changes in risk factors or active disease levels.

health on a subject's life, for instance, recent pain levels or disruptions to sleep.

more.

dentures, however, was about four years.

dental caries would be cost-beneficial.

dysfunction experienced.

#### **4.1 Caries among Indigenous children**

Indigenous children experience more caries that non-Indigenous children in their deciduous teeth (Jamieson et al., 2007). According to the *Child Dental Health Survey* conducted in 1999, the mean number of decayed, missing, and filled deciduous teeth (dmft) in Indigenous children aged 4–10 years who attended a school dental service clinic was significantly higher than for their non-Indigenous counterparts in NSW, SA and the NT (Armfield et al., 2003). The highest dmft scores were for Indigenous six-year-olds, who experienced 2.4 times the dmft of non-Indigenous children of that age.

Four-year-old Indigenous children had more than three times the dental disease experience of their non-Indigenous counterparts. The highest numbers of missing teeth occurred in five-year-old Indigenous children, with a level more than five times that of non-Indigenous five-year-olds. The highest number of filled teeth occurred in eight-year-old Indigenous children. Taken together, the dmft scores indicated much poorer oral health in the deciduous dentition of Indigenous children aged 4-10 years than of their non-Indigenous counterparts, with the largest differences in the younger age groups.

Poorer oral health for Indigenous children continues among those with permanent teeth: the DMFT2 was 1.5 times greater for Indigenous children aged 6-15 years than for their non-Indigenous counterparts, with higher DMFTs for each increasing age group. Indigenous children had higher numbers of permanent teeth with untreated decay, with those aged 15 years having almost three times the average number of their non-Indigenous counterparts. Numbers of filled teeth were similarly higher for Indigenous children, with six- year-old Indigenous children experiencing twice the number of filled teeth than non-Indigenous sixyear-olds.


Note: 1 Data are for 12-month periods: NSW from 2000; SA from 2003; and the NT from 2002 2 Where children had more than one examination, information from the first examination has been used

Table 1. Proportions (%) of children aged 6-17 years with DMFT>0, by Indigenous status and age, New South Wales (NSW), South Australia (SA) and the Northern Territory (NT), 2000-2003

Source: Jamieson, Armfield & Roberts-Thomson, 2007

2 The numbers of missing permanent teeth of children aged 6-15 years were negligible

Indigenous Australians and Oral Health 327

Age group Indigenous Non-Indigenous Rate ratio Proportion (%) Rate Proportion (%) Rate <5 years 51% 907 34% 657 1.4 5-9 years 39% 667 39% 721 0.9 10-14 years 10% 181 27% 501 0.4 Table 2. Proportions and rates of children receiving hospital dental care, by Indigenous status and age group, and Indigenous: non-Indigenous rate ratios, Queensland, Western

The overall rate of hospitalised dental extractions was slightly higher for Indigenous children than for non-Indigenous children, with the rate for Indigenous children less than 5 years of age more than twice that of their non-Indigenous counterparts (Jamieson et al., 2007). Tooth restoration rates were 1.3 times higher for Indigenous children aged less than 5 years than for their non-Indigenous counterparts, but Indigenous children of all ages were

Increased referral rates for hospitalisation might also be indicative of a lack of cultural awareness amongst dentists treating Indigenous Australians. The experience at Pika Wiya Health Service Inc. in Port Augusta has shown that increased cultural sensitivity has resulted in improved oral health outcomes (Parker et al., 2005). The Western Australia Review has also described oral health services for Indigenous Australians in WA. In light of a decreasing labour market, the Centre for Rural and Remote Oral Health (CRROH) has described sustainable models for servicing rural and remote Indigenous populations that include culturally-sensitive education programs and the training of Aboriginal Health Care Workers (Kruger at al., 2010; Pacza et al., 2001; Bazen et al., 2007). CRROH has also been involved in pre-graduate placements for dental students in the region (Bazen et al., 2007).

Caries is much more common among Indigenous adults than among non-Indigenous adults (Slade et al., 2007). According to the NSAOH, Indigenous adults were 2.3 times more likely to have untreated caries than the non-Indigenous adult population, and 57% of Indigenous adults had one or more teeth with untreated decay compared with 25% of non-Indigenous

The severity of decay suffered by Indigenous adults is also notably higher than that experienced by non-Indigenous adults (Slade et al., 2007). According to the NSAOH, Indigenous people 15 years and older had more than three times the number of decayed tooth surfaces than their non-Indigenous counterparts. The greatest difference was in the 35-54 years age group, with Indigenous people experiencing more than five times the

Almost four-fifths (78%) of Indigenous people aged 17-20 years included in the ABC Study were found to have caries, a level 1.2 times that documented for non-Indigenous people of

Data from a large Western Australian retrospective study paints a less favourable picture of the oral health of Indigenous Australians. It calculated an average DMFT score of 8.5, four

times higher than the NSAOH DMFT for the general population (Smith et al., 2007).

Australia, South Australia and the Northern Territory, 2002-03

2 Rate ratio is the Indigenous rate divided by the non-Indigenous rate

less likely than other children to have pulpal and 'other' treatments.

decayed tooth surfaces than their non-Indigenous counterparts.

that age group who participated in the NSAOH (Jamieson et al., 2010a).

Source: Jamieson, Armfield & Roberts-Thomson, 2007

Note: 1 Rates are per 100,000

**4.2 Caries among Indigenous adults** 

adults (Slade et al., 2007).

Where children live affects their experience of caries, with caries more common in rural and remote settings than in metropolitan centres (Jamieson et al., 2007a). According to the *Study of Aboriginal and Torres Strait Islander child oral health in remote communities*, Indigenous children living in rural areas had higher dmft and DMFT scores than Indigenous children in metropolitan areas, and non-Indigenous children in both rural and metropolitan areas had similar oral health, with levels of decayed, filled and missing teeth, deciduous and permanent, lower than among Indigenous children. Cariogenic food products are easily available in metropolitan, rural, and remote communities and, as such, consumption patterns can be considered fairly constant.

Fluoridation of water supplies in metropolitan and many rural areas is fairly consistent, however many remote communities do not have access to artificially fluoridated water, although some naturally occurring fluoride may exist. It is likely that differing levels of water fluoridation are implicated in caries levels. Although water fluoridation has been shown to be an effective method for reducing the prevalence of dental caries, patterns of consumption and distribution of fluoridated water vary across Australia. Fluoridation alone cannot totally negate the effects of poor oral hygiene and highly cariogenic diets. Whilst the increase in caries among Indigenous children in remote communities may be associated with decreased water fluoridation, in light of the widespread availability of cariogenic food, it is likely that reduced access to oral care and oral hygiene education may be important factors in the caries rates of remote Indigenous children. Appropriate oral care includes the use of fluoridated toothpaste twice a day. Fluoridated toothpastes are an important part of preventing decay, however in areas without optimally fluoridated water supplies, the use of fluoridated toothpaste becomes more important. The *SDS* provides annual community visits, but many Indigenous children either are not enrolled in schools or are not present on the day of the visit, and miss the professional care benefits offered by this mainstream service.

Rates for hospital dental care were similar for Indigenous and non-Indigenous children living in metropolitan and rural areas, with rates for children living in rural areas 1.3 times higher than those for children living in metropolitan areas (Jamieson et al., 2007a). The higher rates in rural areas reflect the limited oral health services in these locations. The high rate of extractions in rural areas suggests that either more children in rural locations had unsalvageable teeth or that the delay for another appointment would be unreasonable if restorative treatment was unsuccessful.

The age pattern of hospitalisation for dental care was quite different for Indigenous and non-Indigenous children: more than one-half (51%) of Indigenous children were less than five years of age compared with around one-third (34%) of non-Indigenous children (Jamieson et al., 2007a). Only one-tenth of Indigenous children hospitalised for dental care were aged 10-14 years, compared with more than one-quarter (27%) of non-Indigenous children. Hospitalisation for younger children is usually sought when gross caries results in a need for several or many extractions. In these cases it is done under general anaesthesia in one appointment so as to reduce trauma for the child.

The more uniform distribution of the rates and proportions, as well as the age pattern of hospitalisation for dental care suggests that young Indigenous children had more advanced tooth decay in their deciduous teeth, or had a higher number of deciduous teeth that were affected and required extraction, than did young non-Indigenous children (Jamieson et al., 2007a).

Where children live affects their experience of caries, with caries more common in rural and remote settings than in metropolitan centres (Jamieson et al., 2007a). According to the *Study of Aboriginal and Torres Strait Islander child oral health in remote communities*, Indigenous children living in rural areas had higher dmft and DMFT scores than Indigenous children in metropolitan areas, and non-Indigenous children in both rural and metropolitan areas had similar oral health, with levels of decayed, filled and missing teeth, deciduous and permanent, lower than among Indigenous children. Cariogenic food products are easily available in metropolitan, rural, and remote communities and, as such, consumption

Fluoridation of water supplies in metropolitan and many rural areas is fairly consistent, however many remote communities do not have access to artificially fluoridated water, although some naturally occurring fluoride may exist. It is likely that differing levels of water fluoridation are implicated in caries levels. Although water fluoridation has been shown to be an effective method for reducing the prevalence of dental caries, patterns of consumption and distribution of fluoridated water vary across Australia. Fluoridation alone cannot totally negate the effects of poor oral hygiene and highly cariogenic diets. Whilst the increase in caries among Indigenous children in remote communities may be associated with decreased water fluoridation, in light of the widespread availability of cariogenic food, it is likely that reduced access to oral care and oral hygiene education may be important factors in the caries rates of remote Indigenous children. Appropriate oral care includes the use of fluoridated toothpaste twice a day. Fluoridated toothpastes are an important part of preventing decay, however in areas without optimally fluoridated water supplies, the use of fluoridated toothpaste becomes more important. The *SDS* provides annual community visits, but many Indigenous children either are not enrolled in schools or are not present on the day of the visit, and miss the professional care benefits offered by this mainstream

Rates for hospital dental care were similar for Indigenous and non-Indigenous children living in metropolitan and rural areas, with rates for children living in rural areas 1.3 times higher than those for children living in metropolitan areas (Jamieson et al., 2007a). The higher rates in rural areas reflect the limited oral health services in these locations. The high rate of extractions in rural areas suggests that either more children in rural locations had unsalvageable teeth or that the delay for another appointment would be unreasonable if

The age pattern of hospitalisation for dental care was quite different for Indigenous and non-Indigenous children: more than one-half (51%) of Indigenous children were less than five years of age compared with around one-third (34%) of non-Indigenous children (Jamieson et al., 2007a). Only one-tenth of Indigenous children hospitalised for dental care were aged 10-14 years, compared with more than one-quarter (27%) of non-Indigenous children. Hospitalisation for younger children is usually sought when gross caries results in a need for several or many extractions. In these cases it is done under general anaesthesia in

The more uniform distribution of the rates and proportions, as well as the age pattern of hospitalisation for dental care suggests that young Indigenous children had more advanced tooth decay in their deciduous teeth, or had a higher number of deciduous teeth that were affected and required extraction, than did young non-Indigenous children (Jamieson et al.,

patterns can be considered fairly constant.

restorative treatment was unsuccessful.

one appointment so as to reduce trauma for the child.

service.

2007a).


Table 2. Proportions and rates of children receiving hospital dental care, by Indigenous status and age group, and Indigenous: non-Indigenous rate ratios, Queensland, Western Australia, South Australia and the Northern Territory, 2002-03 Source: Jamieson, Armfield & Roberts-Thomson, 2007

#### Note: 1 Rates are per 100,000

2 Rate ratio is the Indigenous rate divided by the non-Indigenous rate

The overall rate of hospitalised dental extractions was slightly higher for Indigenous children than for non-Indigenous children, with the rate for Indigenous children less than 5 years of age more than twice that of their non-Indigenous counterparts (Jamieson et al., 2007). Tooth restoration rates were 1.3 times higher for Indigenous children aged less than 5 years than for their non-Indigenous counterparts, but Indigenous children of all ages were less likely than other children to have pulpal and 'other' treatments.

Increased referral rates for hospitalisation might also be indicative of a lack of cultural awareness amongst dentists treating Indigenous Australians. The experience at Pika Wiya Health Service Inc. in Port Augusta has shown that increased cultural sensitivity has resulted in improved oral health outcomes (Parker et al., 2005). The Western Australia Review has also described oral health services for Indigenous Australians in WA. In light of a decreasing labour market, the Centre for Rural and Remote Oral Health (CRROH) has described sustainable models for servicing rural and remote Indigenous populations that include culturally-sensitive education programs and the training of Aboriginal Health Care Workers (Kruger at al., 2010; Pacza et al., 2001; Bazen et al., 2007). CRROH has also been involved in pre-graduate placements for dental students in the region (Bazen et al., 2007).

#### **4.2 Caries among Indigenous adults**

Caries is much more common among Indigenous adults than among non-Indigenous adults (Slade et al., 2007). According to the NSAOH, Indigenous adults were 2.3 times more likely to have untreated caries than the non-Indigenous adult population, and 57% of Indigenous adults had one or more teeth with untreated decay compared with 25% of non-Indigenous adults (Slade et al., 2007).

The severity of decay suffered by Indigenous adults is also notably higher than that experienced by non-Indigenous adults (Slade et al., 2007). According to the NSAOH, Indigenous people 15 years and older had more than three times the number of decayed tooth surfaces than their non-Indigenous counterparts. The greatest difference was in the 35-54 years age group, with Indigenous people experiencing more than five times the decayed tooth surfaces than their non-Indigenous counterparts.

Almost four-fifths (78%) of Indigenous people aged 17-20 years included in the ABC Study were found to have caries, a level 1.2 times that documented for non-Indigenous people of that age group who participated in the NSAOH (Jamieson et al., 2010a).

Data from a large Western Australian retrospective study paints a less favourable picture of the oral health of Indigenous Australians. It calculated an average DMFT score of 8.5, four times higher than the NSAOH DMFT for the general population (Smith et al., 2007).


Indigenous Australians and Oral Health 329

A comparison of the mean number of decayed teeth and surfaces (severity) reveals the same trends. Indigenous people aged 17-20 years experienced 1.7 times the mean number of decayed, missing, or filled teeth than their non-Indigenous counterparts (Jamieson et al., 2010a). When broken down into its components, this group experienced 8.2 times the prevalence of decayed teeth. When using the DMFS compared to DMFT, the mean number of decayed, missing, or filled teeth compared to surfaces increased from 1.7 to 2.6, and the

Caries can largely be prevented by maintaining a healthy diet (Harford et al., 2003). Since the arrival of Europeans in Australia in 1788, there has been a rapid change in diet for many Indigenous people from a fibre-rich, high-protein, low-saturated-fat, traditional diet to a diet high in refined carbohydrates and saturated fats (Australian Bureau of Statistics, 2008; Jamieson et al., 2006). This new diet includes a lot of processed and sugary foods and little fresh produce. This is especially true for people living in remote areas where food can be considerably more expensive than in urban areas (Queensland Health Treasury, 2006). Fresh produce may often be in poor condition after being transported long distances. Many Indigenous people, including children, consume a high level of sugary, cariogenic foods, such as carbonated drinks and confectionary (Jamieson et al., 2006). This non-traditional diet

The fluoridation of public water supplies is an effective way to prevent caries (Ehsani & Bailie, 2007). It is considered to be both the most cost-effective and socially equitable way of preventing dental decay and could significantly benefit communities that are socioeconomically disadvantaged, such as remote Indigenous communities. National reports have documented that 20 percent of Australians, most of which live in rural areas, currently do not have access to fluoridated water (Australian Health Ministers' Advisory Council, 2001). These reports have recommended that water fluoridation should be extended to small rural communities. *Healthy mouths healthy lives: Australia's national oral health plan 2004-2013* suggests that water fluoridation should be made available to communities with populations less than 1,000 people (National Advisory Committee on Oral Health, 2004), and there is evidence to suggest that fluoridation may be cost effective in larger remote Indigenous communities (Ehsani & Bailie, 2007). Until fluoridation becomes available to all Indigenous people, they will continue to be at increased risk of dental decay. It should be noted that fluoridation of Brisbane's water supply has begun, and that by the end of 2012, 95% of the population will have access to fluoridated water. With the inclusion of Queensland in community water fluoridation statistics, the percentage of Australians lacking access to

Good oral hygiene is fundamental in preventing caries. Self-care includes frequent toothbrushing with fluoridated toothpaste and requires an understanding of the value of good oral care, as well as resources available to purchase toothbrushes and toothpaste (Jamieson et al., 2006). There is evidence that oral care practices were not necessary with a traditional

mean number of decayed teeth compared to surfaces increased from 8.2 to 10.9.

**4.3 Protective and risk factors for caries** 

substantially increases the risk of caries.

fluoridated water will continue to decrease (AIHW, 2002).

**Water fluoridation** 

**Oral hygiene** 

**Diet** 


Note: 1 Indigenous data from *ABC* study (2006-2007) and non-Indigenous data from the *NSAOH* (2004- 2006)

 2 Prevalence is percentage of people with the condition; confidence interval provides an indication of the reliability of the estimated prevalence

3 Ratio is the Indigenous prevalence divided by the non-Indigenous prevalence

Table 3. Prevalence of caries-related conditions, by Indigenous status, and Indigenous-non-Indigenous ratios, Australia, 2004-2007

Source: Jamieson, Sayers & Roberts-Thomson, 2010a


Note: 1 Indigenous data from *ABC* study (2006-2007) and non-Indigenous data from the *NSAOH* (2004- 2006)

 2 Prevalence is percentage of people with the condition; confidence interval provides an indication of the reliability of the estimated prevalence

3 Ratio is the Indigenous prevalence divided by the non-Indigenous prevalence

4 See text for details of DMFT

Table 4. Mean caries scores, by Indigenous status, and Indigenous-non-Indigenous ratios, Australia, 2004-2007

Source: Jamieson, Sayers & Roberts-Thomson, 2010a

Indigenous people aged 17-20 years had 3.2 times the prevalence of decayed teeth and 2.5 times the prevalence of missing teeth than did their non-Indigenous counterparts. On the other hand, the level of fillings was lower among Indigenous people than among non-Indigenous people: the ratio for filled teeth was 0.5 and for filled surfaces was 0.3. Together with their higher decay rates, these ratios suggest that service utilisation was lower – and levels of untreated caries substantially higher – among this Indigenous population than among same-aged non-Indigenous people who participated in the *NSAOH*.

A comparison of the mean number of decayed teeth and surfaces (severity) reveals the same trends. Indigenous people aged 17-20 years experienced 1.7 times the mean number of decayed, missing, or filled teeth than their non-Indigenous counterparts (Jamieson et al., 2010a). When broken down into its components, this group experienced 8.2 times the prevalence of decayed teeth. When using the DMFS compared to DMFT, the mean number of decayed, missing, or filled teeth compared to surfaces increased from 1.7 to 2.6, and the mean number of decayed teeth compared to surfaces increased from 8.2 to 10.9.

#### **4.3 Protective and risk factors for caries**

#### **Diet**

328 Oral Health Care – Prosthodontics, Periodontology, Biology, Research and Systemic Conditions

Caries 78 74–82 63 51–73 1.2

Note: 1 Indigenous data from *ABC* study (2006-2007) and non-Indigenous data from the *NSAOH* (2004-

2 Prevalence is percentage of people with the condition; confidence interval provides an

Table 3. Prevalence of caries-related conditions, by Indigenous status, and Indigenous-non-

Indigenous Non-Indigenous Ratio

DMFT 4.8 4.3–5.3 2.8 1.8–3.8 1.7

DMFS 8.3 7.2–9.4 3.2 2.1–4.3 2.6

Note: 1 Indigenous data from *ABC* study (2006-2007) and non-Indigenous data from the *NSAOH* (2004-

2 Prevalence is percentage of people with the condition; confidence interval provides an

Table 4. Mean caries scores, by Indigenous status, and Indigenous-non-Indigenous ratios,

Indigenous people aged 17-20 years had 3.2 times the prevalence of decayed teeth and 2.5 times the prevalence of missing teeth than did their non-Indigenous counterparts. On the other hand, the level of fillings was lower among Indigenous people than among non-Indigenous people: the ratio for filled teeth was 0.5 and for filled surfaces was 0.3. Together with their higher decay rates, these ratios suggest that service utilisation was lower – and levels of untreated caries substantially higher – among this Indigenous population than

Prevalence Confidence

indication of the reliability of the estimated prevalence

indication of the reliability of the estimated prevalence

Source: Jamieson, Sayers & Roberts-Thomson, 2010a

3 Ratio is the Indigenous prevalence divided by the non-Indigenous prevalence

among same-aged non-Indigenous people who participated in the *NSAOH*.

3 Ratio is the Indigenous prevalence divided by the non-Indigenous prevalence

interval (95%)

Decayed teeth (DT>0)

Missing teeth (MT>0)

Filled teeth (FT>0)

Decayed teeth (DT)

Decayed surfaces (DS)

2006)

Australia, 2004-2007

4 See text for details of DMFT

Filled surfaces (FS)

2006)

Indigenous ratios, Australia, 2004-2007

Prevalence Confidence

Source: Jamieson, Sayers & Roberts-Thomson, 2010a

Interval (95%)

Indigenous Non-Indigenous Ratio

74 70–79 23 15–34 3.2

52 47–57 21 12–34 2.5

23 19–27 49 38–61 0.5

4.1 3.7–4.5 0.5 0.3–.07 8.2

7.6 6.5–8.7 0.7 0.3–1.0 10.9

0.7 0.5–0.9 2.6 15. –3.7 0.3

Prevalence Confidence

Prevalence Confidence

interval (95%)

Interval (95%)

Caries can largely be prevented by maintaining a healthy diet (Harford et al., 2003). Since the arrival of Europeans in Australia in 1788, there has been a rapid change in diet for many Indigenous people from a fibre-rich, high-protein, low-saturated-fat, traditional diet to a diet high in refined carbohydrates and saturated fats (Australian Bureau of Statistics, 2008; Jamieson et al., 2006). This new diet includes a lot of processed and sugary foods and little fresh produce. This is especially true for people living in remote areas where food can be considerably more expensive than in urban areas (Queensland Health Treasury, 2006). Fresh produce may often be in poor condition after being transported long distances. Many Indigenous people, including children, consume a high level of sugary, cariogenic foods, such as carbonated drinks and confectionary (Jamieson et al., 2006). This non-traditional diet substantially increases the risk of caries.

#### **Water fluoridation**

The fluoridation of public water supplies is an effective way to prevent caries (Ehsani & Bailie, 2007). It is considered to be both the most cost-effective and socially equitable way of preventing dental decay and could significantly benefit communities that are socioeconomically disadvantaged, such as remote Indigenous communities. National reports have documented that 20 percent of Australians, most of which live in rural areas, currently do not have access to fluoridated water (Australian Health Ministers' Advisory Council, 2001). These reports have recommended that water fluoridation should be extended to small rural communities. *Healthy mouths healthy lives: Australia's national oral health plan 2004-2013* suggests that water fluoridation should be made available to communities with populations less than 1,000 people (National Advisory Committee on Oral Health, 2004), and there is evidence to suggest that fluoridation may be cost effective in larger remote Indigenous communities (Ehsani & Bailie, 2007). Until fluoridation becomes available to all Indigenous people, they will continue to be at increased risk of dental decay. It should be noted that fluoridation of Brisbane's water supply has begun, and that by the end of 2012, 95% of the population will have access to fluoridated water. With the inclusion of Queensland in community water fluoridation statistics, the percentage of Australians lacking access to fluoridated water will continue to decrease (AIHW, 2002).

#### **Oral hygiene**

Good oral hygiene is fundamental in preventing caries. Self-care includes frequent toothbrushing with fluoridated toothpaste and requires an understanding of the value of good oral care, as well as resources available to purchase toothbrushes and toothpaste (Jamieson et al., 2006). There is evidence that oral care practices were not necessary with a traditional

Indigenous Australians and Oral Health 331

yet supported directly by the literature), they are likely to be at an increased risk of

Indices exist to measure periodontal disease, however definitions about what to include in an index are contentious, and the use of different definitions has resulted in a wide range of

As with caries, these indices do not measure the effect of periodontal disease on quality of life. Once again, measures like OHIP are useful to gauge the effect of disease on quality of

Children rarely develop severe periodontal disease, but gingivitis is relatively common on the gums of Indigenous children around both deciduous and permanent teeth, especially for older children. Although gingivitis in itself does not cause destruction of periodontal structures, it is inflammation nonetheless and should be prevented. Periodontitis is an exacerbation of gingivitis, however the progression from gingivitis to periodontitis is not certain and only occurs in individuals at risk. Furthermore, the prevention of gingivitis, appropriate oral hygiene, decreases the likelihood of developing dental caries. According to the *Study of Aboriginal and Torres Strait Islander child oral health in remote communities*, the prevalence of gingival bleeding, a common symptom of gingivitis, was higher for Indigenous children aged 6-15 years in South Australia than for their non-Indigenous counterparts (Jamieson et al., 2007a). The level of gingival bleeding among Indigenous fiveyear-olds was almost four times higher than that among non-Indigenous children of the same age. Among 12 year-olds, almost one-half (48%) of Indigenous children had gingival bleeding compared with 23% of non-Indigenous children. The same study found that gingival bleeding was common among Indigenous children in New South Wales. Indigenous children aged 12-14 years had a markedly higher prevalence of bleeding than did their non-Indigenous counterparts, but there was little difference in prevalence between Indigenous and non-Indigenous children 4-12 years. Three-in-five Indigenous children living in remote communities showed some evidence of gingivitis and approximately onein-five children were at moderate risk of developing gingivitis. More than two-fifths (42%) of Indigenous children aged 15-16 years were at moderate risk of developing gingivitis and

Indigenous adults are more likely to suffer from periodontal disease than their non-Indigenous counterparts (Slade et al., 2007). According to the *NSAOH*, almost 27% of Indigenous people 15-74 years had gingivitis; they experienced approximately 1.3 times the prevalence of moderate and severe periodontitis than did their non-Indigenous counterparts. Indigenous people had a slightly higher prevalence of deep (4+mm)

An *ABC*-*NSAOH* comparison of Indigenous and non-Indigenous people aged 17-20 years demonstrates a more notable difference in periodontal diseases between the two groups: Indigenous people had 1.7 times the prevalence of calculus deposits (a risk indicator of periodontal diseases), 1.2 times the prevalence of gingivitis, 9.5 times the prevalence of moderate or severe periodontal disease, and 11.8 times the prevalence of deep periodontal

periodontal pockets and clinical attachment loss than did non-Indigenous people.

pockets than did their non-Indigenous counterparts (Jamieson et al., 2010a).

developing periodontal disease.

25% were at high risk.

life.

prevalences within the same populations.

**5.1 Periodontal disease among Indigenous children** 

**5.2 Periodontal disease among Indigenous adults** 

Indigenous diet, and were not part of some Indigenous cultures (Harford et al., 2003). There are also strong ties between socioeconomic status and oral hygiene with those who are more disadvantaged being less likely to practice good oral hygiene (Harford et al., 2003; Slade et al., 2007). Thus, for economic and socio-cultural reasons, Indigenous people are at increased risk of caries.

#### **Professional dental care**

Many professional dental services are not affordable for, or available to, Indigenous people (Harford et al., 2003). Few dental professionals work in rural or remote locations, and studies have found that private dental care is too costly for many Indigenous people. Similarly, many dental services are not culturally sensitive, thus creating access barriers for Indigenous people. Without professional dental care, Indigenous people are at increased risk of untreated dental decay.

#### **Hypoplasia**

Another important factor for the prevention of caries is having strong teeth from birth (Seow, 1997). Tooth enamel provides a hard, protective surface on the tooth. If the enamel becomes weak, a condition known as enamel hypoplasia may result in increased incidence of caries. Enamel hypoplasia can result from a congenital condition, premature birth, infections during childhood, malnutrition (Pascoe & Seow, 1994) and low birthweight (Lai et al., 1997), many of which occur at higher rates among Indigenous people than in the total population (Australian Health Ministers' Advisory Council, 2008).

#### **5. Periodontal disease**

Periodontal diseases are associated with bacterial infection of the periodontal (gum) tissues causing inflammation. Unlike caries, they are specifically attributed to poor oral hygiene as opposed to a poor diet, together with underlying host susceptibility. Like caries, periodontal disease is preventable and treatable. Periodontal diseases range in severity from gingivitis (a mild and completely reversible form) to periodontitis (a severe destruction of the tissues that support the teeth). Gingivitis is characterised by inflammation and bleeding gums and can be completely cured. Symptoms of periodontitis include the loss of toothsupporting bone and the formation of periodontal pockets (spaces between the gum and tooth), and clinical attachment loss, where bacteria have caused the deterioration of bone and ligament. Periodontitis can result in tooth mobility, partial and total edentulism (loss of all teeth), and halitosis. Most forms of periodontitis do not cause pain, although some forms, namely Acute Necrotising Ulcerative Gingivitis and Acute Necrotising Ulcerative Periodontitis, do cause significant pain. Periodontitis can be localised (to a few teeth) or generalised (to larger areas of the mouth, or the whole mouth). It is predominantly chronic, and may begin in the early 20s age group. However, research suggests that it is typically a disease of ageing and usually occurs later in life (Pihlstrom et al., 2005). Acute forms exist, however these are rare and tend to occur in patients with complicating systemic factors. Acute forms also tend to be localised. Periodontitis risk factors include smoking, diabetes, stress, genetic and epigenetic inherited factors, hormonal imbalance, immunosuppression, maleness, mouth breathing, low socio economic status (SES), poor education, and poor nutrition. As Indigenous Australians are more likely to smoke, have diabetes, have poor nutrition, are typically lower on the SES ladder, and may be at an increased genetic risk (not

Indigenous diet, and were not part of some Indigenous cultures (Harford et al., 2003). There are also strong ties between socioeconomic status and oral hygiene with those who are more disadvantaged being less likely to practice good oral hygiene (Harford et al., 2003; Slade et al., 2007). Thus, for economic and socio-cultural reasons, Indigenous people are at increased

Many professional dental services are not affordable for, or available to, Indigenous people (Harford et al., 2003). Few dental professionals work in rural or remote locations, and studies have found that private dental care is too costly for many Indigenous people. Similarly, many dental services are not culturally sensitive, thus creating access barriers for Indigenous people. Without professional dental care, Indigenous people are at increased

Another important factor for the prevention of caries is having strong teeth from birth (Seow, 1997). Tooth enamel provides a hard, protective surface on the tooth. If the enamel becomes weak, a condition known as enamel hypoplasia may result in increased incidence of caries. Enamel hypoplasia can result from a congenital condition, premature birth, infections during childhood, malnutrition (Pascoe & Seow, 1994) and low birthweight (Lai et al., 1997), many of which occur at higher rates among Indigenous people than in the total

Periodontal diseases are associated with bacterial infection of the periodontal (gum) tissues causing inflammation. Unlike caries, they are specifically attributed to poor oral hygiene as opposed to a poor diet, together with underlying host susceptibility. Like caries, periodontal disease is preventable and treatable. Periodontal diseases range in severity from gingivitis (a mild and completely reversible form) to periodontitis (a severe destruction of the tissues that support the teeth). Gingivitis is characterised by inflammation and bleeding gums and can be completely cured. Symptoms of periodontitis include the loss of toothsupporting bone and the formation of periodontal pockets (spaces between the gum and tooth), and clinical attachment loss, where bacteria have caused the deterioration of bone and ligament. Periodontitis can result in tooth mobility, partial and total edentulism (loss of all teeth), and halitosis. Most forms of periodontitis do not cause pain, although some forms, namely Acute Necrotising Ulcerative Gingivitis and Acute Necrotising Ulcerative Periodontitis, do cause significant pain. Periodontitis can be localised (to a few teeth) or generalised (to larger areas of the mouth, or the whole mouth). It is predominantly chronic, and may begin in the early 20s age group. However, research suggests that it is typically a disease of ageing and usually occurs later in life (Pihlstrom et al., 2005). Acute forms exist, however these are rare and tend to occur in patients with complicating systemic factors. Acute forms also tend to be localised. Periodontitis risk factors include smoking, diabetes, stress, genetic and epigenetic inherited factors, hormonal imbalance, immunosuppression, maleness, mouth breathing, low socio economic status (SES), poor education, and poor nutrition. As Indigenous Australians are more likely to smoke, have diabetes, have poor nutrition, are typically lower on the SES ladder, and may be at an increased genetic risk (not

population (Australian Health Ministers' Advisory Council, 2008).

risk of caries.

**Hypoplasia** 

**Professional dental care** 

risk of untreated dental decay.

**5. Periodontal disease** 

yet supported directly by the literature), they are likely to be at an increased risk of developing periodontal disease.

Indices exist to measure periodontal disease, however definitions about what to include in an index are contentious, and the use of different definitions has resulted in a wide range of prevalences within the same populations.

As with caries, these indices do not measure the effect of periodontal disease on quality of life. Once again, measures like OHIP are useful to gauge the effect of disease on quality of life.

#### **5.1 Periodontal disease among Indigenous children**

Children rarely develop severe periodontal disease, but gingivitis is relatively common on the gums of Indigenous children around both deciduous and permanent teeth, especially for older children. Although gingivitis in itself does not cause destruction of periodontal structures, it is inflammation nonetheless and should be prevented. Periodontitis is an exacerbation of gingivitis, however the progression from gingivitis to periodontitis is not certain and only occurs in individuals at risk. Furthermore, the prevention of gingivitis, appropriate oral hygiene, decreases the likelihood of developing dental caries. According to the *Study of Aboriginal and Torres Strait Islander child oral health in remote communities*, the prevalence of gingival bleeding, a common symptom of gingivitis, was higher for Indigenous children aged 6-15 years in South Australia than for their non-Indigenous counterparts (Jamieson et al., 2007a). The level of gingival bleeding among Indigenous fiveyear-olds was almost four times higher than that among non-Indigenous children of the same age. Among 12 year-olds, almost one-half (48%) of Indigenous children had gingival bleeding compared with 23% of non-Indigenous children. The same study found that gingival bleeding was common among Indigenous children in New South Wales. Indigenous children aged 12-14 years had a markedly higher prevalence of bleeding than did their non-Indigenous counterparts, but there was little difference in prevalence between Indigenous and non-Indigenous children 4-12 years. Three-in-five Indigenous children living in remote communities showed some evidence of gingivitis and approximately onein-five children were at moderate risk of developing gingivitis. More than two-fifths (42%) of Indigenous children aged 15-16 years were at moderate risk of developing gingivitis and 25% were at high risk.

#### **5.2 Periodontal disease among Indigenous adults**

Indigenous adults are more likely to suffer from periodontal disease than their non-Indigenous counterparts (Slade et al., 2007). According to the *NSAOH*, almost 27% of Indigenous people 15-74 years had gingivitis; they experienced approximately 1.3 times the prevalence of moderate and severe periodontitis than did their non-Indigenous counterparts. Indigenous people had a slightly higher prevalence of deep (4+mm) periodontal pockets and clinical attachment loss than did non-Indigenous people.

An *ABC*-*NSAOH* comparison of Indigenous and non-Indigenous people aged 17-20 years demonstrates a more notable difference in periodontal diseases between the two groups: Indigenous people had 1.7 times the prevalence of calculus deposits (a risk indicator of periodontal diseases), 1.2 times the prevalence of gingivitis, 9.5 times the prevalence of moderate or severe periodontal disease, and 11.8 times the prevalence of deep periodontal pockets than did their non-Indigenous counterparts (Jamieson et al., 2010a).

Indigenous Australians and Oral Health 333

Periodontal diseases are also attributed to poor oral hygiene, in which self-care plays an important role. According to the *Study of Aboriginal and Torres Strait Islander child oral health in remote communities*, less than one-fifth of Indigenous children living in remote communities in New South Wales, South Australia and the Northern Territory brushed their teeth at home (20%) or at school (18%), and less than 5% of those younger than five years of age brushed their teeth regularly (Jamieson et al., 2007a). A study in the Top End of the Northern Territory in 2003 found low levels of regular preventive oral health care among remote Indigenous children (Jamieson et al., 2006). The study noted that about 84% of the children in the study used a toothbrush, but only 20% used toothpaste on a daily basis. The use of toothpaste generally started relatively later in life, with the most common commencement age being four years. This may reflect commencement of pre-school and exposure to oral hygiene strategies organised by schools. Children learn their oral self-care habits from seeing what other people do on a daily basis; caregivers who regularly partake in oral self-care habits, such as brushing and/or flossing, are likely to instil such behaviours

Professional dental care is also important in periodontal health (Pihlstrom et al., 2005). According to the *NSAOH*, fewer Indigenous adults than non-Indigenous adults reported visiting a dentist within the last twelve months (51% compared with 60%) (Slade et al., 2007). Similarly, Indigenous people were more than 20% less likely than non-Indigenous

Indigenous people face a number of barriers, including cost, to regular and timely professional dental care (Slade et al., 2007), and the course of periodontitis can be substantially worse for patients without regular access to dental care. Unfortunately, periodontitis and limited dental care (professional and self-care) can establish a 'vicious cycle': the onset of disease makes cleaning more difficult, and, as cleaning becomes more difficult, more acute and deeper bacterial invasion of the tooth surface worsens the level of disease. This cycle eventually results in destruction of the tooth-supporting apparatus and

The main causes of tooth loss are extraction of diseased teeth due to dental caries, periodontal diseases, and trauma (Harford et al., 2003). Complete tooth loss, known as total edentulism, significantly affects oral functioning and quality of life. Tooth loss is overrepresented among Indigenous people and edentulism occurs at younger ages for

Injuries of the head and neck may affect dentition; fractures specifically of the maxilla and mandible are directly related to tooth loss and loss of function (Sclaroff et al., 2000). Fracture of the skull and facial bones, with associated tooth loss, is the third most prevalent head injury in Australia. Tooth loss due to head trauma can markedly reduce quality of life. After adjusting for differences in age, gender and residential location, the rate of hospitalised head

in the children in their household (Mattila et al., 2001).

people to visit a dentist annually (43% compared with 53%).

**Oral hygiene** 

**Professional dental care** 

tooth loss.

**6. Tooth loss** 

Indigenous Australians.

**6.1 Tooth loss due to injury** 

Indigenous people are affected by periodontal diseases at much younger ages than non-Indigenous people (Harford et al., 2003; Armfield et al., 2003; Gracey, 2000). According to the *NSAOH*, Indigenous people aged 15-34 years experienced almost twice the prevalence of moderate or severe periodontitis than their non-Indigenous counterparts (13.5% and 7.3% respectively) (Slade et al., 2007). Compared to non-Indigenous people aged 15-34 years, Indigenous people in the same age group had higher prevalences of deep periodontal pockets (18% compared with 13%), clinical attachment loss (24% compared with 17%), and tooth sites with deep periodontal pockets (1.3% compared with 0.6%).


Note: 1 Indigenous data from *ABC* study (2006-2007) and non-Indigenous data from the *NSAOH* (2004- 2006)

 2 Prevalence is percentage of people with the condition; confidence interval provides an indication of the reliability of the estimated prevalence

3 Ratio is the Indigenous prevalence divided by the non-Indigenous prevalence

Table 5. Prevalence of periodontal risk indicators and periodontal diseases, by Indigenous status, and Indigenous: non-Indigenous ratios, Australia, 2004-2007 Source: Jamieson, Sayers & Roberts-Thomson, 2010a

#### **5.3 Protective and risk factors for periodontal diseases**

#### **Smoking**

Smoking is a significant risk factor for the development, progression and severity of periodontal diseases (Do et al., 2008). According to the *2004-2005 National Aboriginal and Torres Strait Islander health survey*, one-half of the adult Indigenous population smoked daily or regularly, a level more than twice that of non-Indigenous adults (Australian Bureau of Statistics, 2006).

#### **Diabetes**

Diabetes, especially uncontrolled or poorly controlled diabetes, is associated with increased risk of oral infections (Harford et al., 2003). Diabetes/high sugar levels were reported by around 6% of Indigenous people who participated in the *2004-2005 National Aboriginal and Torres Strait Islander health survey* (Australian Bureau of Statistics, 2006). After adjusting for differences in the age structures of the two populations, diabetes/high sugar levels were around 3.4 times more common for Indigenous people than for non-Indigenous people. A 1998-2000 study of periodontal diseases among diabetic and non-diabetic residents of the Anangu Pitjantjatjara lands in South Australia found that Anangu people with diabetes were more than three times as likely as those without diabetes to have 4-5 mm periodontal pockets and almost 10 times as likely to have 6+mm pockets (Endean et al., 2004).

#### **Oral hygiene**

332 Oral Health Care – Prosthodontics, Periodontology, Biology, Research and Systemic Conditions

Indigenous people are affected by periodontal diseases at much younger ages than non-Indigenous people (Harford et al., 2003; Armfield et al., 2003; Gracey, 2000). According to the *NSAOH*, Indigenous people aged 15-34 years experienced almost twice the prevalence of moderate or severe periodontitis than their non-Indigenous counterparts (13.5% and 7.3% respectively) (Slade et al., 2007). Compared to non-Indigenous people aged 15-34 years, Indigenous people in the same age group had higher prevalences of deep periodontal pockets (18% compared with 13%), clinical attachment loss (24% compared with 17%), and

Indigenous Non-Indigenous Ratio

Prevalence Confidence

61 57–66 5.2 2.3–11.5 11.8

27 19–35 2.8 0.8–8.9 9.5

interval (95%)

interval (95%)

Calculus deposits 89 86–92 52 41–63 1.7 Gingivitis 89 86–93 74 65–82 1.2

Note: 1 Indigenous data from *ABC* study (2006-2007) and non-Indigenous data from the *NSAOH* (2004-

2 Prevalence is percentage of people with the condition; confidence interval provides an

Table 5. Prevalence of periodontal risk indicators and periodontal diseases, by Indigenous

Smoking is a significant risk factor for the development, progression and severity of periodontal diseases (Do et al., 2008). According to the *2004-2005 National Aboriginal and Torres Strait Islander health survey*, one-half of the adult Indigenous population smoked daily or regularly, a level more than twice that of non-Indigenous adults (Australian Bureau of

Diabetes, especially uncontrolled or poorly controlled diabetes, is associated with increased risk of oral infections (Harford et al., 2003). Diabetes/high sugar levels were reported by around 6% of Indigenous people who participated in the *2004-2005 National Aboriginal and Torres Strait Islander health survey* (Australian Bureau of Statistics, 2006). After adjusting for differences in the age structures of the two populations, diabetes/high sugar levels were around 3.4 times more common for Indigenous people than for non-Indigenous people. A 1998-2000 study of periodontal diseases among diabetic and non-diabetic residents of the Anangu Pitjantjatjara lands in South Australia found that Anangu people with diabetes were more than three times as likely as those without diabetes to have 4-5 mm periodontal

pockets and almost 10 times as likely to have 6+mm pockets (Endean et al., 2004).

tooth sites with deep periodontal pockets (1.3% compared with 0.6%).

indication of the reliability of the estimated prevalence

status, and Indigenous: non-Indigenous ratios, Australia, 2004-2007

Source: Jamieson, Sayers & Roberts-Thomson, 2010a

**5.3 Protective and risk factors for periodontal diseases** 

3 Ratio is the Indigenous prevalence divided by the non-Indigenous prevalence

Prevalence Confidence

Periodontal pockets 4mm or deeper

Moderate or severe periodontal disease

2006)

**Smoking** 

**Diabetes** 

Statistics, 2006).

Periodontal diseases are also attributed to poor oral hygiene, in which self-care plays an important role. According to the *Study of Aboriginal and Torres Strait Islander child oral health in remote communities*, less than one-fifth of Indigenous children living in remote communities in New South Wales, South Australia and the Northern Territory brushed their teeth at home (20%) or at school (18%), and less than 5% of those younger than five years of age brushed their teeth regularly (Jamieson et al., 2007a). A study in the Top End of the Northern Territory in 2003 found low levels of regular preventive oral health care among remote Indigenous children (Jamieson et al., 2006). The study noted that about 84% of the children in the study used a toothbrush, but only 20% used toothpaste on a daily basis. The use of toothpaste generally started relatively later in life, with the most common commencement age being four years. This may reflect commencement of pre-school and exposure to oral hygiene strategies organised by schools. Children learn their oral self-care habits from seeing what other people do on a daily basis; caregivers who regularly partake in oral self-care habits, such as brushing and/or flossing, are likely to instil such behaviours in the children in their household (Mattila et al., 2001).

#### **Professional dental care**

Professional dental care is also important in periodontal health (Pihlstrom et al., 2005). According to the *NSAOH*, fewer Indigenous adults than non-Indigenous adults reported visiting a dentist within the last twelve months (51% compared with 60%) (Slade et al., 2007). Similarly, Indigenous people were more than 20% less likely than non-Indigenous people to visit a dentist annually (43% compared with 53%).

Indigenous people face a number of barriers, including cost, to regular and timely professional dental care (Slade et al., 2007), and the course of periodontitis can be substantially worse for patients without regular access to dental care. Unfortunately, periodontitis and limited dental care (professional and self-care) can establish a 'vicious cycle': the onset of disease makes cleaning more difficult, and, as cleaning becomes more difficult, more acute and deeper bacterial invasion of the tooth surface worsens the level of disease. This cycle eventually results in destruction of the tooth-supporting apparatus and tooth loss.

#### **6. Tooth loss**

The main causes of tooth loss are extraction of diseased teeth due to dental caries, periodontal diseases, and trauma (Harford et al., 2003). Complete tooth loss, known as total edentulism, significantly affects oral functioning and quality of life. Tooth loss is overrepresented among Indigenous people and edentulism occurs at younger ages for Indigenous Australians.

#### **6.1 Tooth loss due to injury**

Injuries of the head and neck may affect dentition; fractures specifically of the maxilla and mandible are directly related to tooth loss and loss of function (Sclaroff et al., 2000). Fracture of the skull and facial bones, with associated tooth loss, is the third most prevalent head injury in Australia. Tooth loss due to head trauma can markedly reduce quality of life. After adjusting for differences in age, gender and residential location, the rate of hospitalised head

Indigenous Australians and Oral Health 335

appropriate service for Indigenous patients (Jamieson et al., 2008), efforts at the Oral Health Program at Pika Wiya Health Service in Port Augusta have demonstrated greatly increased acceptance of the service and improved attendance rates after the introduction of a

Australia is geographically one of the world's largest countries, with the vast majority of the relatively small population -89% – living along the coast and the vast interior being very sparsely populated. Considering around a quarter of Indigenous Australians live in remote parts of the country, the distance to the nearest dental clinic can be long, and even when transport is available the roads are often in poor condition (Australian Bureau of Statistics,

Again hinging on Australia's immense area, the transport of healthy foods to remote communities is a major issue and for this reason many Indigenous people can have very limited options in terms of their diet. The availability of many healthier food items (for example wholemeal breads, lean meat, reduced-fat milk, and fresh fruits and vegetables) tends to be erratic in the more rural and remote areas (Williams et al., 2011). Fresh foods in particular, when available, can cost up to 30 percent more than in urban parts of the country (Harrison et al., 2007). With limited range and very high prices, those living in rural and remote Australia are more likely to eat the more affordable foods available, often processed foods high in both sugar and carbohydrates. Such foods of course impact negatively on

The fluoridation of drinking water supplies has been lauded as 'the single most effective public health measure for reducing dental caries across the population, with its most pronounced effects among those who are disadvantaged and most at risk' (Acheson 1998, DHS 2000a) (Government of South Australia, 2004: 16). Fluoridation affords those members of the community lacking in financial resources to buy toothbrushes and fluoridated toothpaste access to fluoride in their water, and this can reduce caries by 20–40% (NHMRC 1991, Ahokas et al., 1999). However, rural and remote communities again tend to miss out here – in excess of 80% of remote-living Indigenous people lack access to fluoridated town-

Many Indigenous Australians live in sub-standard housing (Bailie, 2007), a condition strongly linked to higher levels of poor health and disease (ABS, AIHW, 2008). The factors that impact most on oral health include a lack of safe (let alone fluoridated) drinking water, poor sanitation, and overcrowding. A survey conducted in 2008 found 25% of Indigenous people over the age of 15 years were living in overcrowded housing (Australian Bureau of Statistics, 2009), and this has a direct effect on oral health (Jamieson et al 2010) in that the absence of a clean, safe place to store toothbrushes can discourage their use. Another important factor is the frequent movement between houses that many Indigenous Australians make, meaning they may not always carry oral health care products with them.

culturally-sensitive oral health care service (Parker et al., 2005).

2008). For people living in urban areas, transport can also be an issue.

**7.2 Geographical accessibility of oral health services** 

**7.3 Diet** 

general and oral health.

**7.4 Water fluoridation** 

**7.5 Living conditions** 

water supplies (Ehsani and Bailie, 2007).

injury due to assault was 21 times higher for Indigenous people living in Queensland, Western Australia, South Australia and the Northern Territory in the six year period 1 July 1999 to 30 June 2005 than for their non-Indigenous counterparts. The rate ratio was especially high among females: 69 for all ages and 93 for the 30–34 years age group. Whilst this statistic is not specific for tooth loss or dental trauma, it is likely that in light of such high rates of facial trauma increased tooth loss also follows.

#### **6.2 Edentulism**

Edentulism reflects both extensive dental disease and past surgical approaches to the treatment of oral diseases that relied largely on extractions (Slade et al., 2007). Edentulism leads to poorer oral functioning and often to notable discomfort. Individuals missing all of their teeth must either endure with no teeth, which greatly affects a person's ability to eat, or choose to wear full dentures, which are generally uncomfortable and can lead to complications if not properly cleaned and maintained.

Edentulism is strongly correlated to age; in Australia less than 2% of adults aged 35-54 years have complete tooth loss but this increases to 36% for people aged 75 years or older (Slade et al., 2007). The age distribution of edentulism for Indigenous people is noticeably different from that of the total population. The level of complete tooth loss is almost five times higher among Indigenous people aged 35-54 years than among their non-Indigenous counterparts (7.6% compared with 1.6%). There was also a notable difference for those aged 55-74 years; 21% of Indigenous people suffer from edentulism compared with 14% of non-Indigenous people.

#### **7. Barriers to good oral health among Indigenous people**

For many Indigenous Australians there are numerous factors that hinder the maintenance of good oral health. Most of these are linked to socioeconomic disadvantage. They include the cultural and geographical accessibility of oral health services, diet, water fluoridation, living conditions, oral hygiene, the cost of dental care, and lower rates of school attendance for children. Another important issue is the differing understandings of health, as outlined previously. When little of this is understood by mainstream health providers, it is not surprising that this can also constitute a significant barrier. For children, it has been suggested that under-utilisation of the School Dental Service in the Northern Territory may well be a result of low school attendance in some communities, despite the fact the Service provides care to communities regularly (Jamieson et al., 2006).

#### **7.1 Cultural accessibility of oral health services**

For the most part, oral health services tend to stipulate certain rules that are not necessarily compatible with Indigenous culture, in addition to the fact that they ignore the Indigenous understandings of health. Barriers can include communication challenges where Indigenous patients do not speak English as their mother tongue, and a general unwillingness to allow patients to visit accompanied by family members or friends, something often important to Indigenous patients. The current lack of Indigenous dentists, dental therapists and other oral health professionals poses a problem given many Indigenous people may be more likely to visit an Indigenous dentist (Jamieson et al., 2008). While in general the staff of oral health services have no training in cultural sensitivity and no support in providing a more appropriate service for Indigenous patients (Jamieson et al., 2008), efforts at the Oral Health Program at Pika Wiya Health Service in Port Augusta have demonstrated greatly increased acceptance of the service and improved attendance rates after the introduction of a culturally-sensitive oral health care service (Parker et al., 2005).

#### **7.2 Geographical accessibility of oral health services**

Australia is geographically one of the world's largest countries, with the vast majority of the relatively small population -89% – living along the coast and the vast interior being very sparsely populated. Considering around a quarter of Indigenous Australians live in remote parts of the country, the distance to the nearest dental clinic can be long, and even when transport is available the roads are often in poor condition (Australian Bureau of Statistics, 2008). For people living in urban areas, transport can also be an issue.

#### **7.3 Diet**

334 Oral Health Care – Prosthodontics, Periodontology, Biology, Research and Systemic Conditions

injury due to assault was 21 times higher for Indigenous people living in Queensland, Western Australia, South Australia and the Northern Territory in the six year period 1 July 1999 to 30 June 2005 than for their non-Indigenous counterparts. The rate ratio was especially high among females: 69 for all ages and 93 for the 30–34 years age group. Whilst this statistic is not specific for tooth loss or dental trauma, it is likely that in light of such

Edentulism reflects both extensive dental disease and past surgical approaches to the treatment of oral diseases that relied largely on extractions (Slade et al., 2007). Edentulism leads to poorer oral functioning and often to notable discomfort. Individuals missing all of their teeth must either endure with no teeth, which greatly affects a person's ability to eat, or choose to wear full dentures, which are generally uncomfortable and can lead to

Edentulism is strongly correlated to age; in Australia less than 2% of adults aged 35-54 years have complete tooth loss but this increases to 36% for people aged 75 years or older (Slade et al., 2007). The age distribution of edentulism for Indigenous people is noticeably different from that of the total population. The level of complete tooth loss is almost five times higher among Indigenous people aged 35-54 years than among their non-Indigenous counterparts (7.6% compared with 1.6%). There was also a notable difference for those aged 55-74 years; 21% of Indigenous people suffer from edentulism compared with 14% of non-Indigenous

For many Indigenous Australians there are numerous factors that hinder the maintenance of good oral health. Most of these are linked to socioeconomic disadvantage. They include the cultural and geographical accessibility of oral health services, diet, water fluoridation, living conditions, oral hygiene, the cost of dental care, and lower rates of school attendance for children. Another important issue is the differing understandings of health, as outlined previously. When little of this is understood by mainstream health providers, it is not surprising that this can also constitute a significant barrier. For children, it has been suggested that under-utilisation of the School Dental Service in the Northern Territory may well be a result of low school attendance in some communities, despite the fact the Service

For the most part, oral health services tend to stipulate certain rules that are not necessarily compatible with Indigenous culture, in addition to the fact that they ignore the Indigenous understandings of health. Barriers can include communication challenges where Indigenous patients do not speak English as their mother tongue, and a general unwillingness to allow patients to visit accompanied by family members or friends, something often important to Indigenous patients. The current lack of Indigenous dentists, dental therapists and other oral health professionals poses a problem given many Indigenous people may be more likely to visit an Indigenous dentist (Jamieson et al., 2008). While in general the staff of oral health services have no training in cultural sensitivity and no support in providing a more

high rates of facial trauma increased tooth loss also follows.

complications if not properly cleaned and maintained.

**7. Barriers to good oral health among Indigenous people** 

provides care to communities regularly (Jamieson et al., 2006).

**7.1 Cultural accessibility of oral health services** 

**6.2 Edentulism** 

people.

Again hinging on Australia's immense area, the transport of healthy foods to remote communities is a major issue and for this reason many Indigenous people can have very limited options in terms of their diet. The availability of many healthier food items (for example wholemeal breads, lean meat, reduced-fat milk, and fresh fruits and vegetables) tends to be erratic in the more rural and remote areas (Williams et al., 2011). Fresh foods in particular, when available, can cost up to 30 percent more than in urban parts of the country (Harrison et al., 2007). With limited range and very high prices, those living in rural and remote Australia are more likely to eat the more affordable foods available, often processed foods high in both sugar and carbohydrates. Such foods of course impact negatively on general and oral health.

#### **7.4 Water fluoridation**

The fluoridation of drinking water supplies has been lauded as 'the single most effective public health measure for reducing dental caries across the population, with its most pronounced effects among those who are disadvantaged and most at risk' (Acheson 1998, DHS 2000a) (Government of South Australia, 2004: 16). Fluoridation affords those members of the community lacking in financial resources to buy toothbrushes and fluoridated toothpaste access to fluoride in their water, and this can reduce caries by 20–40% (NHMRC 1991, Ahokas et al., 1999). However, rural and remote communities again tend to miss out here – in excess of 80% of remote-living Indigenous people lack access to fluoridated townwater supplies (Ehsani and Bailie, 2007).

#### **7.5 Living conditions**

Many Indigenous Australians live in sub-standard housing (Bailie, 2007), a condition strongly linked to higher levels of poor health and disease (ABS, AIHW, 2008). The factors that impact most on oral health include a lack of safe (let alone fluoridated) drinking water, poor sanitation, and overcrowding. A survey conducted in 2008 found 25% of Indigenous people over the age of 15 years were living in overcrowded housing (Australian Bureau of Statistics, 2009), and this has a direct effect on oral health (Jamieson et al 2010) in that the absence of a clean, safe place to store toothbrushes can discourage their use. Another important factor is the frequent movement between houses that many Indigenous Australians make, meaning they may not always carry oral health care products with them.

Indigenous Australians and Oral Health 337

social determinants of oral health. In order to deliver results, any strategy must deal with the broad range of factors that continue to underlie Indigenous disadvantage in Australia, as well as providing a long-term plan capable of making progress even as the political and economic scenarios change (Thomson et al., 2010). A successful and sustainable approach will also require the input of Indigenous people and health organisations. While the rates of all kinds of diseases, oral and systemic, are on average much higher in the Indigenous community, we can choose to regard this as an opportunity rather than just a miserable state of affairs. Any targeted response to improve oral health for Indigenous Australians is likely to create much broader health benefits for the population, just as initiatives aimed at reducing the rates of diabetes or heart disease will most probably result in improved oral

Abbott, P. & Yu, C. (2007). A clinical classification of the status of the pulp and the root canal

Aboriginal and Torres Strait Islander Social Justice Commissioner (2005). *Social justice report* 

Ahokas, J., Demos, L., Donohue, D., Killalea, S., McNeil, J. & Rix, C. (1999). *Review of water* 

Armfield, J.; Roberts-Thomson, K. & Spencer, A. (2003). *The child dental health survey,* 

Australian Bureau of Statistics. (2006). *National Aboriginal and Torres Strait Islander Health Survey: Australia, 2004-05,* Australian Bureau of Statistics, Canberra, Australia. Australian Bureau of Statistics. (2008). *Population characteristics, Aboriginal and Torres Strait* 

Australian Bureau of Statistics. (2009). *National Aboriginal and Torres Strait Islander social* 

Australian Health Ministers' Advisory Council, Steering Committee for National Planning

Australian Health Ministers' Advisory Council. (2008). *Aboriginal and Torres Strait Islander* 

http://www.abs.gov.au/ausstats/abs@.nsf/mf/4714.0?OpenDocument Australian Bureau of Statistics, Australian Institute of Health and Welfare. (2008). *The health* 

system. *Australian Dental Journal*, Vol. 52, Issue supplement s1 (March 2007), pp.

*2005*. Sydney: Human Rights & Equal Opportunity Commission, ISSN 1321-11,

*fluoridation and fluoride intake from discretionary fluoride supplements: review for NHMRC*. Royal Melbourne Institute of Technology and Monash University,

*Australia 1999: trends across the 1990s.* AIHW, ISBN 978-1-74024-252-3, Canberra,

*Islander Australians,* Australian Bureau of Statistics, ABS Catalogue no. 4713.0,

*and welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008.* Australian Bureau of Statistics and Australian Institute of Health and Welfare, *ISSN* 1441-2004,

for Oral Health. (2001). *Oral health of Australians: national planning for oral health improvement: final report,* South Australian Department of Human Services,

*health performance framework report 2008,* Department of Health and Ageing,

health.

**9. References** 

S17–S31, *ISSN*: 1834-7819.

Sydney, Australia.

Melbourne, Australia.

Canberra, Australia.

Canberra, Australia.

Adelaide, Australia.

Canberra, Australia.

*survey, 2008*, accessed June 15, 2011 at

Australia.

#### **7.6 Oral hygiene**

Poor oral health results in large part from a lack of oral hygiene. The limited availability of toothbrushes, toothpaste and floss certainly impedes the maintenance of good oral hygiene in some remote communities, but it seems probable that the importance of good oral hygiene is not always recognised by Indigenous people – overall their use of toothbrushes and fluoridated toothpaste is below suggested levels (Jamieson et al., 2006). Given the evidence that the traditional Indigenous diet before colonisation did not necessitate oral selfcare, such practice has not featured in many Indigenous cultures (Harford et al., 2003).

#### **7.7 Professional dental care**

Medicare is the Australian government's program enabling free treatment for patients of public hospitals as well as free or subsidised treatment by certain medical practitioners. It does not include provisions for any preventive oral health services. While low-income earners are entitled to concessions for public dental treatment, oral health services are often out of reach for many Indigenous people as a result of their expense (Slade et al., 2007). The majority of dental surgeries demand payment on the day, and the National Survey of Adult Oral Health found that Indigenous people were 1.5 times more likely than non-Indigenous people to have difficulty paying even a modest AU\$100 dental bill.

#### **7.8 The dental-medical divide**

Traditionally, the dental and medical fields have tended to be viewed as completely separate entities. In Australia the two professions have evolved quite separately, and one of the drawbacks of this is 'a general public mostly failing to grasp that the oral cavity relates in dynamic fashion with the rest of our being' (Widdop, 2005). In recent years there has been growing recognition of the links between oral and systemic health, and as a result this disciplinary divide is slowly breaking down (Guynup, 2006). The body of research indicating these links continues to grow, and the connections surely have strong relevance for Indigenous Australians given their poorer health in many different areas, oral and otherwise. While this chapter focuses on improving oral health for Indigenous Australians, it does so with a strong emphasis on the need for an overhaul of Indigenous health in general. It also acknowledges that there may be benefits to be had from an increased awareness amongst the general public of the importance of oral health to general health. The connections between oral health and overall health also give us reason to be optimistic about the broader benefits that could come from effective measures to improve oral health amongst Indigenous Australians.

#### **8. Conclusion**

There are many issues contributing to the higher rates of caries, periodontal diseases, and partial and total edentulism experienced by Indigenous Australians, particularly the cultural, economic and geographical factors limiting their access to services. Both the Australian government and the dental sector have a responsibility to address the inequalities in oral health. Today some progress is being made and we are seeing more and more services created with the goal of reducing the gap – so far, however, no program has offered a comprehensive plan targeted at the entire Indigenous population, only certain communities within it. Of course all factors must be considered within the context of the social determinants of oral health. In order to deliver results, any strategy must deal with the broad range of factors that continue to underlie Indigenous disadvantage in Australia, as well as providing a long-term plan capable of making progress even as the political and economic scenarios change (Thomson et al., 2010). A successful and sustainable approach will also require the input of Indigenous people and health organisations. While the rates of all kinds of diseases, oral and systemic, are on average much higher in the Indigenous community, we can choose to regard this as an opportunity rather than just a miserable state of affairs. Any targeted response to improve oral health for Indigenous Australians is likely to create much broader health benefits for the population, just as initiatives aimed at reducing the rates of diabetes or heart disease will most probably result in improved oral health.

#### **9. References**

336 Oral Health Care – Prosthodontics, Periodontology, Biology, Research and Systemic Conditions

Poor oral health results in large part from a lack of oral hygiene. The limited availability of toothbrushes, toothpaste and floss certainly impedes the maintenance of good oral hygiene in some remote communities, but it seems probable that the importance of good oral hygiene is not always recognised by Indigenous people – overall their use of toothbrushes and fluoridated toothpaste is below suggested levels (Jamieson et al., 2006). Given the evidence that the traditional Indigenous diet before colonisation did not necessitate oral selfcare, such practice has not featured in many Indigenous cultures (Harford et al., 2003).

Medicare is the Australian government's program enabling free treatment for patients of public hospitals as well as free or subsidised treatment by certain medical practitioners. It does not include provisions for any preventive oral health services. While low-income earners are entitled to concessions for public dental treatment, oral health services are often out of reach for many Indigenous people as a result of their expense (Slade et al., 2007). The majority of dental surgeries demand payment on the day, and the National Survey of Adult Oral Health found that Indigenous people were 1.5 times more likely than non-Indigenous

Traditionally, the dental and medical fields have tended to be viewed as completely separate entities. In Australia the two professions have evolved quite separately, and one of the drawbacks of this is 'a general public mostly failing to grasp that the oral cavity relates in dynamic fashion with the rest of our being' (Widdop, 2005). In recent years there has been growing recognition of the links between oral and systemic health, and as a result this disciplinary divide is slowly breaking down (Guynup, 2006). The body of research indicating these links continues to grow, and the connections surely have strong relevance for Indigenous Australians given their poorer health in many different areas, oral and otherwise. While this chapter focuses on improving oral health for Indigenous Australians, it does so with a strong emphasis on the need for an overhaul of Indigenous health in general. It also acknowledges that there may be benefits to be had from an increased awareness amongst the general public of the importance of oral health to general health. The connections between oral health and overall health also give us reason to be optimistic about the broader benefits that could come from effective measures to improve oral health

There are many issues contributing to the higher rates of caries, periodontal diseases, and partial and total edentulism experienced by Indigenous Australians, particularly the cultural, economic and geographical factors limiting their access to services. Both the Australian government and the dental sector have a responsibility to address the inequalities in oral health. Today some progress is being made and we are seeing more and more services created with the goal of reducing the gap – so far, however, no program has offered a comprehensive plan targeted at the entire Indigenous population, only certain communities within it. Of course all factors must be considered within the context of the

people to have difficulty paying even a modest AU\$100 dental bill.

**7.6 Oral hygiene** 

**7.7 Professional dental care** 

**7.8 The dental-medical divide** 

amongst Indigenous Australians.

**8. Conclusion** 


http://www.abs.gov.au/ausstats/abs@.nsf/mf/4714.0?OpenDocument


Indigenous Australians and Oral Health 339

Irvine, J.; Kirov, E. & Thomson, N. (2003). Diabetes, In: *The Health of Indigenous Australians*,

Jamieson, L.M., Bailie, R.S., Beneforti, M., Koster, C.R., Spencer, A.J. (2006). Dental self-care

Jamieson, L.M.; Armfield, J.M. & Roberts-Thomson, K.F. (2007). *Oral health of Aboriginal and* 

Jamieson, L.M., Parker, E.J. & Richards, L. (2008). Using qualitative methodology to inform

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**21** 

*Thailand* 

Suttatip Kamolmatyakul *Prince of Songkla University* 

**Oral Health Knowledge, Attitude** 

**and Practices of Parents/Caregivers** 

Parents usually are the primary decision makers on matters affecting their children's health and health care (Cafferata & Kasper, 1985; Hickson & Clayton, 2002). Moreover, in everyday life, parents function as role models for their children, and therefore, parents' own dental hygiene habits are very meaningful. Parental characteristics and beliefs may also be an important consideration in attempts made to improve children's oral health. Therefore, in attempts to achieve the best oral health outcomes for children, parents should be considered as key persons in ensuring the well-being of young children. This can improve the preventive dental care children receive at home and their use of professional dental services (Inglehart et al., 2002). In addition, appreciating their knowledge, attitude and practices about their children's oral health may help the dental community understand some of the

It is important to initiate basic good oral health habits in childhood so that the appropriate dental norms are established and then maintained into adult life. The family is the first institution that influences child behavior and development, especially mothers, who are the primary model for developing behavior (Blinkhorn, 1981). Therefore, childhood is an important period of life that needs to be monitored closely so that the child will grow up healthy. However, recent rapid social expansion in many societies creates a negative impact on child-rearing. Parents have to transfer their caring role to caregivers and may compromise the health status of young children including their oral health. This consequence is especially important for preschool children because they are totally

The most important negative impact to child oral health is Early Childhood Caries (ECC) (Milnes, 1996; Tinanoff & O'Sullivan 1997; Tinanoff, 1998) which may compromise growth and development of affected children (Acs et al., 1992; Ayhan et al., 1996). Several factors could contribute to a high rate of ECC (Seow, 1998; Reisine & Douglass 1998), such as parent health beliefs and attitudes towards their own dental care which is a significant predictor of children's dental care utilization (Amen & Clarke, 2001). Sarnat *et al*. reported that the more positive the mother's attitude regarding her child, the fewer carious teeth were noted, the better the child's oral hygiene, and the more dental treatment the child received (Sarnat et al., 1984). Sasahara *et al*. showed that mothers' oral health behavior was associated with the prevalence and severity of dental caries in their children (Sasahara et al., 1998).

reasons why children do not receive the dental care they need.

**1. Introduction** 

dependent on adults.


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### **Oral Health Knowledge, Attitude and Practices of Parents/Caregivers**

Suttatip Kamolmatyakul *Prince of Songkla University Thailand* 

#### **1. Introduction**

340 Oral Health Care – Prosthodontics, Periodontology, Biology, Research and Systemic Conditions

Pihlstrom BL, Michalowicz BS, Johnson NW. Periodontal diseases. *Lancet.* 2005;366:1809-

Queensland Health Treasury. (2006). *The 2006 healthy food access basket survey*. Accessed August 5, 2011 at http://www.health.qld.gov.au/ph/documents/hpu/33125.pdf Sclaroff, A.; Elluru, R.G. & Gay, W.D. (2000). Dental implantation for restoration of

Seow, K.W. (1997). Effects of pre-term birth on oral growth and development. *Australian Dental Journal*, Vol.42, No.2, (April 2007), pp. 85-91, *ISSN*: 1834-7819 Slade GD, Spencer AJ. Development and evaluation of the Oral Health Impact Profile.

Slade, G.D.; Spencer, A.J. & Roberts-Thomson, K.F. (2007) *Australia's dental generations: the* 

Smith K, Kruger E, Dyson K, Tennant M. (2007). Oral health in rural and remote Western

Thomson, N. (Ed.) 2003. *The Health of Indigenous Australians*, Oxford University Press, ISBN

Dental and Ophthalmic Services Division. (2005). *Choosing better oral health: an oral health plan* 

Widdop, F. (2005). *Crossing divides: an ADRF perspective.* Australian Dental Association,

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*for England*, Department of Health, London, UK.

Aboriginal Community in Port Augusta, South Australia [preliminary report]. *Rural and Remote Health*, Vol.5, No.2, (April 2005), pp. 254-261, ISSN 1445-6354 Pascoe, L. & Seow, K. (1994). Enamel hypoplasia and dental caries in Australian Aboriginal

children: prevalence and correlation between the two diseases. *Pediatric Dentistry*,

posttraumatic deformities: avulsion injuries. *Facial Plastic Surgery*, Vol. 16, No. 2,

*national survey of adult oral health 2004-06*, Australian Institute of Health and

Australian indigenous communities: a two-year retrospective analysis of 999 people. *International Dental Journal*, Vol.57, No.2, (April 2007), pp. 93-99, ISSN 1875Parents usually are the primary decision makers on matters affecting their children's health and health care (Cafferata & Kasper, 1985; Hickson & Clayton, 2002). Moreover, in everyday life, parents function as role models for their children, and therefore, parents' own dental hygiene habits are very meaningful. Parental characteristics and beliefs may also be an important consideration in attempts made to improve children's oral health. Therefore, in attempts to achieve the best oral health outcomes for children, parents should be considered as key persons in ensuring the well-being of young children. This can improve the preventive dental care children receive at home and their use of professional dental services (Inglehart et al., 2002). In addition, appreciating their knowledge, attitude and practices about their children's oral health may help the dental community understand some of the reasons why children do not receive the dental care they need.

It is important to initiate basic good oral health habits in childhood so that the appropriate dental norms are established and then maintained into adult life. The family is the first institution that influences child behavior and development, especially mothers, who are the primary model for developing behavior (Blinkhorn, 1981). Therefore, childhood is an important period of life that needs to be monitored closely so that the child will grow up healthy. However, recent rapid social expansion in many societies creates a negative impact on child-rearing. Parents have to transfer their caring role to caregivers and may compromise the health status of young children including their oral health. This consequence is especially important for preschool children because they are totally dependent on adults.

The most important negative impact to child oral health is Early Childhood Caries (ECC) (Milnes, 1996; Tinanoff & O'Sullivan 1997; Tinanoff, 1998) which may compromise growth and development of affected children (Acs et al., 1992; Ayhan et al., 1996). Several factors could contribute to a high rate of ECC (Seow, 1998; Reisine & Douglass 1998), such as parent health beliefs and attitudes towards their own dental care which is a significant predictor of children's dental care utilization (Amen & Clarke, 2001). Sarnat *et al*. reported that the more positive the mother's attitude regarding her child, the fewer carious teeth were noted, the better the child's oral hygiene, and the more dental treatment the child received (Sarnat et al., 1984). Sasahara *et al*. showed that mothers' oral health behavior was associated with the prevalence and severity of dental caries in their children (Sasahara et al., 1998).

Oral Health Knowledge, Attitude and Practices of Parents/Caregivers 343

AAPD's recommendations on Infant Oral Health Care. (Revised 1989, 1994, 2001, 2004,

1. All primary health care professionals who serve mothers and infants provide parent/caregiver education on the etiology and prevention of ECC. Oral health counseling and referral for a comprehensive oral examination and treatment during

2. The infectious and transmissible nature of bacteria that cause ECC and methods of oral health risk assessment, anticipatory guidance, and early intervention be included in the curriculum of all medical, nursing, and allied health professional programs.

3. Every infant receives an oral health risk assessment from his/her primary health care provider or qualified health care professional by 6 months of age. This initial visit

4. Parents or caregivers establish a dental home for infants by 12 months of age. The

• recording thorough medical (infant) and dental (mother or primary caregiver and

• assessing the infant's risk of developing caries and determining an appropriate prevention plan and interval for periodic reevaluation based upon that

• providing anticipatory guidance regarding dental and oral development, fluoride status, non-nutritive sucking habits, teething, injury prevention, oral hygiene

• planning for comprehensive care in accordance with accepted guidelines and

• referring patients to the appropriate health professional if intervention is

5. Health care professionals and all other stakeholders in children's oral health should support the identification of a dental home for all infants at 12 months of age.

6. Legislators, policy makers, and third party payers are educated about the benefits of early interventions in order to support efforts that improve access to oral health care

Table 1. The American Academy of Pediatric Dentistry recommendations on Infant Oral

an initial oral examination within six months of the eruption of the first primary tooth and no later than twelve months of age should be carried out. The other recommendation is

• assessing the patient's risk of developing oral disease using a caries risk

pregnancy is especially important for the mother.

• providing education on infant oral health; and • evaluating and optimizing fluoride exposure.

following should be accomplished at that visit:

• completing a thorough oral examination;

instruction, and the effects of diet on the dentition;

periodicity schedules for pediatric oral health;

should consist of the following:

assessment;

infant) histories;

assessment;

necessary.

for infants and children.

Health Care

2009)

Okada et. al. illustrated that parent oral health behavior could influence their children's gingival health and dental caries directly and/or indirectly through its effect on children's oral health behavior. (Okada et al., 2002).

Even though it has been widely studied, ECC remains a serious public health problem, especially in countries where there is no national program of oral health assessment and no legitimate primary oral health care. Many aspects related to ECC have been investigated including etiology, risk factors, consequences, oral health promotion and preventive measures. Attempts to solve ECC have also been studied intensively. However, there is still no effective program to overcome this problem. A lot of infants and young children around the world, not only in developing countries but also in developed countries (Pitts & Palmer, 1994; Widstrom & Hiiri, 1998), are still facing this severe health problem. There have been many studies focusing on mothers'/caregivers' knowledge, attitude and practices (Kamolmatyakul & Saiong, 2007; Okada et al., 2002; Sarnat et al., 1984; Sasahara et al., 1998). Many studies have shown that good levels of attitude and knowledge did not result in good practice (Benitez et al., 1994; Kamolmatyakul & Saiong, 2007; Tinanoff et al., 1999). Our study demonstrated that despite good levels of knowledge and attitude in oral health, caregivers seem to be unable to apply them to everyday practice (Kamolmatyakul & Saiong, 2007). Therefore, instead of focusing on providing knowledge to mothers/caregivers, more practical programs to let them "do it" in the course will probably result in less carious teeth in young children's mouths. There is no ''magic bullet''. However, this chapter intends to focus on the attempt to generate a universally effective, caries-prevention program which will help improve better oral health for all, starting from a very young age, as a good foundation for a happy smile, as shown in figure 1.

Fig. 1. Soft and hard tissues of a young child's mouth should be seen as the foundation for a lifetime free from preventable oral disease

#### **2. Childhood oral health**

Infant oral health care should be seen as the foundation on which a lifetime of preventive education and dental care can be built. In order to help assure optimal oral health in childhood, the American Academy of Pediatric Dentistry (AAPD) recommend that infant oral health care should begin ideally with prenatal oral health counseling for parents. Then

Okada et. al. illustrated that parent oral health behavior could influence their children's gingival health and dental caries directly and/or indirectly through its effect on children's

Even though it has been widely studied, ECC remains a serious public health problem, especially in countries where there is no national program of oral health assessment and no legitimate primary oral health care. Many aspects related to ECC have been investigated including etiology, risk factors, consequences, oral health promotion and preventive measures. Attempts to solve ECC have also been studied intensively. However, there is still no effective program to overcome this problem. A lot of infants and young children around the world, not only in developing countries but also in developed countries (Pitts & Palmer, 1994; Widstrom & Hiiri, 1998), are still facing this severe health problem. There have been many studies focusing on mothers'/caregivers' knowledge, attitude and practices (Kamolmatyakul & Saiong, 2007; Okada et al., 2002; Sarnat et al., 1984; Sasahara et al., 1998). Many studies have shown that good levels of attitude and knowledge did not result in good practice (Benitez et al., 1994; Kamolmatyakul & Saiong, 2007; Tinanoff et al., 1999). Our study demonstrated that despite good levels of knowledge and attitude in oral health, caregivers seem to be unable to apply them to everyday practice (Kamolmatyakul & Saiong, 2007). Therefore, instead of focusing on providing knowledge to mothers/caregivers, more practical programs to let them "do it" in the course will probably result in less carious teeth in young children's mouths. There is no ''magic bullet''. However, this chapter intends to focus on the attempt to generate a universally effective, caries-prevention program which will help improve better oral health for all, starting from a very young age, as a good

Fig. 1. Soft and hard tissues of a young child's mouth should be seen as the foundation for a

Infant oral health care should be seen as the foundation on which a lifetime of preventive education and dental care can be built. In order to help assure optimal oral health in childhood, the American Academy of Pediatric Dentistry (AAPD) recommend that infant oral health care should begin ideally with prenatal oral health counseling for parents. Then

oral health behavior. (Okada et al., 2002).

foundation for a happy smile, as shown in figure 1.

lifetime free from preventable oral disease

**2. Childhood oral health** 

AAPD's recommendations on Infant Oral Health Care. (Revised 1989, 1994, 2001, 2004, 2009)

	- assessing the patient's risk of developing oral disease using a caries risk assessment;
	- providing education on infant oral health; and
	- evaluating and optimizing fluoride exposure.
	- recording thorough medical (infant) and dental (mother or primary caregiver and infant) histories;
	- completing a thorough oral examination;
	- assessing the infant's risk of developing caries and determining an appropriate prevention plan and interval for periodic reevaluation based upon that assessment;
	- providing anticipatory guidance regarding dental and oral development, fluoride status, non-nutritive sucking habits, teething, injury prevention, oral hygiene instruction, and the effects of diet on the dentition;
	- planning for comprehensive care in accordance with accepted guidelines and periodicity schedules for pediatric oral health;
	- referring patients to the appropriate health professional if intervention is necessary.

Table 1. The American Academy of Pediatric Dentistry recommendations on Infant Oral Health Care

an initial oral examination within six months of the eruption of the first primary tooth and no later than twelve months of age should be carried out. The other recommendation is

Oral Health Knowledge, Attitude and Practices of Parents/Caregivers 345

adhere to non-shedding tooth surfaces. After colonization, they produce acid from sugars which, over time, demineralizes tooth structure (Loesche, 1969). The process normally takes place at the smooth surfaces of upper teeth starting from the central incisors, extending gradually to the lateral incisors, the first primary molars, canines, and then the second primary molars (Edelstein et al., 2009). Figure 2 demonstrates an example of severe ECC in a young child who attended the dental hospital at Prince of Songkla University, Thailand.

There are many factors influencing ECC including biological (feeding practices, diet, and MS level of primary caregivers) and social (sociopsychological, socioenvironmental, and socioeconomic status) factors (Edelstein et al., 2009). Starting from the 1990s, these multiple factors have been raised in an attempt to focus attention on, rather than ascribing sole causation to, inappropriate feeding practices (Reisine & Douglass, 1998). Oral health has a significant impact on overall health and well-being. The consequences of ECC, when left untreated, can become painful and cause many alterations including chewing patterns, eating and dietary nutrition, learning, speech and communication, playing, sleeping and, quality of life, in addition to potential growth restriction (Schroth, et al., 2009). Children with ECC have been reported to have a high risk of decay in both primary and permanent dentition. These could cause mal-alignment and crowding of permanent teeth that consequently result in a malocclusion. In addition, early tooth loss may result in speech difficulties as well as associated self-esteem issues due to altered appearance (Schroth et al., 2007b). Therefore, the importance of each influencing factor should be emphasized to all

The association between the salivary MS level and ECC is well documented (Berkowitz, 2003). The relationship of MS levels between children and their mothers/caregivers has also been evaluated since the mid-1970s (Douglass et al., 2008). Therefore, managing adult reservoirs and interfering with transmission may reduce dental caries onset and experience. Parisotto et al. showed that the higher the levels of maternal salivary MS, the greater the risk of transmission of MS to their infant (Parisotto et al., 2010). Apart from MS salivary levels, the mother's oral hygiene, snack frequency, periodontal disease, and socioeconomic status are also associated with infant colonization (Wan et al., 2001). In addition, the plaque index

In 2011, the AAPD's recommendations for infant's oral health state that "frequent night time bottle feeding with milk and ad libitum breast-feeding are associated with, but not consistently implicated in, ECC". Not only milk, but bottle feeding with juice/soft drink

Improper diet and nutrition was also reported to be associated with caries in young children; for example, soda or other sugared beverage intakes, greater frequency of

**2.2 Factors influencing and consequences of ECC?** 

involved agencies and health team personnel.

**2.2.1.1 Salivary mutans streptococci levels and visible plaque.** 

of young children is a strong predictor of caries (Mattila et al., 1998).

and repeated use of a sippy cup also increase caries risk (AAPD, 2011b).

**2.2.1 Biological determinants of ECC** 

**2.2.1.2 Breast- and bottle-feeding** 

**2.2.1.3 Diet** 

anticipatory guidance including preventive education and appropriate therapeutic intervention for the infant. These can enhance the opportunity for a lifetime of freedom from preventable oral disease (AAPD, 2011a).

The AAPD also recognizes that infant oral health is one of the foundations upon which preventive education and dental care must be built to enhance the opportunity for a lifetime free from preventable oral disease. The AAPD proposes recommendations for preventive strategies, oral health risk assessment, anticipatory guidance, and therapeutic interventions to be followed by dental, medical, nursing, and allied health professional programs. Table 1 shows AAPD's recommendations for Infant Oral Health Care that have been adopted since 1986 and periodically revised in 1989, 1994, 2001, 2004, and 2009 (AAPD, 2010a).

#### **2.1 What is ECC and its etiology?**

A current definition of ECC, adopted by the AAPD, is the presence of 1 or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child under the age of 6 (AAPD, 2011b). ECC has been termed the most prevalent pediatric infectious disease and the most common chronic disease of children in U.S.A. (US Dept of Health and Human Services, 2000). One of the major virulent cariesproducing organisms is Mutans streptococci (MS). MS vertical transmission from mothers to infants is the primary source of dental caries (Berkowitz & Jones, 1985; Douglass et al., 2008). However, horizontal transmission between siblings of a similar age or children in a day care center has already been reported (Emanuelsson & Wang, 1998; Mattos-Graner et al., 2001; Mitchell et al., 2009; Van Loveren, 2000). MS can be detected in many locations in the oral cavity. The furrows of the tongue are an important ecological niche in predentate infants (Berkowitz, 2006; Law et al., 2007; Tanner et al., 2002). Transmission of MS may occur from the time of birth. However, significant colonization occurs after dental eruption, as MS can

Fig. 2. Caries progression of Early Childhood Caries (ECC) starting from maxillary central incisors and extends gradually to the maxillary lateral incisors, maxillary first primary molars, maxillary canines, and then second primary molar. (Photo courtesy of Dr. Aunwaya Kaewpitak, Prince of Songkla University, Songkla, Thailand)

anticipatory guidance including preventive education and appropriate therapeutic intervention for the infant. These can enhance the opportunity for a lifetime of freedom from

The AAPD also recognizes that infant oral health is one of the foundations upon which preventive education and dental care must be built to enhance the opportunity for a lifetime free from preventable oral disease. The AAPD proposes recommendations for preventive strategies, oral health risk assessment, anticipatory guidance, and therapeutic interventions to be followed by dental, medical, nursing, and allied health professional programs. Table 1 shows AAPD's recommendations for Infant Oral Health Care that have been adopted since

A current definition of ECC, adopted by the AAPD, is the presence of 1 or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child under the age of 6 (AAPD, 2011b). ECC has been termed the most prevalent pediatric infectious disease and the most common chronic disease of children in U.S.A. (US Dept of Health and Human Services, 2000). One of the major virulent cariesproducing organisms is Mutans streptococci (MS). MS vertical transmission from mothers to infants is the primary source of dental caries (Berkowitz & Jones, 1985; Douglass et al., 2008). However, horizontal transmission between siblings of a similar age or children in a day care center has already been reported (Emanuelsson & Wang, 1998; Mattos-Graner et al., 2001; Mitchell et al., 2009; Van Loveren, 2000). MS can be detected in many locations in the oral cavity. The furrows of the tongue are an important ecological niche in predentate infants (Berkowitz, 2006; Law et al., 2007; Tanner et al., 2002). Transmission of MS may occur from the time of birth. However, significant colonization occurs after dental eruption, as MS can

Fig. 2. Caries progression of Early Childhood Caries (ECC) starting from maxillary central incisors and extends gradually to the maxillary lateral incisors, maxillary first primary molars, maxillary canines, and then second primary molar. (Photo courtesy of Dr. Aunwaya

Kaewpitak, Prince of Songkla University, Songkla, Thailand)

1986 and periodically revised in 1989, 1994, 2001, 2004, and 2009 (AAPD, 2010a).

preventable oral disease (AAPD, 2011a).

**2.1 What is ECC and its etiology?** 

adhere to non-shedding tooth surfaces. After colonization, they produce acid from sugars which, over time, demineralizes tooth structure (Loesche, 1969). The process normally takes place at the smooth surfaces of upper teeth starting from the central incisors, extending gradually to the lateral incisors, the first primary molars, canines, and then the second primary molars (Edelstein et al., 2009). Figure 2 demonstrates an example of severe ECC in a young child who attended the dental hospital at Prince of Songkla University, Thailand.

#### **2.2 Factors influencing and consequences of ECC?**

There are many factors influencing ECC including biological (feeding practices, diet, and MS level of primary caregivers) and social (sociopsychological, socioenvironmental, and socioeconomic status) factors (Edelstein et al., 2009). Starting from the 1990s, these multiple factors have been raised in an attempt to focus attention on, rather than ascribing sole causation to, inappropriate feeding practices (Reisine & Douglass, 1998). Oral health has a significant impact on overall health and well-being. The consequences of ECC, when left untreated, can become painful and cause many alterations including chewing patterns, eating and dietary nutrition, learning, speech and communication, playing, sleeping and, quality of life, in addition to potential growth restriction (Schroth, et al., 2009). Children with ECC have been reported to have a high risk of decay in both primary and permanent dentition. These could cause mal-alignment and crowding of permanent teeth that consequently result in a malocclusion. In addition, early tooth loss may result in speech difficulties as well as associated self-esteem issues due to altered appearance (Schroth et al., 2007b). Therefore, the importance of each influencing factor should be emphasized to all involved agencies and health team personnel.

#### **2.2.1 Biological determinants of ECC**

#### **2.2.1.1 Salivary mutans streptococci levels and visible plaque.**

The association between the salivary MS level and ECC is well documented (Berkowitz, 2003). The relationship of MS levels between children and their mothers/caregivers has also been evaluated since the mid-1970s (Douglass et al., 2008). Therefore, managing adult reservoirs and interfering with transmission may reduce dental caries onset and experience. Parisotto et al. showed that the higher the levels of maternal salivary MS, the greater the risk of transmission of MS to their infant (Parisotto et al., 2010). Apart from MS salivary levels, the mother's oral hygiene, snack frequency, periodontal disease, and socioeconomic status are also associated with infant colonization (Wan et al., 2001). In addition, the plaque index of young children is a strong predictor of caries (Mattila et al., 1998).

#### **2.2.1.2 Breast- and bottle-feeding**

In 2011, the AAPD's recommendations for infant's oral health state that "frequent night time bottle feeding with milk and ad libitum breast-feeding are associated with, but not consistently implicated in, ECC". Not only milk, but bottle feeding with juice/soft drink and repeated use of a sippy cup also increase caries risk (AAPD, 2011b).

#### **2.2.1.3 Diet**

Improper diet and nutrition was also reported to be associated with caries in young children; for example, soda or other sugared beverage intakes, greater frequency of

Oral Health Knowledge, Attitude and Practices of Parents/Caregivers 347

low-birth weight babies. Additionally, women with poor oral health have the chance to infect their babies with cariogenic bacteria and thus increase their children's risk of caries at an early age. Moreover, change of frequent consumption of sugar-containing drinks and sugary snacks should be promoted. These lessons would alter practices through education for pregnant women, mothers/caregivers and school children. Finally, the selection of foods

In order to implement effective programs to solve ECC problems, the investigation of knowledge, attitude and practice is essential. Many researchers have tried to assess the relationship between attitude, knowledge and practice on oral health (Ab-Murat & Watt, 2006; Al-Omiri et al., 2006; Smyth et al., 2007). Firstly, they indicated that strong knowledge of oral health exhibits better oral care practice (Smyth et al., 2007). Secondly, people with a more positive attitude towards oral health are predisposed by better knowledge in how to take care of their teeth (Al-Omiri et al., 2006). Thirdly, some researchers showed that appropriate oral health education can help to cultivate healthy oral health practice (Ab-Murat & Watt, 2006). Finally, the change to healthy attitude and practice can be created by providing adequate information, motivation and practice of the procedure with the subjects (Smyth et al., 2007). However, such knowledge that mothers/caregivers know about the concept of the first dental visit before the child's first birthday does not necessarily translate into practices that are likely to prevent ECC (Schroth et al.; 2005; Schroth et al.; 2007a). These data from westernized countries are similar to our study in Thailand. Most parents attending the Prince of Songkla University dental hospital in Thailand had a good level of knowledge and a positive attitude about their children's oral health. However, some of them still could not follow some of the recommendations for preventive pediatric dental care. Therefore, knowledge may not result in appropriate behavior. This discrepancy between dental knowledge and parents oral health care practices indicates a need for oral health education. However, influencing the oral health behavior of parents is difficult. Therefore, we suggested that it may be more practical to offer comprehensive oral health educational programs for children at school (Kamolmatyakul & Saiong, 2007). Based on influencing factors, these programs should involve not only the educational aspect but also aspects of attitude and most importantly, how the practical behaviors can be developed. Therefore, implementation of these programs should involve not only pediatric dentists, allied health professionals, nursery staff, and teachers in kindergarten, but also health policy personnel.

available in the communities should be enabled.

**2.4 Mothers'/caregivers' attitude, knowledge and practice** 

However, the most important persons are mothers/caregivers.

Infants and toddlers are most susceptible to ECC. Therefore, proper oral care for this age group should be implemented for all persons involved. The first group should be the mothers/caregivers. Since these young children's oral health is totally dependent on their caregivers, a program for these adults is very important. The program should start from the prenatal period. All pregnant women should be scheduled to receive counseling and oral health care during pregnancy. They should also be registered in a dental home program to make sure that their infants undergo oral health assessment by the first birthday. Importantly, the program will help them follow each step of the program without any

**2.5 Programs for mothers/caregivers** 

problem.

carbohydrate intake, and greater frequency of eating occasions (Mariri et al., 2003). Another important aspect is the quality of fluid intake such as "high-juice group", "highcarbohydrate soft drinks", "high-water group", and "high-milk group". The milk group causes the least caries experience (Sohn et al., 2006). Additionally, normative diet behaviors are correlated with overall caries experience. These include not consuming the recommended five fruits and vegetables on a daily basis and not eating breakfast (Dye et al., 2004). Moreover, the importance of sugar comsumption should also be emphasized. Although toothbrushing has been shown to be essential for prevention of caries, the most important element has to do with the frequency of sugar consumption (Ainamo, 1980). Recently, Kalsbeek and Verrips reported a positive relationship between sweets/snacks consumption and caries occurrence (Kalsbeek & Verrips, 1994).

#### **2.2.2 Social determinants of ECC**

Many social determinants affect children's general health as well as oral health. These include personal, cultural, communal and economic factors which influence dental health behaviors and nutritional habits. They are powerful determinants for when or whether families seek dental health care (Waldman, 1995). The maturity of the parents is another important aspect in the family issue; they may be ill-equipped to bring up their children. These habits would show up daily by allowing their children to watch TV for hours, by frequent feeding of unhealthy snacks, and also by using sweets to comfort the child during temper tantrums. All these features should be emphasized in children with caries (Mattila et al., 2000). Therefore, preventive dentistry that concentrates only on the oral health of the child is inadequate. Attention must be focused on the whole family, their dental health habits, and their lifestyles. These strategies need to be emphasized not only by dental staff, but also the involved agents and health team personnel.

#### **2.3 Attempts to solve ECC**

ECC is the result of the interplay of substrate, oral bacteria, and the host, as well as the family, social, and economic conditions. Therefore, health-promotion policies that emphasize community empowerment and address the determinants of health are needed along with strategies that focus on disease prevention. Changes in the modern world results in high caries prevalence among young children, not only in developing countries but also in developed countries which used to have a low prevalence of ECC. Both are now facing the problems of ECC consequences (Mattila et al., 2000; AAP, 2011a). Therefore, effective programs to solve ECC problems will benefit all children around the world. Based on ECC influencing factors, the American Academy of Pediatrics (AAP) recommended (AAP, 2011) that ECC prevention should start during the prenatal period, progress through the perinatal period, and then continue with the mother and infant within the context of preschool programs. Since a vertical transmission of cariogenic bacteria usually occurs from mother to child, the approach to create good oral health in children involves first including pregnant women in oral health screening, dental treatment, and oral health hygiene instruction. In addition, their nutrition should be bolstered along with the use of fluoride toothpaste. These strategies can assist in the prevention of ECC. Second, these prenatal visits would also provide an opportunity to build awareness about the importance of oral health for mothers in relation to their infants. Examples of important lessons for mothers include appropriate oral health care during the perinatal period of pregnancy, as it would prevent preterm and

carbohydrate intake, and greater frequency of eating occasions (Mariri et al., 2003). Another important aspect is the quality of fluid intake such as "high-juice group", "highcarbohydrate soft drinks", "high-water group", and "high-milk group". The milk group causes the least caries experience (Sohn et al., 2006). Additionally, normative diet behaviors are correlated with overall caries experience. These include not consuming the recommended five fruits and vegetables on a daily basis and not eating breakfast (Dye et al., 2004). Moreover, the importance of sugar comsumption should also be emphasized. Although toothbrushing has been shown to be essential for prevention of caries, the most important element has to do with the frequency of sugar consumption (Ainamo, 1980). Recently, Kalsbeek and Verrips reported a positive relationship between sweets/snacks

Many social determinants affect children's general health as well as oral health. These include personal, cultural, communal and economic factors which influence dental health behaviors and nutritional habits. They are powerful determinants for when or whether families seek dental health care (Waldman, 1995). The maturity of the parents is another important aspect in the family issue; they may be ill-equipped to bring up their children. These habits would show up daily by allowing their children to watch TV for hours, by frequent feeding of unhealthy snacks, and also by using sweets to comfort the child during temper tantrums. All these features should be emphasized in children with caries (Mattila et al., 2000). Therefore, preventive dentistry that concentrates only on the oral health of the child is inadequate. Attention must be focused on the whole family, their dental health habits, and their lifestyles. These strategies need to be emphasized not only by dental staff,

ECC is the result of the interplay of substrate, oral bacteria, and the host, as well as the family, social, and economic conditions. Therefore, health-promotion policies that emphasize community empowerment and address the determinants of health are needed along with strategies that focus on disease prevention. Changes in the modern world results in high caries prevalence among young children, not only in developing countries but also in developed countries which used to have a low prevalence of ECC. Both are now facing the problems of ECC consequences (Mattila et al., 2000; AAP, 2011a). Therefore, effective programs to solve ECC problems will benefit all children around the world. Based on ECC influencing factors, the American Academy of Pediatrics (AAP) recommended (AAP, 2011) that ECC prevention should start during the prenatal period, progress through the perinatal period, and then continue with the mother and infant within the context of preschool programs. Since a vertical transmission of cariogenic bacteria usually occurs from mother to child, the approach to create good oral health in children involves first including pregnant women in oral health screening, dental treatment, and oral health hygiene instruction. In addition, their nutrition should be bolstered along with the use of fluoride toothpaste. These strategies can assist in the prevention of ECC. Second, these prenatal visits would also provide an opportunity to build awareness about the importance of oral health for mothers in relation to their infants. Examples of important lessons for mothers include appropriate oral health care during the perinatal period of pregnancy, as it would prevent preterm and

consumption and caries occurrence (Kalsbeek & Verrips, 1994).

but also the involved agents and health team personnel.

**2.2.2 Social determinants of ECC** 

**2.3 Attempts to solve ECC** 

low-birth weight babies. Additionally, women with poor oral health have the chance to infect their babies with cariogenic bacteria and thus increase their children's risk of caries at an early age. Moreover, change of frequent consumption of sugar-containing drinks and sugary snacks should be promoted. These lessons would alter practices through education for pregnant women, mothers/caregivers and school children. Finally, the selection of foods available in the communities should be enabled.

#### **2.4 Mothers'/caregivers' attitude, knowledge and practice**

In order to implement effective programs to solve ECC problems, the investigation of knowledge, attitude and practice is essential. Many researchers have tried to assess the relationship between attitude, knowledge and practice on oral health (Ab-Murat & Watt, 2006; Al-Omiri et al., 2006; Smyth et al., 2007). Firstly, they indicated that strong knowledge of oral health exhibits better oral care practice (Smyth et al., 2007). Secondly, people with a more positive attitude towards oral health are predisposed by better knowledge in how to take care of their teeth (Al-Omiri et al., 2006). Thirdly, some researchers showed that appropriate oral health education can help to cultivate healthy oral health practice (Ab-Murat & Watt, 2006). Finally, the change to healthy attitude and practice can be created by providing adequate information, motivation and practice of the procedure with the subjects (Smyth et al., 2007). However, such knowledge that mothers/caregivers know about the concept of the first dental visit before the child's first birthday does not necessarily translate into practices that are likely to prevent ECC (Schroth et al.; 2005; Schroth et al.; 2007a). These data from westernized countries are similar to our study in Thailand. Most parents attending the Prince of Songkla University dental hospital in Thailand had a good level of knowledge and a positive attitude about their children's oral health. However, some of them still could not follow some of the recommendations for preventive pediatric dental care. Therefore, knowledge may not result in appropriate behavior. This discrepancy between dental knowledge and parents oral health care practices indicates a need for oral health education. However, influencing the oral health behavior of parents is difficult. Therefore, we suggested that it may be more practical to offer comprehensive oral health educational programs for children at school (Kamolmatyakul & Saiong, 2007). Based on influencing factors, these programs should involve not only the educational aspect but also aspects of attitude and most importantly, how the practical behaviors can be developed. Therefore, implementation of these programs should involve not only pediatric dentists, allied health professionals, nursery staff, and teachers in kindergarten, but also health policy personnel. However, the most important persons are mothers/caregivers.

#### **2.5 Programs for mothers/caregivers**

Infants and toddlers are most susceptible to ECC. Therefore, proper oral care for this age group should be implemented for all persons involved. The first group should be the mothers/caregivers. Since these young children's oral health is totally dependent on their caregivers, a program for these adults is very important. The program should start from the prenatal period. All pregnant women should be scheduled to receive counseling and oral health care during pregnancy. They should also be registered in a dental home program to make sure that their infants undergo oral health assessment by the first birthday. Importantly, the program will help them follow each step of the program without any problem.

Oral Health Knowledge, Attitude and Practices of Parents/Caregivers 349

assumes the responsibility. This depends on the child's anatomic/physiological development, improving skills, different motivational forces, changing lifestyles and anatomic and physiological changes associated with growing up. The program should facilitate mothers/caregivers to clean their infant's mouth with a clean cloth after each feeding or at least once a day before bed time. Then as soon as the first tooth erupts, they should be cleaned with a soft toothbrush. This will help reduce bacterial colonization. The protocol of activities which should be demonstrated and supervised to mothers/caregivers includes age-appropriate tooth brushing with age-appropriate amount of fluoridated toothpaste twice daily using a soft toothbrush of age-appropriate size, rinsing 0.05% sodium fluoride mouth rinse once a day, and flossing with dental floss to help dislodge food and reduce bacterial plaque levels. Flossing should be initiated around three years of age when adjacent posterior tooth surfaces cannot be cleansed with a toothbrush. The amount of fluoride toothpaste to be used has to be emphasized to mothers/caregivers. According to AAPD guidelines, a 'smear' of fluoridated toothpaste should be used in a child under the age of 2 and a 'pea-size' amount should be used in all children aged 2 to 5 (AAPD 2011b).

General dentists can provide oral health service to pregnant women/mothers during prenatal, perinatal and postnatal periods, while pediatric dentists can provide oral health services to children starting from infancy through adolescence. Since oral health services for pregnant women/mothers are already discussed above, this section will only deal with children oral health services. Pediatric dentists are the first professionals directly involved in oral health care service for children. They have an opportunity to see children much earlier and thus capture the parents' interest in appropriate oral health milestones and the consequences of improper habits and behaviors. Implementation of an anticipatory guidance to oral health promotional education is an organized way for all oral health providers to enjoy the attention of parents and be more successful in good oral health care

Early access to oral health providers to establish a dental home should be organized no later than when the child reaches 12 months of age. This will ensure that the full range of oral health-promotion and interceptive disease-prevention services will be provided. Oral hygiene measures should be implemented no later than the time of the first primary tooth eruption. However, mothers/caregivers should be taught to clean infants' mouths after each feeding or at least once a day before bed time, as soon as possible, even before tooth eruption. Professionally-applied topical fluoride, such as fluoride varnish and fluoride gel, should be considered for children at risk for caries. Systemically-administered fluoride should be considered for all children with moderate/high caries risk who drink fluoride deficient water (<0.6 ppm), after assessing all other dietary sources of fluoride exposure

The AAPD encourages physicians, nurses and other health care professionals to educate pregnant women about perinatal and infant oral health (AAPD, 2011a). Since physicians, nurses, and other health care professionals are far more likely to see new mothers and infants than are dentists, it is important that they be aware of the ECC infectious etiology and associated risk factors, make suitable decisions regarding timely and effective intervention, and assist the establishment of the dental home or merge oral health assessment/intervention as part of a regular holistic child health care clinic program.

**2.6 Programs for dentists and allied health professionals** 

for children.

(AAPD, 2011a).

#### **2.5.1 Programs related to mothers/caregivers' oral health**

Community-based activities should be used to emphasize the importance of oral health for the pregnant woman and her infant(s). In terms of knowledge, they should be educated about the importance of oral health, the transmissible nature of bacteria, and the etiology and prevention of ECC. For example, plaque deposits on tooth surface, improper consumption of snacks, and frequent consumption between meals of sugar-containing snacks or drinks (e.g., juice, milk, formula, soda) are strong caries predictors that increase caries risk. The influences of cariogenicity of certain foods, snacks and beverages and the frequency of consumption of these substances that are related to caries should also be emphasized. Moreover, parents need to be educated regarding other powerful social determinants for children. The most powerful aspects are the issues of being well-equipped to bring up their children. These involve, firstly, avoiding saliva-sharing behaviors (e.g., sharing cups, spoons and other utensils, or cleaning a dropped pacifier or toy with their mouth). Secondly, frequent night time ad libitum breast-feeding, as well as bottle feeding with milk and sugar-containing beverages should be included in educational programs. Finally, repeated use of a sippy or no-spill cup, and frequent consumption between meals of sugar-containing snacks or drinks (e.g., soda, juice, milk, formula) that increase the risk of caries should also be emphasized and discouraged.

The above knowledge should not only be taught in a lecture manner, but also able to be implemented with the possibility of suitable practical methods for them to really apply it. In order to achieve the practical behavior, a good attitude should be implemented, such as good general health depends on good habits (eating, sleeping and routine exercise) and thus dental health also depends on good habits (proper tooth brushing, regular dental visits and a good diet). Parents' self-confidence in bringing up their children in a consistent and logical manner should also be emphasized. Therefore, the programs could build up the parents' attitude that they can be models for their children through a good lifestyle.

In terms of appropriate practical behaviors, the implemented programs should involve oral health services in order to create an impact on the MS reservoir suppresses in mother's/caregiver's mouths, inhibit the MS transmission and decrease the child's caries rate. Oral health services should be provided to pregnant women to get their oral examined and cleaned and to have any needed periodontal and dental work performed before their infant is born. This service would include an oral examination, professional prophylaxis, fluoride treatment, early intervention such as removal of active caries with subsequent restoration, and the use of xylitol chewing gum (AAPD, 2010b).

#### **2.5.2 Programs related to children's oral health**

After implementation of knowledge and attitude to mothers/caregivers, the next step is the practical programs to promote appropriate child rearing behaviors instead of improper ones, such as allowing the child to watch TV for hours, frequent feeding of sugar and sweets, and using sweets to comfort during temper tantrums. The most important factor of all that needs to be included is an infant oral health care program because it is one of the foundations upon which promotional education and oral health care must be built to enhance the chance of a lifetime free from preventable oral disease. The program of promotional activity includes promoting teeth cleaning, which is an example that has to be modified according to the age of the child. At first, oral hygiene is the parent's responsibility, then the parent and child must work together, and gradually, the child

Community-based activities should be used to emphasize the importance of oral health for the pregnant woman and her infant(s). In terms of knowledge, they should be educated about the importance of oral health, the transmissible nature of bacteria, and the etiology and prevention of ECC. For example, plaque deposits on tooth surface, improper consumption of snacks, and frequent consumption between meals of sugar-containing snacks or drinks (e.g., juice, milk, formula, soda) are strong caries predictors that increase caries risk. The influences of cariogenicity of certain foods, snacks and beverages and the frequency of consumption of these substances that are related to caries should also be emphasized. Moreover, parents need to be educated regarding other powerful social determinants for children. The most powerful aspects are the issues of being well-equipped to bring up their children. These involve, firstly, avoiding saliva-sharing behaviors (e.g., sharing cups, spoons and other utensils, or cleaning a dropped pacifier or toy with their mouth). Secondly, frequent night time ad libitum breast-feeding, as well as bottle feeding with milk and sugar-containing beverages should be included in educational programs. Finally, repeated use of a sippy or no-spill cup, and frequent consumption between meals of sugar-containing snacks or drinks (e.g., soda, juice, milk, formula) that increase the risk of

The above knowledge should not only be taught in a lecture manner, but also able to be implemented with the possibility of suitable practical methods for them to really apply it. In order to achieve the practical behavior, a good attitude should be implemented, such as good general health depends on good habits (eating, sleeping and routine exercise) and thus dental health also depends on good habits (proper tooth brushing, regular dental visits and a good diet). Parents' self-confidence in bringing up their children in a consistent and logical manner should also be emphasized. Therefore, the programs could build up the parents'

In terms of appropriate practical behaviors, the implemented programs should involve oral health services in order to create an impact on the MS reservoir suppresses in mother's/caregiver's mouths, inhibit the MS transmission and decrease the child's caries rate. Oral health services should be provided to pregnant women to get their oral examined and cleaned and to have any needed periodontal and dental work performed before their infant is born. This service would include an oral examination, professional prophylaxis, fluoride treatment, early intervention such as removal of active caries with subsequent

After implementation of knowledge and attitude to mothers/caregivers, the next step is the practical programs to promote appropriate child rearing behaviors instead of improper ones, such as allowing the child to watch TV for hours, frequent feeding of sugar and sweets, and using sweets to comfort during temper tantrums. The most important factor of all that needs to be included is an infant oral health care program because it is one of the foundations upon which promotional education and oral health care must be built to enhance the chance of a lifetime free from preventable oral disease. The program of promotional activity includes promoting teeth cleaning, which is an example that has to be modified according to the age of the child. At first, oral hygiene is the parent's responsibility, then the parent and child must work together, and gradually, the child

attitude that they can be models for their children through a good lifestyle.

restoration, and the use of xylitol chewing gum (AAPD, 2010b).

**2.5.2 Programs related to children's oral health** 

**2.5.1 Programs related to mothers/caregivers' oral health** 

caries should also be emphasized and discouraged.

assumes the responsibility. This depends on the child's anatomic/physiological development, improving skills, different motivational forces, changing lifestyles and anatomic and physiological changes associated with growing up. The program should facilitate mothers/caregivers to clean their infant's mouth with a clean cloth after each feeding or at least once a day before bed time. Then as soon as the first tooth erupts, they should be cleaned with a soft toothbrush. This will help reduce bacterial colonization. The protocol of activities which should be demonstrated and supervised to mothers/caregivers includes age-appropriate tooth brushing with age-appropriate amount of fluoridated toothpaste twice daily using a soft toothbrush of age-appropriate size, rinsing 0.05% sodium fluoride mouth rinse once a day, and flossing with dental floss to help dislodge food and reduce bacterial plaque levels. Flossing should be initiated around three years of age when adjacent posterior tooth surfaces cannot be cleansed with a toothbrush. The amount of fluoride toothpaste to be used has to be emphasized to mothers/caregivers. According to AAPD guidelines, a 'smear' of fluoridated toothpaste should be used in a child under the age of 2 and a 'pea-size' amount should be used in all children aged 2 to 5 (AAPD 2011b).

#### **2.6 Programs for dentists and allied health professionals**

General dentists can provide oral health service to pregnant women/mothers during prenatal, perinatal and postnatal periods, while pediatric dentists can provide oral health services to children starting from infancy through adolescence. Since oral health services for pregnant women/mothers are already discussed above, this section will only deal with children oral health services. Pediatric dentists are the first professionals directly involved in oral health care service for children. They have an opportunity to see children much earlier and thus capture the parents' interest in appropriate oral health milestones and the consequences of improper habits and behaviors. Implementation of an anticipatory guidance to oral health promotional education is an organized way for all oral health providers to enjoy the attention of parents and be more successful in good oral health care for children.

Early access to oral health providers to establish a dental home should be organized no later than when the child reaches 12 months of age. This will ensure that the full range of oral health-promotion and interceptive disease-prevention services will be provided. Oral hygiene measures should be implemented no later than the time of the first primary tooth eruption. However, mothers/caregivers should be taught to clean infants' mouths after each feeding or at least once a day before bed time, as soon as possible, even before tooth eruption. Professionally-applied topical fluoride, such as fluoride varnish and fluoride gel, should be considered for children at risk for caries. Systemically-administered fluoride should be considered for all children with moderate/high caries risk who drink fluoride deficient water (<0.6 ppm), after assessing all other dietary sources of fluoride exposure (AAPD, 2011a).

The AAPD encourages physicians, nurses and other health care professionals to educate pregnant women about perinatal and infant oral health (AAPD, 2011a). Since physicians, nurses, and other health care professionals are far more likely to see new mothers and infants than are dentists, it is important that they be aware of the ECC infectious etiology and associated risk factors, make suitable decisions regarding timely and effective intervention, and assist the establishment of the dental home or merge oral health assessment/intervention as part of a regular holistic child health care clinic program.

Oral Health Knowledge, Attitude and Practices of Parents/Caregivers 351

the health policy personnel/government should incorporate programs to make sure legislators, policy makers, and third party payers are well-informed regarding the importance of early interventions of ECC. They can then facilitate to support the continuing programs for good oral health in children. The first requirement would be providing knowledge for pregnant women (the most important aspect is education regarding the infectious and transmissible nature of bacteria that causes ECC) to have a good attitude where they can really take care of their own oral health. Moreover, proper oral health services for mothers/caregivers should also be prepared (oral examination, fluoride treatment, professional prophylaxis, early intervention such as removal of active caries with subsequent restoration of remaining tooth structure). Next, health care professionals and all other stakeholders in childrens oral health should support the implementation of a dental home for all infants by 12 months of age. The dental home concept refers to a continuing relationship between health personnel and child, where the child's access to holistic and coordinated oral health care and prevention is the main focus and tailored to the needs of the child. The details of a dental home include, firstly, thorough medical (infant) and dental (parent and infant) histories, a thorough oral examination, performance of an ageappropriate tooth brushing demonstration and prophylaxis. Secondly, fluoride varnish delivered as part of a regular child health clinic program. These procedures can be provided by trained health auxiliaries, community health workers, family physicians, or pediatricians. Alternative health or child care professionals and dental auxiliaries (or trained lay child care workers such as early childhood development workers) should be recruited to ensure access to fluoride-varnish programs. Thirdly, sealant placement on deep grooves and fissures on primary teeth should be delivered by pediatric dentists. Finally, investigating the infant's risk of developing caries and determining a prevention plan and interval for periodic

In the communities where it is difficult to recruit and retain an adequate number of dentists, health policy personnel should arrange for other oral health and primary health care providers to deliver oral health services and promote an early dental visit within the first year of life. Recent studies, noting that a majority of pediatricians and general dentists were not advising patients to see a dentist by 1 year of age, point to the need for increased infant oral health care education in the medical and dental communities (AAPD, 2011a). It is important to develop oral health information programs to pediatricians. Information on oral health should be included in medical curricula and residency (Balaban et al.; 2011). Therefore, oral health training should be incorporated into pediatric and family medicine

For older children, health policy personnel should set a program that facilitates students to take responsibility for their own oral health. This will diminish dependency on oral health personnel. Among teenagers, schools would serve as the best platform for oral health care instruction. The oral health programs should be intensified to promote oral healthcare as a lifelong practice. After incorporation of oral health promotion activities into the school's curriculum, more attempts in the form of educational materials (tooth brushing techniques, healthy food etc.) and general health promotion activities related to oral health need to be carried out. Another important school health policy that needs implementation is healthy eating behavior that bans unhealthy foods and drinks in the school premises. Healthy foods must be made available in the school canteens, while the canteens should be prohibited from selling unhealthy food and drinks such as soda and those with high sugar

reevaluation should also be scheduled.

residency programs.

Physicians, nurses, physician extenders and child health associates all can intervene at an appropriate point with any child. A similar program in dentistry delivers a well-defined source of information that can be organized by all members of the office team. Regardless, multidisciplinary approaches are needed to promote good oral health in preschool children. These require collaboration among dentists, especially pediatric dentists, allied health professionals, child-care centers personnel, and health policy personnel such as decisionmakers, policy-makers, and researchers involved with young children.

#### **2.7 Programs for child-care centers personel**

Child-care center personnel comprise of nursery staff and center-based program staff such as staff in day-care centers, pre-kindergartens, nursery schools and teachers in kindergarten. Increasing health promotion in out-of-home child-care settings could improve the oral health of preschool age children. The AAPD encourages child-care centers' staff, early education providers, and parents to implement promotional practices that can decrease the risk of developing ECC in children (AAPD, 2011c). The program could be prepared step by step. First, the health staff, preferably a pediatric dentist, should monitor program practices regarding oral health. Then the individualized recommendations for each program should be carried out at least once a year. Second, the concept of the dental home should be promoted by educating their personnel as well as mothers/caregivers on the importance of oral health and providing assistance with implementation of a dental home no later than 12 months of the child's age. Third, keep oral health records, merging with the child's health report, starting at age 12 months. It should address the child's oral health needs as well as any special instructions given to mothers/caregivers. Fourth, sponsor on-site age appropriate oral health promotion programs for children that will encourage good oral hygiene and dietary practices, injury prevention, and the importance of regular scheduled dental visits. Fifth, provide in-service training programs for the personnel regarding proper nutrition choices, links between diet and tooth decay, oral hygiene concepts, and children's oral health issues including appropriate initial response to traumatic injuries along with complication and dental consequences. Personnel with an understanding of these concepts in their minds are a great benefit in caring for children. Sixth, encourage mothers/caregivers to be active partners in the children's health care process and grant an individualized education plan, one that is responsive to cultural values and beliefs, to meet every family's needs. Written material should be provided and, at a minimum, tackle oral health promotion and disease prevention and the timing of oral health visits. Seventh, integrate oral health activities as part of the daily health care of each child such as oral hygiene practices at least once daily after a meal. Eighth, supply well-balanced diets of low caries-risk, and optimally-fluoridated drinking water accessible for consumption throughout the day. Finally, in terms of general/dental health habits, not permitting infants and toddlers to have bottles/sippy cups in the crib or to carry them while walking, and minimizing saliva-sharing activities (e.g., sharing utensils, orally cleansing a pacifier) help decrease an infant's or toddler's acquisition of cariogenic microbes (AAPD, 2011c).

#### **2.8 Programs for health policy personnel/government**

It is important that the oral health needs of infants and young children be addressed as early as possible and as a part of good child-care since dental disease is preventable. Therefore,

Physicians, nurses, physician extenders and child health associates all can intervene at an appropriate point with any child. A similar program in dentistry delivers a well-defined source of information that can be organized by all members of the office team. Regardless, multidisciplinary approaches are needed to promote good oral health in preschool children. These require collaboration among dentists, especially pediatric dentists, allied health professionals, child-care centers personnel, and health policy personnel such as decision-

Child-care center personnel comprise of nursery staff and center-based program staff such as staff in day-care centers, pre-kindergartens, nursery schools and teachers in kindergarten. Increasing health promotion in out-of-home child-care settings could improve the oral health of preschool age children. The AAPD encourages child-care centers' staff, early education providers, and parents to implement promotional practices that can decrease the risk of developing ECC in children (AAPD, 2011c). The program could be prepared step by step. First, the health staff, preferably a pediatric dentist, should monitor program practices regarding oral health. Then the individualized recommendations for each program should be carried out at least once a year. Second, the concept of the dental home should be promoted by educating their personnel as well as mothers/caregivers on the importance of oral health and providing assistance with implementation of a dental home no later than 12 months of the child's age. Third, keep oral health records, merging with the child's health report, starting at age 12 months. It should address the child's oral health needs as well as any special instructions given to mothers/caregivers. Fourth, sponsor on-site age appropriate oral health promotion programs for children that will encourage good oral hygiene and dietary practices, injury prevention, and the importance of regular scheduled dental visits. Fifth, provide in-service training programs for the personnel regarding proper nutrition choices, links between diet and tooth decay, oral hygiene concepts, and children's oral health issues including appropriate initial response to traumatic injuries along with complication and dental consequences. Personnel with an understanding of these concepts in their minds are a great benefit in caring for children. Sixth, encourage mothers/caregivers to be active partners in the children's health care process and grant an individualized education plan, one that is responsive to cultural values and beliefs, to meet every family's needs. Written material should be provided and, at a minimum, tackle oral health promotion and disease prevention and the timing of oral health visits. Seventh, integrate oral health activities as part of the daily health care of each child such as oral hygiene practices at least once daily after a meal. Eighth, supply well-balanced diets of low caries-risk, and optimally-fluoridated drinking water accessible for consumption throughout the day. Finally, in terms of general/dental health habits, not permitting infants and toddlers to have bottles/sippy cups in the crib or to carry them while walking, and minimizing saliva-sharing activities (e.g., sharing utensils, orally cleansing a pacifier) help decrease an infant's or toddler's acquisition of

makers, policy-makers, and researchers involved with young children.

**2.7 Programs for child-care centers personel** 

cariogenic microbes (AAPD, 2011c).

**2.8 Programs for health policy personnel/government** 

It is important that the oral health needs of infants and young children be addressed as early as possible and as a part of good child-care since dental disease is preventable. Therefore, the health policy personnel/government should incorporate programs to make sure legislators, policy makers, and third party payers are well-informed regarding the importance of early interventions of ECC. They can then facilitate to support the continuing programs for good oral health in children. The first requirement would be providing knowledge for pregnant women (the most important aspect is education regarding the infectious and transmissible nature of bacteria that causes ECC) to have a good attitude where they can really take care of their own oral health. Moreover, proper oral health services for mothers/caregivers should also be prepared (oral examination, fluoride treatment, professional prophylaxis, early intervention such as removal of active caries with subsequent restoration of remaining tooth structure). Next, health care professionals and all other stakeholders in childrens oral health should support the implementation of a dental home for all infants by 12 months of age. The dental home concept refers to a continuing relationship between health personnel and child, where the child's access to holistic and coordinated oral health care and prevention is the main focus and tailored to the needs of the child. The details of a dental home include, firstly, thorough medical (infant) and dental (parent and infant) histories, a thorough oral examination, performance of an ageappropriate tooth brushing demonstration and prophylaxis. Secondly, fluoride varnish delivered as part of a regular child health clinic program. These procedures can be provided by trained health auxiliaries, community health workers, family physicians, or pediatricians. Alternative health or child care professionals and dental auxiliaries (or trained lay child care workers such as early childhood development workers) should be recruited to ensure access to fluoride-varnish programs. Thirdly, sealant placement on deep grooves and fissures on primary teeth should be delivered by pediatric dentists. Finally, investigating the infant's risk of developing caries and determining a prevention plan and interval for periodic reevaluation should also be scheduled.

In the communities where it is difficult to recruit and retain an adequate number of dentists, health policy personnel should arrange for other oral health and primary health care providers to deliver oral health services and promote an early dental visit within the first year of life. Recent studies, noting that a majority of pediatricians and general dentists were not advising patients to see a dentist by 1 year of age, point to the need for increased infant oral health care education in the medical and dental communities (AAPD, 2011a). It is important to develop oral health information programs to pediatricians. Information on oral health should be included in medical curricula and residency (Balaban et al.; 2011). Therefore, oral health training should be incorporated into pediatric and family medicine residency programs.

For older children, health policy personnel should set a program that facilitates students to take responsibility for their own oral health. This will diminish dependency on oral health personnel. Among teenagers, schools would serve as the best platform for oral health care instruction. The oral health programs should be intensified to promote oral healthcare as a lifelong practice. After incorporation of oral health promotion activities into the school's curriculum, more attempts in the form of educational materials (tooth brushing techniques, healthy food etc.) and general health promotion activities related to oral health need to be carried out. Another important school health policy that needs implementation is healthy eating behavior that bans unhealthy foods and drinks in the school premises. Healthy foods must be made available in the school canteens, while the canteens should be prohibited from selling unhealthy food and drinks such as soda and those with high sugar

Oral Health Knowledge, Attitude and Practices of Parents/Caregivers 353

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levels. Although parents play an important role in influencing their children's eating behavior, a more effective method would be empowering the children to make healthy food choices. At this age, these students are more likely to buy food on their own as compared to primary school children (Cheah et al., 2010).

#### **3. Conclusion**

Dental caries is a disease that generally is preventable. Early risk assessment allows for identification of parent-infant groups who are at risk for ECC and would benefit from early preventive intervention. The ultimate goal of early assessment is the timely delivery of educational information to populations at high risk for developing caries in order to prevent the need for later surgical intervention. The most important population is mothers/caregivers. The implementation of systems to promote good oral health for all should be the responsibility of health policy personnel/the government. Combined approaches must be implemented. Strategies should begin with community engagement and always include primary care providers and other community health workers. Arangement programs should involve not only dentists, but also allied health professionals and child-care center personnel. Moreover, these programs should not only be arranged for preventive dentistry which concentrates only on the oral health of the child, but attention must also be focused on the whole family, its dental health habits and lifestyles. A combination of approaches is required to organize these programs. These include recommendations for preventive oral health and clinical care for young infants and pregnant women by primary health care providers, community-based health-promotion initiatives, oral health workforce and access issues, and advocacy for community water fluoridation and fluoride-varnish program access. Further community based research on the epidemiology, prevention, management, and microbiology of ECC would also be beneficial.

#### **4. Acknowledgment**

I would like to express my appreciation to Professor Anthony Blinkhorn and Dr. Fiona Blinkhorn in initiating and supporting my work in this field. I owe thanks to Dr. Aunwaya Kaewpitak for her patient's picture of ECC. My special thanks go to Mr. Mitchell Atkins and Mr. Glenn Kern Shingledecker for critical reading of the manuscript.

#### **5. References**


levels. Although parents play an important role in influencing their children's eating behavior, a more effective method would be empowering the children to make healthy food choices. At this age, these students are more likely to buy food on their own as compared to

Dental caries is a disease that generally is preventable. Early risk assessment allows for identification of parent-infant groups who are at risk for ECC and would benefit from early preventive intervention. The ultimate goal of early assessment is the timely delivery of educational information to populations at high risk for developing caries in order to prevent the need for later surgical intervention. The most important population is mothers/caregivers. The implementation of systems to promote good oral health for all should be the responsibility of health policy personnel/the government. Combined approaches must be implemented. Strategies should begin with community engagement and always include primary care providers and other community health workers. Arangement programs should involve not only dentists, but also allied health professionals and child-care center personnel. Moreover, these programs should not only be arranged for preventive dentistry which concentrates only on the oral health of the child, but attention must also be focused on the whole family, its dental health habits and lifestyles. A combination of approaches is required to organize these programs. These include recommendations for preventive oral health and clinical care for young infants and pregnant women by primary health care providers, community-based health-promotion initiatives, oral health workforce and access issues, and advocacy for community water fluoridation and fluoride-varnish program access. Further community based research on the epidemiology, prevention, management, and microbiology of ECC would also be beneficial.

I would like to express my appreciation to Professor Anthony Blinkhorn and Dr. Fiona Blinkhorn in initiating and supporting my work in this field. I owe thanks to Dr. Aunwaya Kaewpitak for her patient's picture of ECC. My special thanks go to Mr. Mitchell Atkins and

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**3. Conclusion** 

**4. Acknowledgment** 

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**22** 

*Brazil* 

**Systemic Methods of Fluoride** 

**and the Risk for Dental Fluorosis** 

Consuelo Fernanda Macedo de Souza, José Ferreira Lima Júnior, Maria Soraya P. Franco Adriano and Fabio Correia Sampaio *Federal University of Paraíba and Federal University of Campina Grande* 

The benefits from ingesting fluoride for controlling dental caries have been suggested more than a century ago. Later in the 1940s, the well conducted water fluoridation program developed in the United States established the potential for delivering fluoride in public water supplies which opened the opportunity for other systemic methods: salt, milk and supplements (Hunstadbraten, 1982; Hoffmann-Axthelm, 1981). Due to its systemic effect, fluoride has been regarded as effective only if ingested for a long period. The low doses proposed were regarded as safe enough to guarantee the most beneficial effect against

From a historical perspective, the use of fluoride can be divided into two periods: 1) the earlier era, which goes from 1940s up to 1960s, when water fluoridation was basically the only source of fluoride ingestion and 2) the later era when fluoride could be ingested from multiple sources (soft drinks, infant formulas, vitamins, tablets) (Murray et al., 1991). Hence, due to the widespread of fluoride and the updated knowledge about its mechanisms of action, the general opinion about effectiveness and risk of systemic methods of fluoride are completely different from decades ago. Nevertheless, these methods are still recommended in many countries and receive support from recognized international committees and associations. In contrast, many dental practitioners have conflicting opinions about the safety and benefits of having a water fluoridation program

In addition to the multiple sources of fluoride, the systemic methods for delivering fluoride are also questioned because several studies have consistently indicated that fluoride's action relies mainly on its post-eruptive effect from topical contact with the tooth structure. The situation gets more obscure when the emerging problem of dental fluorosis can also be attributed to early uncontrolled ingestion of fluoride toothpaste by children as well as other sources (Hellwig & Lennon, 2004; Sampaio & Levy, 2011). This may give the impression that a widely used topical method of fluoride such as dentifrice is the solely contributor for dental fluorosis whereas a systemic method of fluoride such as water fluoridation is ineffective since it is a systemic method to deliver fluoride and most of fluoride effect comes from topical sources. These are points of view which can jeopardize the use of fluoride on an

**1. Introduction** 

in their city.

dental caries with minimal fluorosis.

individual basis or in a community level.


### **Systemic Methods of Fluoride and the Risk for Dental Fluorosis**

Consuelo Fernanda Macedo de Souza, José Ferreira Lima Júnior, Maria Soraya P. Franco Adriano and Fabio Correia Sampaio *Federal University of Paraíba and Federal University of Campina Grande Brazil* 

#### **1. Introduction**

356 Oral Health Care – Prosthodontics, Periodontology, Biology, Research and Systemic Conditions

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The benefits from ingesting fluoride for controlling dental caries have been suggested more than a century ago. Later in the 1940s, the well conducted water fluoridation program developed in the United States established the potential for delivering fluoride in public water supplies which opened the opportunity for other systemic methods: salt, milk and supplements (Hunstadbraten, 1982; Hoffmann-Axthelm, 1981). Due to its systemic effect, fluoride has been regarded as effective only if ingested for a long period. The low doses proposed were regarded as safe enough to guarantee the most beneficial effect against dental caries with minimal fluorosis.

From a historical perspective, the use of fluoride can be divided into two periods: 1) the earlier era, which goes from 1940s up to 1960s, when water fluoridation was basically the only source of fluoride ingestion and 2) the later era when fluoride could be ingested from multiple sources (soft drinks, infant formulas, vitamins, tablets) (Murray et al., 1991). Hence, due to the widespread of fluoride and the updated knowledge about its mechanisms of action, the general opinion about effectiveness and risk of systemic methods of fluoride are completely different from decades ago. Nevertheless, these methods are still recommended in many countries and receive support from recognized international committees and associations. In contrast, many dental practitioners have conflicting opinions about the safety and benefits of having a water fluoridation program in their city.

In addition to the multiple sources of fluoride, the systemic methods for delivering fluoride are also questioned because several studies have consistently indicated that fluoride's action relies mainly on its post-eruptive effect from topical contact with the tooth structure. The situation gets more obscure when the emerging problem of dental fluorosis can also be attributed to early uncontrolled ingestion of fluoride toothpaste by children as well as other sources (Hellwig & Lennon, 2004; Sampaio & Levy, 2011). This may give the impression that a widely used topical method of fluoride such as dentifrice is the solely contributor for dental fluorosis whereas a systemic method of fluoride such as water fluoridation is ineffective since it is a systemic method to deliver fluoride and most of fluoride effect comes from topical sources. These are points of view which can jeopardize the use of fluoride on an individual basis or in a community level.

Systemic Methods of Fluoride and the Risk for Dental Fluorosis 359

topical. The fluoride present in the fluid phases of the oral environment is the most

Since fluoride may inhibit the demineralization or enhance remineralization mainly by topical processes, the most effective fluoride regimens are those when frequent low fluoride concentrations are achieved in the oral environment. As a result, topical methods for delivering fluoride gained a status of most effective ones (Limeback, 1999). However, one must bear in mind that traditional systemic methods such as water fluoridation cannot be excluded because its effectiveness can be also topical though in general it is classified as systemic fluoride method. Another point of remark is that regardless the method (topical or systemic) fluoride treatments do not introduce a new substance but rather increase the concentration of an existing one in the oral environment. It must be pointed out that fluoride may also have some antibacterial effect when high concentrations are maintained in the oral cavity. This effect is mainly achieved in topical applications of very high amount of fluoride incorporated in the formula such as varnishes and gels. Hence, it can be suggested that fluoride has more than one mechanism of action for caries arrestment and these mechanisms can be simultaneously in action when exposure to fluoride takes place. Since dental caries is a multifactorial disease caused by the interplay of different factors of the oral environment the duration and cessation of a fluoride exposure must be considered when searching for its

The beneficial interference of fluoride in the caries development is directly dependent on a constant and permanent level of fluoride in the oral environment (Fejerskov, 2004). There is no need for a high concentration of fluoride because low concentrations can be sufficient for the control of mineral tooth loss. This is a key point when considering the use of fluoride for caries preventive purposes which is different from caries arrestment (Sampaio & Levy, 2011). According to Buzalaf (2011), a good understanding of the mechanism of action of fluoride can be achieved if you consider five "pools" of fluoride categories in the oral environment: 1) outer fluoride (present outside enamel, in the biofilm or saliva), 2) fluoride in the solid phase (incorporated in the mineral structure, also known as fluorhydroyapatite), 3) fluoride in the enamel fluid, 4) fluoride adsorbed in the crystal surface, also known as loosely-bound and finally 5) calcium fluoride material (Ca2F, globules that are formed just after the application of high concentrated fluoride products such as varnishes and gels) (Figure 1). Our current understanding about the mechanisms of action of fluoride can be summarized when these categories are evaluated in two aspects: fluoride effect on the inhibition of demineralization and its effect on promoting remineralization. Both are processes of the same chemical reaction and both are equally important for caries control.

The fluoride category known as loosely-bound fluoride is the "pool" that effectively protects the dental enamel from mineral dissolution. Note that the fluoride incorporated in the solid phase has little or no effect. However, the fluoride present in the enamel fluid is also important since this is the fluoride category that can increase the loosely-bound fluoride which protects the enamel crystal by inhibition of demineralization (Arends & Christoffersen, 1990). The calcium fluoride category is also an important source of fluoride and it is formed when there is more than 100 ppm of fluoride in the oral environment. This means that this type of fluoride is available when dental products are used. The mechanism of action of this fluoride category can be explained by the formation of calcium fluoride

important strategy for controlling dental caries (Buzalaf, 2011).

mechanism of action.

**2.1 Inhibition of demineralization** 

One of the main problems when studying fluoride in Dentistry is its paradox of combining beneficial and pathological effects in the same chemical element. Taking other water contaminants such as arsenic, there is no doubt about its deleterious effects on human health. Moreover, no beneficial effect exists when considering an ingestion of low doses of arsenic (Hughes, 2002). For fluoride the situation is different. There is an evident advantageous clinical effect when low doses are used together with the concomitant risk for dental fluorosis. Since the borderline of benefits and risks of fluoride can be rather close, researchers around the world have focused on strategies for controlling the amount of fluoride intake. In addition, other aspects on the use of fluoride must be discussed. For instance, there are many epidemiological and biological evidences that ingestion of high amount of fluoride can result in aesthetically undesirable dental fluorosis; how much of this effect is unacceptable is a matter of debate. As a result of the fluoride debate, more and more clinicians and researchers regard this issue as an important topic for discussion and a challenging problem for dental professionals.

Thus, the aim of this paper is to critically review the current role of systemic methods to deliver fluoride considering the risk for dental fluorosis.

#### **2. The mechanism of action of fluoride**

Although the mechanism of action of fluoride is well established today, a series of studies was necessary to recognize its cariostatic effect.

Fluoride is an ion naturally found on soil, air and water due to chemical weathering of minerals that contains this element (Murray at el., 1991). This ion has the capacity of inhibiting and activating enzymatic systems as well as a tendency to fixate on hard tissues (bones and teeth). On the teeth this fixation occurs through the substitution of the hydroxyl ion from the hydroxyapatite by the fluoride ion resulting on fluorapatite during the demineralization–remineralization process of the enamel. One interesting observation is that the fluoride effect on the de-remineralization equilibrium is of outmost relevancy, being more important than the incorporation of fluoride in the dental tissue. Actually, this incorporation is an obvious consequence of the fluoride effect on the demineralizationremineralization process and not the beneficial aspect in itself as it has been thought previously (Fejerskov, 2004). One important study that demonstrated that fluoride incorporated into enamel (structurally bound fluoride) was not effective in inhibiting demineralization of a hard tissue was carried out in Scandinavia (Øggard et al., 1988). The researchers prepared in situ devices and placed human and shark enamel slabs in oral appliances. Why shark enamel? The shark enamel is composed of pure fluorapatite (30,000 ppm) whereas the maximum amount of fluoride in human enamel is much lower (4,800 ppm). The oral removable appliances were used by volunteers that allowed bacterial plaque accumulation (oral biofilms) and the development of carious lesions. Microradiographic analyses showed that carious lesions were present in both types of enamel tissues (human and shark). One first conclusion of this study was that incorporation of fluoride into enamel is not the main mechanism for controlling dental caries development. Moreover, the authors compared the mineral loss data obtained to previous data of enamel exposed to 0.2% of sodium fluoride. The results showed that the mineral loss in human enamel exposed to sodium fluoride was lower than that of shark enamel without any additional treatment. In summary, this work provided evidence that the primary mode of action of fluoride is

One of the main problems when studying fluoride in Dentistry is its paradox of combining beneficial and pathological effects in the same chemical element. Taking other water contaminants such as arsenic, there is no doubt about its deleterious effects on human health. Moreover, no beneficial effect exists when considering an ingestion of low doses of arsenic (Hughes, 2002). For fluoride the situation is different. There is an evident advantageous clinical effect when low doses are used together with the concomitant risk for dental fluorosis. Since the borderline of benefits and risks of fluoride can be rather close, researchers around the world have focused on strategies for controlling the amount of fluoride intake. In addition, other aspects on the use of fluoride must be discussed. For instance, there are many epidemiological and biological evidences that ingestion of high amount of fluoride can result in aesthetically undesirable dental fluorosis; how much of this effect is unacceptable is a matter of debate. As a result of the fluoride debate, more and more clinicians and researchers regard this issue as an important topic for discussion and a

Thus, the aim of this paper is to critically review the current role of systemic methods to

Although the mechanism of action of fluoride is well established today, a series of studies

Fluoride is an ion naturally found on soil, air and water due to chemical weathering of minerals that contains this element (Murray at el., 1991). This ion has the capacity of inhibiting and activating enzymatic systems as well as a tendency to fixate on hard tissues (bones and teeth). On the teeth this fixation occurs through the substitution of the hydroxyl ion from the hydroxyapatite by the fluoride ion resulting on fluorapatite during the demineralization–remineralization process of the enamel. One interesting observation is that the fluoride effect on the de-remineralization equilibrium is of outmost relevancy, being more important than the incorporation of fluoride in the dental tissue. Actually, this incorporation is an obvious consequence of the fluoride effect on the demineralizationremineralization process and not the beneficial aspect in itself as it has been thought previously (Fejerskov, 2004). One important study that demonstrated that fluoride incorporated into enamel (structurally bound fluoride) was not effective in inhibiting demineralization of a hard tissue was carried out in Scandinavia (Øggard et al., 1988). The researchers prepared in situ devices and placed human and shark enamel slabs in oral appliances. Why shark enamel? The shark enamel is composed of pure fluorapatite (30,000 ppm) whereas the maximum amount of fluoride in human enamel is much lower (4,800 ppm). The oral removable appliances were used by volunteers that allowed bacterial plaque accumulation (oral biofilms) and the development of carious lesions. Microradiographic analyses showed that carious lesions were present in both types of enamel tissues (human and shark). One first conclusion of this study was that incorporation of fluoride into enamel is not the main mechanism for controlling dental caries development. Moreover, the authors compared the mineral loss data obtained to previous data of enamel exposed to 0.2% of sodium fluoride. The results showed that the mineral loss in human enamel exposed to sodium fluoride was lower than that of shark enamel without any additional treatment. In summary, this work provided evidence that the primary mode of action of fluoride is

challenging problem for dental professionals.

**2. The mechanism of action of fluoride** 

was necessary to recognize its cariostatic effect.

deliver fluoride considering the risk for dental fluorosis.

topical. The fluoride present in the fluid phases of the oral environment is the most important strategy for controlling dental caries (Buzalaf, 2011).

Since fluoride may inhibit the demineralization or enhance remineralization mainly by topical processes, the most effective fluoride regimens are those when frequent low fluoride concentrations are achieved in the oral environment. As a result, topical methods for delivering fluoride gained a status of most effective ones (Limeback, 1999). However, one must bear in mind that traditional systemic methods such as water fluoridation cannot be excluded because its effectiveness can be also topical though in general it is classified as systemic fluoride method. Another point of remark is that regardless the method (topical or systemic) fluoride treatments do not introduce a new substance but rather increase the concentration of an existing one in the oral environment. It must be pointed out that fluoride may also have some antibacterial effect when high concentrations are maintained in the oral cavity. This effect is mainly achieved in topical applications of very high amount of fluoride incorporated in the formula such as varnishes and gels. Hence, it can be suggested that fluoride has more than one mechanism of action for caries arrestment and these mechanisms can be simultaneously in action when exposure to fluoride takes place. Since dental caries is a multifactorial disease caused by the interplay of different factors of the oral environment the duration and cessation of a fluoride exposure must be considered when searching for its mechanism of action.

The beneficial interference of fluoride in the caries development is directly dependent on a constant and permanent level of fluoride in the oral environment (Fejerskov, 2004). There is no need for a high concentration of fluoride because low concentrations can be sufficient for the control of mineral tooth loss. This is a key point when considering the use of fluoride for caries preventive purposes which is different from caries arrestment (Sampaio & Levy, 2011). According to Buzalaf (2011), a good understanding of the mechanism of action of fluoride can be achieved if you consider five "pools" of fluoride categories in the oral environment: 1) outer fluoride (present outside enamel, in the biofilm or saliva), 2) fluoride in the solid phase (incorporated in the mineral structure, also known as fluorhydroyapatite), 3) fluoride in the enamel fluid, 4) fluoride adsorbed in the crystal surface, also known as loosely-bound and finally 5) calcium fluoride material (Ca2F, globules that are formed just after the application of high concentrated fluoride products such as varnishes and gels) (Figure 1). Our current understanding about the mechanisms of action of fluoride can be summarized when these categories are evaluated in two aspects: fluoride effect on the inhibition of demineralization and its effect on promoting remineralization. Both are processes of the same chemical reaction and both are equally important for caries control.

#### **2.1 Inhibition of demineralization**

The fluoride category known as loosely-bound fluoride is the "pool" that effectively protects the dental enamel from mineral dissolution. Note that the fluoride incorporated in the solid phase has little or no effect. However, the fluoride present in the enamel fluid is also important since this is the fluoride category that can increase the loosely-bound fluoride which protects the enamel crystal by inhibition of demineralization (Arends & Christoffersen, 1990). The calcium fluoride category is also an important source of fluoride and it is formed when there is more than 100 ppm of fluoride in the oral environment. This means that this type of fluoride is available when dental products are used. The mechanism of action of this fluoride category can be explained by the formation of calcium fluoride

Systemic Methods of Fluoride and the Risk for Dental Fluorosis 361

fluoride will provide a more resistant tissue to dental caries which is not in tune with the actual understanding of fluoride's mode of action (Fejerskov, 2004). However, it must be emphasized that the incorporation of fluoride in this situation is only possible due to the fact that there is a partial dissolved crystal which presents free calcium for fluoride incorporation. Thus, the frequent presence of fluoride in the oral environment during the acidic challenge is as relevant as it is its effect of incorporation. Hence the presence of fluoride at high concentrations is a key strategy for caries control or arrestment of carious

In addition to the understanding of fluoride modes of action, it is also important to observe the concentrations of fluoride used in different methods. The ideal or 'optimal' concentration of fluoride will be the one that will have maximum preventive effect with a minimal risk for dental fluorosis. This is rather difficult to consider since individual variations in fluoride bioavailability and cultural habits may influence the intake of fluoride

It must be pointed out that the classification of 'systemic' and 'topic' is related to its way of delivery and not to its mode of action. In other words, the mode of action of water fluoridation for caries control is explained by the topical contact of water fluoride on the teeth when someone is drinking water and eating food prepared with fluoridated water. One additional effect is the redistribution of fluoride in the oral cavity by means of saliva (Whitford, 1996). Hence, as stated before, fluoride acts mainly by its topical effect but this is not an argument to invalidate the systemic methods of fluoride. On the other hand, topical and 'systemic' methods of fluoride delivery may be involved with a high rate of fluoride ingestion. Taking fluoride toothpaste as an example, it is classified as a topical method but there is no guarantee that some ingestion of fluoride may occur when a child is under

So, if low sustained levels of fluoride is maintained in the oral fluids, some level of loosely bound fluoride will be available and a significantly control of caries progression and also reversal of carious lesions may occur. The low levels of fluoride are those found after many hours on resting dental plaque and saliva, and resulting from the regular use of fluoride toothpastes. Another source of low levels of fluoride are the constant exposure to this substance from water, milk, salt or whatsoever source is available on the oral environment

The only recognized side effects of high ingestion of fluoride are dental and skeletal fluorosis (Whitford, 1996). Since skeletal fluorosis occurs only in naturally fluoridated regions where extreme high concentrations of fluoride are found in the water, the focus of this chapter will be on dental fluorosis. In addition to the dose differences for the risk of dental and skeletal fluorosis, one must bear in mind that individuals with dental fluorosis are those who were exposed to fluoride from birth up to 6-7 years of age, exactly the period of tooth formation. For skeletal fluorosis the context is much more complicated. The doseresponse outcome is not clear since the different ages reflect different "turn-over" of fluoride in bones. In addition to age and fluoride dose, variables such as gender, calcium intake from the diet, duration of fluoride intake and renal efficiency in fluoride handling are relevant

from systemic methods such as water, salt or milk (Newbrun, 2010).

lesions (Featherstone, 1999).

toothbrushing procedure.

(Lynch et al., 2004).

**3. Dental fluorosis** 

**2.3 How much fluoride is necessary?** 

(Ca2F) and its dissolution when there is a pH fall (acidic challenge). During this acid attack, the calcium fluoride material (globules) are dissolved releasing an ionic fluoride, in other words, a fluoride that will be present at the enamel fluid which can be adsorbed by the enamel crystal avoiding the demineralization process. In summary, the loosely bound and calcium fluoride material are sources of fluoride that will protect the enamel from the mineral loss.

Fig. 1. Schematic representation of fluoride effect on tooth enamel. Note that the numbers represent different categories of fluoride: (1) outer fluoride, (2) fluoride incorporated in the mineral structure, (3) fluoride in the enamel fluid, (4) fluoride adsorbed in the crystal surface, also known as loosely-bound, (5) calcium fluoride material (Ca2F, globules that are formed just after the application of high concentrated fluoride products)

#### **2.2 Promoting remineralization**

When a carious lesion is already present, an acidic challenge is frequently occurring. Under this circumstance, when pH is below 5.5 – a critical pH for dental enamel, the remineralization can naturally take place since saliva is generally supersaturated with respect to dental enamel. If fluoride is present in this acidic medium during dissolution of hydroxyapatite, the solution will be highly supersaturated with respect to hydroxyapatite and all potential mineral loss will actually be preserved in the partially demineralized dental crystals. In other words, traces of fluoride in the fluid phase can control mineral loss. After several cycles of dissolution and reprecipitation, the enamel crystals will be somehow more resistant to future acidic challenges. At this point one may argue that the incorporation of fluoride will provide a more resistant tissue to dental caries which is not in tune with the actual understanding of fluoride's mode of action (Fejerskov, 2004). However, it must be emphasized that the incorporation of fluoride in this situation is only possible due to the fact that there is a partial dissolved crystal which presents free calcium for fluoride incorporation. Thus, the frequent presence of fluoride in the oral environment during the acidic challenge is as relevant as it is its effect of incorporation. Hence the presence of fluoride at high concentrations is a key strategy for caries control or arrestment of carious lesions (Featherstone, 1999).

#### **2.3 How much fluoride is necessary?**

360 Oral Health Care – Prosthodontics, Periodontology, Biology, Research and Systemic Conditions

(Ca2F) and its dissolution when there is a pH fall (acidic challenge). During this acid attack, the calcium fluoride material (globules) are dissolved releasing an ionic fluoride, in other words, a fluoride that will be present at the enamel fluid which can be adsorbed by the enamel crystal avoiding the demineralization process. In summary, the loosely bound and calcium fluoride material are sources of fluoride that will protect the enamel from the

Fig. 1. Schematic representation of fluoride effect on tooth enamel. Note that the numbers represent different categories of fluoride: (1) outer fluoride, (2) fluoride incorporated in the mineral structure, (3) fluoride in the enamel fluid, (4) fluoride adsorbed in the crystal surface, also known as loosely-bound, (5) calcium fluoride material (Ca2F, globules that are

When a carious lesion is already present, an acidic challenge is frequently occurring. Under this circumstance, when pH is below 5.5 – a critical pH for dental enamel, the remineralization can naturally take place since saliva is generally supersaturated with respect to dental enamel. If fluoride is present in this acidic medium during dissolution of hydroxyapatite, the solution will be highly supersaturated with respect to hydroxyapatite and all potential mineral loss will actually be preserved in the partially demineralized dental crystals. In other words, traces of fluoride in the fluid phase can control mineral loss. After several cycles of dissolution and reprecipitation, the enamel crystals will be somehow more resistant to future acidic challenges. At this point one may argue that the incorporation of

formed just after the application of high concentrated fluoride products)

**2.2 Promoting remineralization** 

mineral loss.

In addition to the understanding of fluoride modes of action, it is also important to observe the concentrations of fluoride used in different methods. The ideal or 'optimal' concentration of fluoride will be the one that will have maximum preventive effect with a minimal risk for dental fluorosis. This is rather difficult to consider since individual variations in fluoride bioavailability and cultural habits may influence the intake of fluoride from systemic methods such as water, salt or milk (Newbrun, 2010).

It must be pointed out that the classification of 'systemic' and 'topic' is related to its way of delivery and not to its mode of action. In other words, the mode of action of water fluoridation for caries control is explained by the topical contact of water fluoride on the teeth when someone is drinking water and eating food prepared with fluoridated water. One additional effect is the redistribution of fluoride in the oral cavity by means of saliva (Whitford, 1996). Hence, as stated before, fluoride acts mainly by its topical effect but this is not an argument to invalidate the systemic methods of fluoride. On the other hand, topical and 'systemic' methods of fluoride delivery may be involved with a high rate of fluoride ingestion. Taking fluoride toothpaste as an example, it is classified as a topical method but there is no guarantee that some ingestion of fluoride may occur when a child is under toothbrushing procedure.

So, if low sustained levels of fluoride is maintained in the oral fluids, some level of loosely bound fluoride will be available and a significantly control of caries progression and also reversal of carious lesions may occur. The low levels of fluoride are those found after many hours on resting dental plaque and saliva, and resulting from the regular use of fluoride toothpastes. Another source of low levels of fluoride are the constant exposure to this substance from water, milk, salt or whatsoever source is available on the oral environment (Lynch et al., 2004).

#### **3. Dental fluorosis**

The only recognized side effects of high ingestion of fluoride are dental and skeletal fluorosis (Whitford, 1996). Since skeletal fluorosis occurs only in naturally fluoridated regions where extreme high concentrations of fluoride are found in the water, the focus of this chapter will be on dental fluorosis. In addition to the dose differences for the risk of dental and skeletal fluorosis, one must bear in mind that individuals with dental fluorosis are those who were exposed to fluoride from birth up to 6-7 years of age, exactly the period of tooth formation. For skeletal fluorosis the context is much more complicated. The doseresponse outcome is not clear since the different ages reflect different "turn-over" of fluoride in bones. In addition to age and fluoride dose, variables such as gender, calcium intake from the diet, duration of fluoride intake and renal efficiency in fluoride handling are relevant

Systemic Methods of Fluoride and the Risk for Dental Fluorosis 363

30.0

70.0

57.5 62.5

33.3

66.7

42.5 37.7

73.1 71.0

26.9 29.0

**Malnourished (n = 137)** 

**Low water Fluoride (< 0.7ppm)**

**Moderate Waer Fluoride (0,7-1.0 ppm)**

**Moderate Water Fluoride** 

**( n = 24)**

**(** *n* **= 87)**

**High Water Fluoride (1.0 – 4.8 ppm)**

**(** *n* **= 26)**

**Well-nourished**

**(***n* **=140)**

**No fluorosis**

**With fluorosis**

**(n =273)**

**(n = 100)**

**(n = 513)**

Fig. 3. Distribution of children with and without dental fluorosis in an epidemiologic study assessing the influence of malnutrition on the risk for dental fluorosis. (Source: Sampaio et

There is some consensus that the mechanism by which fluoride interferes with the enamel maturation process that can result in fluorosis is a multi-factorial model (den Besten & Li, 2011). The major theory behind this mechanism is the retention of amelogenin proteins that delay the maturation of the enamel. As a result, the enamel becomes hypomineralized and

al., 1999)

factors which influence the outcome. The bone lesions are a combination of osteosclerosis, osteomalacia and osteoporosis of varying degrees which can also make diagnosis a difficult task (Krishnamachari, 1996).

Dental fluorosis is an enamel opacity due to a long-term ingestion of fluoride during tooth formation period. The tooth appearance can vary from narrow white lines to "cloudy" white spots or brown areas with pits. Loss of enamel is also frequent in more severe cases (Figure 2).

Fig. 2. This is a case of severe dental fluorosis in a 13-year-old child who consumed naturally water fluoride with 4.8 ppm. Note that the dark brown stains are limited to upper incisors. The lower incisors were the less affected teeth

The severity of the disease will depend on several factors such as dosage, duration of exposition, the activity stage of the protein, age and individual susceptibility. Fluorotic enamel is characterized by the retention of amelogenins in the early maturation stage of development and the formation of enamel which have a hypomineralized subsurface and more porous tissue. This is a conflicting point. Since dental fluorosis is related to high consumption of fluoride during tooth development, many dental professionals make the assumption that this tooth condition is related to a high concentration of fluoride in the dental tissues (enamel and dentin). Actually, it is the opposite situation. The white chalk appearance of the enamel is related to the light refraction of this tissue that presents a high porous appearance due the hypomineralized subsurface (Levy, 2003).

There are many individual and environmental variables that may interfere with the severity of dental fluorosis. Malnutrition has been one of these variables (Murray et al., 1991). However, in a study performed in the semi-arid region of Brazil where there was a 20% prevalence of malnutrition the prevalence of dental fluorosis was virtually the same regardless the fluoride level in the drinking water (Sampaio et al., 1999). However, the observation that malnutrition prevalence was not related to dental fluorosis cannot be disregarded since this is an epidemiologic observation for a specific group.

Genetic background appears to have a role in the pathogenesis of dental fluorosis. Moreover, altitude, renal problems and individual cultural habits may also be considered (Buzalaf, 2011).

factors which influence the outcome. The bone lesions are a combination of osteosclerosis, osteomalacia and osteoporosis of varying degrees which can also make diagnosis a difficult

Dental fluorosis is an enamel opacity due to a long-term ingestion of fluoride during tooth formation period. The tooth appearance can vary from narrow white lines to "cloudy" white spots or brown areas with pits. Loss of enamel is also frequent in more severe cases (Figure

Fig. 2. This is a case of severe dental fluorosis in a 13-year-old child who consumed naturally water fluoride with 4.8 ppm. Note that the dark brown stains are limited to upper incisors.

The severity of the disease will depend on several factors such as dosage, duration of exposition, the activity stage of the protein, age and individual susceptibility. Fluorotic enamel is characterized by the retention of amelogenins in the early maturation stage of development and the formation of enamel which have a hypomineralized subsurface and more porous tissue. This is a conflicting point. Since dental fluorosis is related to high consumption of fluoride during tooth development, many dental professionals make the assumption that this tooth condition is related to a high concentration of fluoride in the dental tissues (enamel and dentin). Actually, it is the opposite situation. The white chalk appearance of the enamel is related to the light refraction of this tissue that presents a high

There are many individual and environmental variables that may interfere with the severity of dental fluorosis. Malnutrition has been one of these variables (Murray et al., 1991). However, in a study performed in the semi-arid region of Brazil where there was a 20% prevalence of malnutrition the prevalence of dental fluorosis was virtually the same regardless the fluoride level in the drinking water (Sampaio et al., 1999). However, the observation that malnutrition prevalence was not related to dental fluorosis cannot be

Genetic background appears to have a role in the pathogenesis of dental fluorosis. Moreover, altitude, renal problems and individual cultural habits may also be considered

porous appearance due the hypomineralized subsurface (Levy, 2003).

disregarded since this is an epidemiologic observation for a specific group.

task (Krishnamachari, 1996).

The lower incisors were the less affected teeth

(Buzalaf, 2011).

2).

Fig. 3. Distribution of children with and without dental fluorosis in an epidemiologic study assessing the influence of malnutrition on the risk for dental fluorosis. (Source: Sampaio et al., 1999)

There is some consensus that the mechanism by which fluoride interferes with the enamel maturation process that can result in fluorosis is a multi-factorial model (den Besten & Li, 2011). The major theory behind this mechanism is the retention of amelogenin proteins that delay the maturation of the enamel. As a result, the enamel becomes hypomineralized and

Systemic Methods of Fluoride and the Risk for Dental Fluorosis 365

beverages consumed less than tap water, but these products can be a source of fluoride. Considering that the highest industrialized part of the country is receiving fluoridated water, a 'halo effect' is likely to be significant. In fluoridated areas, powder milk and infant formulas can be extra sources of fluoride due to the additive effect of the fluoridated water

Estimates of infant fluoride intake from Brazilian food are considered to be low and seldom more than 0.25 mg daily. However, in a fluoridated city (0.7 ppm), the estimated fluoride intake including the fluoride products (toothpaste and rinse) may increase and possibly reach the threshold for dental fluorosis according to the fluorosis index for the community

How much fluoride can result in dental fluorosis? This is a general question that is always present among dentists, patients and health authorities. First it must be pointed out that even individuals with a very low fluoride intake from the water might show some degree of dental fluorosis. Considering the intake solely by water, the amount of fluoride can be directly related to some effect. However, this is not that simple anymore since other sources of fluoride are available nowadays (Levy, 2003). Therefore the 'optimal' fluoride level that would prevent caries without resulting in fluorosis is somehow a theoretical value since bioavailability of fluoride varies among individuals (Sampaio et al., 1999). Nevertheless, the dose that may cause dental fluorosis is within the range of 0.05-0.07 mg F/Kg body weight per day. This means that children who present a fluoride intake above the threshold of 0.07 mg F/Kg per day will probably present some degree of dental fluorosis (Buzalaf, 2011). The upper central incisors are the teeth of more aesthetic concern. The risk period of fluorosis for maxillary central incisor teeth is between 15 and 24 months for males and between 21 and 30

**4. Systemic fluoridation methods and the risk for dental fluorosis** 

In spite of the safety of most methods of fluoride delivery, an overlap of systemic methods may take place. There is also the risk of a high intake of fluoride due to a combination of water fluoridation and the ingestion of fluoride from toothpastes (Sampaio & Levy, 2011). These are important aspects that a dental professional must consider before establishing a fluoridation program on an individual basis or as an authority in public health office. This is a specific relevant issue regarding systemic fluoride methods. In most circumstances, the dental professionals just follow political decisions about these methods. In many cases the information is scarce and most part of the population is not aware of fluoridation programs. In spite of the general decisions taken by groups or general assemblies, the professional must be aware if a systemic fluoride method is being applied in their own community. For instance, most Brazilian dentists are not aware if there is a water fluoridation program in their hometown in spite of the fact that there is a national program for water fluoridation (Sampaio et al., 2010). This is also valid for countries where salt fluoridation is available and the dentist do not ask if the patient is a fluoride salt consumer. Some authorities consider that systemic fluoride methods are advantageous in comparison to topical methods because the beneficial effect occurs without the evident knowledge of the patient and also the dentist. This is rather disturbing since the lack of knowledge on whether a systemic method is available can create at least two negative interpretations. First, not knowing if someone is drinking fluoridated water or consuming fluoridated salt can jeopardize any community program since most people will not be aware of the beneficial aspect of the measure. Second,

(Sampaio et al., 2010).

(Omena et al., 2006).

months for females (Bårdsen, 1999).

porous. The understanding of these events is important because the dental fluorosis diagnosis is sometimes complicated by other enamel defects (Levy, 2003).

Discoloration of the enamel, as seen in figure 2, is due to a secondary uptake of colored substances into the porous enamel. Thus, this is actually a posteruptive condition due to dietary habits and not an indication of fluorosis severity (Sampaio & Levy, 2011).

During the examination for dental fluorosis, the enamel surface must be clean and dry. When the enamel surface is dried, the water in the enamel pores will be replaced by air. Hence, even slight enamel opacities can be observed. This procedure, which is used for scoring fluorosis with a fluorosis index (Dean index or Thysltrup and Fejerskov index), can classify dental fluorosis on different degrees, and differentiate fluorosis from other enamel opacities (Murray et al., 1991).

Fig. 4. The clinical appearance of carious lesions known as white spots. Note the opaque aspect of the lesions, the curved shapes close to the gingival margin. These are some of the points to consider that these white lesions are not related to dental fluorosis. In addition, the lesions are limited to gingival margin. The patient has also gingivitis in a clear indication that these are active carious lesions. The final diagnosis is confirmed by the fact that the patient did not live in areas with water fluoridation systems and avoided the use of fluoride toothpaste since childhood

Enamel hypoplasias are the most common opacity to be confounded with fluorosis. However, hypoplasias are generally enamel lesions of round or oval shapes with marked borders. In addition, hypoplasia may affect a single tooth in contrast to fluorosis that can be observed in contralateral teeth or in the whole dentition. These basic features can help the clinician to differentiate these opacities from fluorosis.

In recent years it has been noticed that the prevalence of enamel fluorosis is increasing in several countries. However less than 40% of dental fluorosis is caused by ingestion of water while the majority is caused by the halo effect that is the addition of the other sources of fluoride such as industrialized food and beverages (Buzalaf, 2011). In Brazil, soft drinks are

porous. The understanding of these events is important because the dental fluorosis

Discoloration of the enamel, as seen in figure 2, is due to a secondary uptake of colored substances into the porous enamel. Thus, this is actually a posteruptive condition due to

During the examination for dental fluorosis, the enamel surface must be clean and dry. When the enamel surface is dried, the water in the enamel pores will be replaced by air. Hence, even slight enamel opacities can be observed. This procedure, which is used for scoring fluorosis with a fluorosis index (Dean index or Thysltrup and Fejerskov index), can classify dental fluorosis on different degrees, and differentiate fluorosis from other enamel

Fig. 4. The clinical appearance of carious lesions known as white spots. Note the opaque aspect of the lesions, the curved shapes close to the gingival margin. These are some of the points to consider that these white lesions are not related to dental fluorosis. In addition, the lesions are limited to gingival margin. The patient has also gingivitis in a clear indication that these are active carious lesions. The final diagnosis is confirmed by the fact that the patient did not live in areas with water fluoridation systems and avoided the use of fluoride

Enamel hypoplasias are the most common opacity to be confounded with fluorosis. However, hypoplasias are generally enamel lesions of round or oval shapes with marked borders. In addition, hypoplasia may affect a single tooth in contrast to fluorosis that can be observed in contralateral teeth or in the whole dentition. These basic features can help the

In recent years it has been noticed that the prevalence of enamel fluorosis is increasing in several countries. However less than 40% of dental fluorosis is caused by ingestion of water while the majority is caused by the halo effect that is the addition of the other sources of fluoride such as industrialized food and beverages (Buzalaf, 2011). In Brazil, soft drinks are

diagnosis is sometimes complicated by other enamel defects (Levy, 2003).

opacities (Murray et al., 1991).

toothpaste since childhood

clinician to differentiate these opacities from fluorosis.

dietary habits and not an indication of fluorosis severity (Sampaio & Levy, 2011).

beverages consumed less than tap water, but these products can be a source of fluoride. Considering that the highest industrialized part of the country is receiving fluoridated water, a 'halo effect' is likely to be significant. In fluoridated areas, powder milk and infant formulas can be extra sources of fluoride due to the additive effect of the fluoridated water (Sampaio et al., 2010).

Estimates of infant fluoride intake from Brazilian food are considered to be low and seldom more than 0.25 mg daily. However, in a fluoridated city (0.7 ppm), the estimated fluoride intake including the fluoride products (toothpaste and rinse) may increase and possibly reach the threshold for dental fluorosis according to the fluorosis index for the community (Omena et al., 2006).

How much fluoride can result in dental fluorosis? This is a general question that is always present among dentists, patients and health authorities. First it must be pointed out that even individuals with a very low fluoride intake from the water might show some degree of dental fluorosis. Considering the intake solely by water, the amount of fluoride can be directly related to some effect. However, this is not that simple anymore since other sources of fluoride are available nowadays (Levy, 2003). Therefore the 'optimal' fluoride level that would prevent caries without resulting in fluorosis is somehow a theoretical value since bioavailability of fluoride varies among individuals (Sampaio et al., 1999). Nevertheless, the dose that may cause dental fluorosis is within the range of 0.05-0.07 mg F/Kg body weight per day. This means that children who present a fluoride intake above the threshold of 0.07 mg F/Kg per day will probably present some degree of dental fluorosis (Buzalaf, 2011). The upper central incisors are the teeth of more aesthetic concern. The risk period of fluorosis for maxillary central incisor teeth is between 15 and 24 months for males and between 21 and 30 months for females (Bårdsen, 1999).

#### **4. Systemic fluoridation methods and the risk for dental fluorosis**

In spite of the safety of most methods of fluoride delivery, an overlap of systemic methods may take place. There is also the risk of a high intake of fluoride due to a combination of water fluoridation and the ingestion of fluoride from toothpastes (Sampaio & Levy, 2011). These are important aspects that a dental professional must consider before establishing a fluoridation program on an individual basis or as an authority in public health office. This is a specific relevant issue regarding systemic fluoride methods. In most circumstances, the dental professionals just follow political decisions about these methods. In many cases the information is scarce and most part of the population is not aware of fluoridation programs. In spite of the general decisions taken by groups or general assemblies, the professional must be aware if a systemic fluoride method is being applied in their own community. For instance, most Brazilian dentists are not aware if there is a water fluoridation program in their hometown in spite of the fact that there is a national program for water fluoridation (Sampaio et al., 2010). This is also valid for countries where salt fluoridation is available and the dentist do not ask if the patient is a fluoride salt consumer. Some authorities consider that systemic fluoride methods are advantageous in comparison to topical methods because the beneficial effect occurs without the evident knowledge of the patient and also the dentist. This is rather disturbing since the lack of knowledge on whether a systemic method is available can create at least two negative interpretations. First, not knowing if someone is drinking fluoridated water or consuming fluoridated salt can jeopardize any community program since most people will not be aware of the beneficial aspect of the measure. Second,

Systemic Methods of Fluoride and the Risk for Dental Fluorosis 367

true today. A general estimate indicates that over 300 million people in almost 40 countries are exposed to fluoride from adjusted fluoridated water supplies. Most of the individuals of this estimation are located in the United States (195 million people). In spite of being a safe method, recently, the Department of Health and Human Services of the United States proposed a new standardized level of 0.7 ppm fluoride throughout the country as an appropriate level for maximizing benefits while minimizing any risks associated with excessive ingestion (Department of Health and Human Services, 2011). This a precaution measure and must not be interpreted as a limitation of water fluoridation. Actually, the precaution is based on the fact that temperature is no longer a good indicator of fluoride intake. First, most American children in summer live in air conditioning environment most part of their lives. Second, there is an evident raise in the use of dental fluoride products

In the early seventies several industrialized countries went through a bitter emotional fight about water fluoridation. In some countries, the anti-fluoride people were the winners of the public debate and fluoride was discredited. The fluoride fight did not subside until the people were able to see by themselves the dramatic improvements in their children's dental health and also the decline in their own dental bills due to topical fluoride and fluoride toothpastes. Even though water fluoridation is much more popular in the Americas than in European countries, this method can be regarded as a low cost method to deliver fluoride, particularly for those communities where oral health care and particularly fluoride dentifrices are not available and/or not affordable. Variables that influence the costs per capita of a fluoridation project include: a) the size of the community (the smaller the community, the higher the per capita cost); b) the prevalence of dental caries in the population; c) the number of water sources; d) the type of equipment; e) the fluoride compound and f) the availability of technical support (Sampaio & Levy, 2011). In general, there is a consensus that water fluoridation can be most advantageous for more deprived communities where other health policies are less available, however, at least for the Brazilian situation, water fluoridation is present in most affordable areas of the country whereas the regions where it is most needed it is not available yet (Gabardo et al., 2008). Water is by large the main source of fluoride intake for human beings (Whitfrod, 1996). In general, the natural fluoride present in the fresh-water do not exceed 0.3 ppm (mg/L). This is a matter of confusion. Most people do not differentiate the natural fluoride from the controlled water fluoridation programs. This is important since most severe cases of dental fluorosis are related to rural areas where the patients have been consuming high amount of fluoride in the water for a long time ( Sampaio et al., 1999). On the other hand there is the urban patient who is not exposed to high amounts of fluoride, in general the mother was careful enough to avoid ingestion of fluoride toothpaste and possibly only a mild fluorosis may occur. These are different situations and must be taken under different interpretations

because dental fluorosis perception is also different (Murray et al., 1991).

dental fluorosis is higher (Levy, 2003).

be underestimated (Sampaio & Levy, 2011).

For rural areas or more desert types of climate, one interesting strategy for public health is to monitor water fluoride levels in order to estimate the fluoride intake. Mapping fluoride in areas is very important because in many tropical areas the chances of finding severe cases of

Finally, it is already evident that the percentage level of effectiveness of water fluoridation in many areas is lower than in others due to the more widespread use of other fluoride modalities. Nevertheless, water fluoridation is still a valuable health measure and must not

which can result in an increase in the fluoride intake.

the ignorance can be an opportunity for a problem of overlapping methods. This was the case of Brazil in the 90´s when a national water fluoridation program would overlap with a proposal of salt fluoridation for the majority of the population (Kalamatianos & Narvai, 2006).

Another issue regarding the risk of dental fluorosis is: how much of fluorosis is acceptable? This is a real dilemma that can be solved by accepting that the use of fluoride products may result in mild dental fluorosis in the population. On the other hand, if fluoride is not used at all there is the inconvenience of not preventing the appearance of a disease (caries) that could be prevented if such product was used. This dilemma can be solved by admitting that the use of such products would be reasonable and that its benefit would exceed its damages. Moreover, the mild fluorosis that is produced in most cases has no significance at all for the majority of the population.

In addition to the fact that dentists must be aware of the systemic methods in their places of work, it is also important to know the types of fluoride that are used and the respective concentrations. Table 1 provides some of the fluoride salts that are commonly used for 'systemic method'.


Table 1. Fluoride compounds and concentrations that are usually used in different 'systemic' fluoride methods. (Source: Sampaio & Levy, 2011)

Here we have a review of most important aspects about some community systemic methods.

#### **4.1 Water fluoridation**

The water fluoridation is one of the most common delivery methods of fluoride. It presents a lower cost and long range. However for water fluoridation to be effective it has to be a continuous process and the concentration of fluoride has to be well controlled. The recommended concentration varies between 0.7 and 1.2 ppm, depending on the average regional temperature. The lower levels of fluoride are recommended for warmer regions. In these locations the intake of water tends to be higher (Sampaio et al., 2010).

Fluoridation of public water is considered to be one of the ten most important public health measures in the last century being recommended by international health organizations. In addition, there is scientific evidence proving beneficial and safe effects of fluoridation on human health. The inverse relationship between higher fluoride contents of drinking water and lower levels of dental caries experience demonstrated by Dean half century ago is still

the ignorance can be an opportunity for a problem of overlapping methods. This was the case of Brazil in the 90´s when a national water fluoridation program would overlap with a proposal of salt fluoridation for the majority of the population (Kalamatianos & Narvai,

Another issue regarding the risk of dental fluorosis is: how much of fluorosis is acceptable? This is a real dilemma that can be solved by accepting that the use of fluoride products may result in mild dental fluorosis in the population. On the other hand, if fluoride is not used at all there is the inconvenience of not preventing the appearance of a disease (caries) that could be prevented if such product was used. This dilemma can be solved by admitting that the use of such products would be reasonable and that its benefit would exceed its damages. Moreover, the mild fluorosis that is produced in most cases has no significance at all for the

In addition to the fact that dentists must be aware of the systemic methods in their places of work, it is also important to know the types of fluoride that are used and the respective concentrations. Table 1 provides some of the fluoride salts that are commonly used for

**F-methods F-compounds F-concentrations** 

fluorosilicate, sodium fluoride

phosphate fluoride, potassium fluoride, calcium fluoride

Table 1. Fluoride compounds and concentrations that are usually used in different 'systemic'

Here we have a review of most important aspects about some community systemic

The water fluoridation is one of the most common delivery methods of fluoride. It presents a lower cost and long range. However for water fluoridation to be effective it has to be a continuous process and the concentration of fluoride has to be well controlled. The recommended concentration varies between 0.7 and 1.2 ppm, depending on the average regional temperature. The lower levels of fluoride are recommended for warmer regions. In

Fluoridation of public water is considered to be one of the ten most important public health measures in the last century being recommended by international health organizations. In addition, there is scientific evidence proving beneficial and safe effects of fluoridation on human health. The inverse relationship between higher fluoride contents of drinking water and lower levels of dental caries experience demonstrated by Dean half century ago is still

these locations the intake of water tends to be higher (Sampaio et al., 2010).

Salt fluoridation potassium fluoride , sodium fluoride 250-300 mg/kg

monofluorophosphate

0.7 - 1.2 mg/L

0.25 – 1.0 mg/day

5 mg/L

Water fluoridation hydrofluorosilicate (FSA), sodium

Milk fluoridation Sodium fluoride or disodium

Dietary F-supplements sodium fluoride, acidulated

fluoride methods. (Source: Sampaio & Levy, 2011)

2006).

majority of the population.

'systemic method'.

methods.

**4.1 Water fluoridation** 

true today. A general estimate indicates that over 300 million people in almost 40 countries are exposed to fluoride from adjusted fluoridated water supplies. Most of the individuals of this estimation are located in the United States (195 million people). In spite of being a safe method, recently, the Department of Health and Human Services of the United States proposed a new standardized level of 0.7 ppm fluoride throughout the country as an appropriate level for maximizing benefits while minimizing any risks associated with excessive ingestion (Department of Health and Human Services, 2011). This a precaution measure and must not be interpreted as a limitation of water fluoridation. Actually, the precaution is based on the fact that temperature is no longer a good indicator of fluoride intake. First, most American children in summer live in air conditioning environment most part of their lives. Second, there is an evident raise in the use of dental fluoride products which can result in an increase in the fluoride intake.

In the early seventies several industrialized countries went through a bitter emotional fight about water fluoridation. In some countries, the anti-fluoride people were the winners of the public debate and fluoride was discredited. The fluoride fight did not subside until the people were able to see by themselves the dramatic improvements in their children's dental health and also the decline in their own dental bills due to topical fluoride and fluoride toothpastes. Even though water fluoridation is much more popular in the Americas than in European countries, this method can be regarded as a low cost method to deliver fluoride, particularly for those communities where oral health care and particularly fluoride dentifrices are not available and/or not affordable. Variables that influence the costs per capita of a fluoridation project include: a) the size of the community (the smaller the community, the higher the per capita cost); b) the prevalence of dental caries in the population; c) the number of water sources; d) the type of equipment; e) the fluoride compound and f) the availability of technical support (Sampaio & Levy, 2011). In general, there is a consensus that water fluoridation can be most advantageous for more deprived communities where other health policies are less available, however, at least for the Brazilian situation, water fluoridation is present in most affordable areas of the country whereas the regions where it is most needed it is not available yet (Gabardo et al., 2008).

Water is by large the main source of fluoride intake for human beings (Whitfrod, 1996). In general, the natural fluoride present in the fresh-water do not exceed 0.3 ppm (mg/L). This is a matter of confusion. Most people do not differentiate the natural fluoride from the controlled water fluoridation programs. This is important since most severe cases of dental fluorosis are related to rural areas where the patients have been consuming high amount of fluoride in the water for a long time ( Sampaio et al., 1999). On the other hand there is the urban patient who is not exposed to high amounts of fluoride, in general the mother was careful enough to avoid ingestion of fluoride toothpaste and possibly only a mild fluorosis may occur. These are different situations and must be taken under different interpretations because dental fluorosis perception is also different (Murray et al., 1991).

For rural areas or more desert types of climate, one interesting strategy for public health is to monitor water fluoride levels in order to estimate the fluoride intake. Mapping fluoride in areas is very important because in many tropical areas the chances of finding severe cases of dental fluorosis is higher (Levy, 2003).

Finally, it is already evident that the percentage level of effectiveness of water fluoridation in many areas is lower than in others due to the more widespread use of other fluoride modalities. Nevertheless, water fluoridation is still a valuable health measure and must not be underestimated (Sampaio & Levy, 2011).

Systemic Methods of Fluoride and the Risk for Dental Fluorosis 369

(45 kg per person/year) (Sampaio & Levy, 2011). Latin America has one of the highest estimates among developing countries with 110 kg per person/year, but this is regarded as low when compared to developed countries. Conversely to salt fluoridation, which can be linked to hypertension, milk fluoridation programs have the appeal of nutrition for children. This is a positive aspect when promoting health. However, the favorable features of milk can be strongly compromised when sucrose is added. In spite of the fact that cow´s milk is essentially non-cariogenic, the addition of sucrose in the milk can promote early caries in young children. Thus, the milk consumption must not increase the sucrose consumption as well. Concerning the effectiveness of fluoridated milk for caries, few randomized clinical studies were conducted. This is also the same for dental fluorosis. However, a recent observation in a Peruvian town with milk fluoridation program showed high consumption of fluoride due to high concentration of fluoride in the drinking water. This is a clear evidence of an overlap of systemic methods that must be avoided (Rodrigues at

Today, there is clear evidence that fluorosis is increasing worldwide. This concern raises doubts about the beneficial aspects of systemic fluoride methods. But there are clear evidences that these methods have more beneficial effects than risks. For instance, in spite of the potential risk for dental fluorosis, dietary fluoride supplements are regarded as effective in preventing caries and are still available in several countries. This method was not discussed in this paper but this issue is also relevant (Buzalaf, 2011). The recent reduction in fluoride levels in the water communities cannot be interpreted as a limitation of the method. Conversely, this adjustment proves that water fluoridation is still necessary. So, what we know about the risk of dental fluorosis? First, the issue is not as simple as it was before (when water fluoridation started), since today it can involve several sources of fluoride. Second, an 'optimal' dose is a theoretical value, maybe we should work with range of risk and range of concentrations in systemic methods. Third, the classification of systemic x topical methods is no longer valid and might be changed. These major categories might be better classified as: professional methods (varnishes, gels) community methods (salt, water, milk) and individual methods (toothpastes, mouthrinses and supplements). Considering these categories, operational strategies can be more straightforward on the basis of those

**5. Risk of fluorosis: What do we know and how to minimize it?** 

who are in charge of the method: the dentist, the health authority or the patient.

acceptable risk when compared to the preventive benefits.

well as in a communal basis is important.

Other point of concern is that some degree of enamel fluorosis is inevitable with water fluoridation. However, most cases of dental fluorosis are of mild severity. Future studies about fluorosis perception will be valuable for evaluating the level of concern of the population about dental fluorosis. Dean regarded an increased prevalence of fluorosis as an

There are good strategies to minimize the risk of dental fluorosis. The first step is to get the information about the methods of delivering fluoride in a region or town (including toothpastes). Thus, investigating the possible sources of fluoride on an individual basis as

The risk of developing fluorosis shows a different trend on urban and rural communities. It is a more common cause of fluorosis on rural communities the high content of fluoride on the drinking water, such as groundwater. On the contrary it is more common on urban

al., 2010).

#### **4.2 Salt fluoridation**

This method was introduced in the 1950s following the successful program of iodine against goiter. It was idealized as an option for water fluoridation but reproducing the idea of incorporating fluoride in the tooth (Marthaler, 2005). Today, the aim is to reach communities and regions in the world where oral care prevention measures, and particularly fluoride toothpastes, are not available. This method is successfully implemented in almost all Latin American countries and in some European countries (France, Germany and Switzerland). The levels of 250-300 mg/kg of fluoride in salt are regarded as the ideal range of concentration while the concentration of 200 mg/kg of fluoride is regarded as the minimal acceptable level of fluoride. One positive aspect of salt fluoridation is the very low cost for implementation. However, there is one major point of concern: somehow promoting salt fluoridation could be contraindicated from the perspective of general public health because the greater the salt consumption the greater could be the link to hypertension. On the other hand, most estimates indicate that usually the patients are consuming low salt diets (less than 5 g of NaCl per person per day) and taking this amount of salt, essential hypertension will be uncommon. Moreover, there is no doubt that some salt is required by man, and estimates of normal daily requirements for adults have ranged up to 15 g per day (Dahl, 2005).

Regarding the overlapping of fluoride delivery methods, similar to water fluoridation, some concern has come to a debate. Thus, the simultaneous combination of fluoride ingested from both dentifrice and salt can be a problem? Available data suggest that this combination has not resulted in objectionable enamel fluorosis levels (Menghini, 2005).

In summary, there is no doubt that salt fluoridation is a systemic method of very low cost. Salt fluoridation can be considered as a systemic method of choice when water fluoridation is technically difficult or due to economic or socio-cultural reasons it cannot be implemented (Sampaio & Levy, 2011). Finally, the drawbacks for implementing a salt fluoridation program (such as variation in ingestion, difficulties in maintaining the ideal concentration and concerns with hypertension) are minimal when compared to the advantages of this method.

#### **4.3 Milk fluoridation**

The first milk fluoridation experience was developed in Bulgaria, in the cities of Plovdiv and Asenovgrad, in 1988. Then the experience was expanded to other European countries and also to Chile, Peru and China (Bánóczy et al., 2005). Since the amounts of water and milk consumed daily are different, in terms of caries prevention the fluoride concentration should be 1 mg/L and 5 mg/L for water and milk, respectively. These values were considered before the last American resolution of reducing the levels of fluoride in the drinking water (Department of Health and Human Services, 2011). Thus, taking water fluoride as reference new publications are needed for the update of levels of fluoride in milk as well as for other methods. A possible change in fluoride levels in milk is very important since this is the most popular systemic method in some countries. An interesting aspect about milk fluoridation is its use among children. This is the target age group and well conducted school-based programs have been developed (Horowitz, 1982; Rodrigues et al., 2010). As a result, most data available for this method are from studies with children. Milk consumption varies considerably when comparing different regions of the world. The consumption is higher in developed countries (212 kg per person/year) whereas it is lower in developing countries

This method was introduced in the 1950s following the successful program of iodine against goiter. It was idealized as an option for water fluoridation but reproducing the idea of incorporating fluoride in the tooth (Marthaler, 2005). Today, the aim is to reach communities and regions in the world where oral care prevention measures, and particularly fluoride toothpastes, are not available. This method is successfully implemented in almost all Latin American countries and in some European countries (France, Germany and Switzerland). The levels of 250-300 mg/kg of fluoride in salt are regarded as the ideal range of concentration while the concentration of 200 mg/kg of fluoride is regarded as the minimal acceptable level of fluoride. One positive aspect of salt fluoridation is the very low cost for implementation. However, there is one major point of concern: somehow promoting salt fluoridation could be contraindicated from the perspective of general public health because the greater the salt consumption the greater could be the link to hypertension. On the other hand, most estimates indicate that usually the patients are consuming low salt diets (less than 5 g of NaCl per person per day) and taking this amount of salt, essential hypertension will be uncommon. Moreover, there is no doubt that some salt is required by man, and estimates of normal daily requirements for adults have ranged up to 15 g per day (Dahl,

Regarding the overlapping of fluoride delivery methods, similar to water fluoridation, some concern has come to a debate. Thus, the simultaneous combination of fluoride ingested from both dentifrice and salt can be a problem? Available data suggest that this combination has

In summary, there is no doubt that salt fluoridation is a systemic method of very low cost. Salt fluoridation can be considered as a systemic method of choice when water fluoridation is technically difficult or due to economic or socio-cultural reasons it cannot be implemented (Sampaio & Levy, 2011). Finally, the drawbacks for implementing a salt fluoridation program (such as variation in ingestion, difficulties in maintaining the ideal concentration and concerns with hypertension) are minimal when compared to the advantages of this

The first milk fluoridation experience was developed in Bulgaria, in the cities of Plovdiv and Asenovgrad, in 1988. Then the experience was expanded to other European countries and also to Chile, Peru and China (Bánóczy et al., 2005). Since the amounts of water and milk consumed daily are different, in terms of caries prevention the fluoride concentration should be 1 mg/L and 5 mg/L for water and milk, respectively. These values were considered before the last American resolution of reducing the levels of fluoride in the drinking water (Department of Health and Human Services, 2011). Thus, taking water fluoride as reference new publications are needed for the update of levels of fluoride in milk as well as for other methods. A possible change in fluoride levels in milk is very important since this is the most popular systemic method in some countries. An interesting aspect about milk fluoridation is its use among children. This is the target age group and well conducted school-based programs have been developed (Horowitz, 1982; Rodrigues et al., 2010). As a result, most data available for this method are from studies with children. Milk consumption varies considerably when comparing different regions of the world. The consumption is higher in developed countries (212 kg per person/year) whereas it is lower in developing countries

not resulted in objectionable enamel fluorosis levels (Menghini, 2005).

**4.2 Salt fluoridation** 

2005).

method.

**4.3 Milk fluoridation** 

(45 kg per person/year) (Sampaio & Levy, 2011). Latin America has one of the highest estimates among developing countries with 110 kg per person/year, but this is regarded as low when compared to developed countries. Conversely to salt fluoridation, which can be linked to hypertension, milk fluoridation programs have the appeal of nutrition for children. This is a positive aspect when promoting health. However, the favorable features of milk can be strongly compromised when sucrose is added. In spite of the fact that cow´s milk is essentially non-cariogenic, the addition of sucrose in the milk can promote early caries in young children. Thus, the milk consumption must not increase the sucrose consumption as well. Concerning the effectiveness of fluoridated milk for caries, few randomized clinical studies were conducted. This is also the same for dental fluorosis. However, a recent observation in a Peruvian town with milk fluoridation program showed high consumption of fluoride due to high concentration of fluoride in the drinking water. This is a clear evidence of an overlap of systemic methods that must be avoided (Rodrigues at al., 2010).

#### **5. Risk of fluorosis: What do we know and how to minimize it?**

Today, there is clear evidence that fluorosis is increasing worldwide. This concern raises doubts about the beneficial aspects of systemic fluoride methods. But there are clear evidences that these methods have more beneficial effects than risks. For instance, in spite of the potential risk for dental fluorosis, dietary fluoride supplements are regarded as effective in preventing caries and are still available in several countries. This method was not discussed in this paper but this issue is also relevant (Buzalaf, 2011). The recent reduction in fluoride levels in the water communities cannot be interpreted as a limitation of the method. Conversely, this adjustment proves that water fluoridation is still necessary. So, what we know about the risk of dental fluorosis? First, the issue is not as simple as it was before (when water fluoridation started), since today it can involve several sources of fluoride. Second, an 'optimal' dose is a theoretical value, maybe we should work with range of risk and range of concentrations in systemic methods. Third, the classification of systemic x topical methods is no longer valid and might be changed. These major categories might be better classified as: professional methods (varnishes, gels) community methods (salt, water, milk) and individual methods (toothpastes, mouthrinses and supplements). Considering these categories, operational strategies can be more straightforward on the basis of those who are in charge of the method: the dentist, the health authority or the patient.

Other point of concern is that some degree of enamel fluorosis is inevitable with water fluoridation. However, most cases of dental fluorosis are of mild severity. Future studies about fluorosis perception will be valuable for evaluating the level of concern of the population about dental fluorosis. Dean regarded an increased prevalence of fluorosis as an acceptable risk when compared to the preventive benefits.

There are good strategies to minimize the risk of dental fluorosis. The first step is to get the information about the methods of delivering fluoride in a region or town (including toothpastes). Thus, investigating the possible sources of fluoride on an individual basis as well as in a communal basis is important.

The risk of developing fluorosis shows a different trend on urban and rural communities. It is a more common cause of fluorosis on rural communities the high content of fluoride on the drinking water, such as groundwater. On the contrary it is more common on urban

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communities the development of fluorosis due to the irrational use of toothpaste by children under 6 years old (Sampaio et al., 2010)

The emerging concern about dental fluorosis must be evaluated in the perspective that systemic methods were already operating when other sources of fluoride were introduced. Thus, the effectiveness of fluoride is not the same for all methods since caries burden is lowering off. It is true that a reclassification to substitute the traditional systemic versus topical methods is necessary. What is not necessary is to simply oppose systemic fluoride methods as long as caries is still the most prevalent disease in many parts of the world.

#### **6. Concluding remarks**


#### **7. Acknowledgment**

This study was supported by the Brazilian National Council for Research and Development (CNPq) grants n. 576703/2008-7 and 555137/2010-4 and Foundation of Research of Paraiba PP-SUS 093/10.

#### **8. References**


communities the development of fluorosis due to the irrational use of toothpaste by children

The emerging concern about dental fluorosis must be evaluated in the perspective that systemic methods were already operating when other sources of fluoride were introduced. Thus, the effectiveness of fluoride is not the same for all methods since caries burden is lowering off. It is true that a reclassification to substitute the traditional systemic versus topical methods is necessary. What is not necessary is to simply oppose systemic fluoride methods as long as caries is still the most prevalent disease in many parts of the world.

• Most studies support the view that the caries-preventive effect of fluoride is mainly post-eruptive. This evidence must not be interpreted as a true limitation of systemic fluoride methods since a topical effect will take place when someone is ingesting

• Dietary F intake must be considered before any systemic method of fluoridation is implemented. Hence, it is very important to monitor the total fluoride intake of children in the first 3 years of life in order to avoid undesirable aesthetically fluorosis,

• Most systemic methods available are of low cost showing a good cost-benefit relation. • The overlapping of systemic methods of delivering fluoride must be avoided in order to

• Dental fluorosis related to systemic fluoride methods are of minor concern since mild dental fluorosis is the majority of the cases observed from clinical and epidemiological

• Reclassification to substitute the traditional 'systemic' versus 'topical' methods is necessary. The major categories might be classified as : professional methods (varnishes, gels) community methods (salt, water, milk) and individual methods

This study was supported by the Brazilian National Council for Research and Development (CNPq) grants n. 576703/2008-7 and 555137/2010-4 and Foundation of Research of Paraiba

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**6. Concluding remarks** 

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**7. Acknowledgment** 

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### *Edited by Mandeep Singh Virdi*

Geriatric dentistry, or gerodontics, is the branch of dental care dealing with older adults involving the diagnosis, prevention, and treatment of problems associated with normal aging and age-related diseases as part of an interdisciplinary team with other healthcare professionals. Prosthodontics is the dental specialty pertaining to the diagnosis, treatment planning, rehabilitation, and maintenance of the oral function, comfort, appearance, and health of patients with clinical conditions associated with missing or deficient teeth and/or oral and maxillofacial tissues using biocompatible materials. Periodontology, or Periodontics, is the specialty of oral healthcare that concerns supporting structures of teeth, diseases, and conditions that affect them. The supporting tissues are known as the periodontium, which includes the gingiva (gums), alveolar bone, cementum, and the periodontal ligament. Oral biology deals with the microbiota and their interaction within the oral region. Research in oral health and systemic conditions concerns the effect of various systemic conditions on the oral cavity and conversely helps to diagnose various systemic conditions.

Oral Health Care -

Prosthodontics, Periodontology, Biology, Research and Systemic Conditions

Oral Health Care

Prosthodontics, Periodontology, Biology,

Research and Systemic Conditions

*Edited by Mandeep Singh Virdi*

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