Dental Caries Strategies

Strategies for caries prevention
Review article
Acta Medica Academica 2013;42(2):117-130
DOI: 10.5644/ama2006-124.80
Dental caries: Strategies to control this preventable disease
Andrew Rugg-Gunn*
School of Dental Sciences Objective. To provide a brief commentary review of strategies to con-
Newcastle University, UK trol dental caries. Dental decay is one of man’s most prevalent diseases.
In many counties, severity increased in parallel with importation of
sugar, reaching its zenith about 1950s and 1960s. Since then, severity
has declined in many countries, due to the wide use of fluoride espe-
cially in toothpaste, but dental caries remains a disease of medical, social
and economic importance. Within the EU in 2011, the cost of dental
Corresponding author:
treatment was estimated to be €79 billion. The pathogenesis is well un-
Andrew Rugg-Gunn, Morven
derstood: bacteria in dental plaque (biofilm) metabolise dietary sugars
Boughmore Road, Sidmouth
to acids which then dissolve dental enamel and dentine. Possible ap-
Devon EX10 8SH, UK
proaches to control caries development, therefore, involve: removal of
andrew@rugg-gunn.net
plaque, reducing the acidogenic potential of plaque, reduction in sugar
Tel.: + 44 13 95 578 746 consumption, increasing the tooth’s resistance to acid attack, and coat-
ing the tooth surface to form a barrier between plaque and enamel. At
the present time, only three approaches are of practical importance: sug-
ar control, fluoride, and fissure sealing. The evidence that dietary sug-
ars are the main cause of dental caries is extensive, and comes from six
Received: 27 January 2013
types of study. Without sugar, caries would be negligible. Fluoride acts
Accepted: 19 March 2013
in several ways to aid caries prevention. Ways of delivering fluoride can
be classed as: ‘automatic’, ‘home care’ and ‘professional care’: the most
important of these are discussed in detail in four articles in this issue of
Copyright © 2013 by the Acta Medica Academica. Conclusion. Dental caries is preventable –
Academy of Sciences and Arts individuals, communities and countries need strategies to achieve this.
of Bosnia and Herzegovina.
E-mail for permission to publish: Key words: Dental caries, Diet, Nutrition, Fluoride, Public health
amabih@anubih.ba strategies.
Introduction ventable is not yet prevented. The aim of this

article is to provide a commentary review of
Dental decay is commonly called dental
strategies to control dental caries.
‘caries’, from the Latin word meaning rot-
tenness. It is one of the most common of
chronic diseases and is of medical, social Size of the problem
and economic importance. Yet its cause is
well known and methods of preventing its While ancient civilisations experienced
occurrence and progression have been de- dental decay, it is largely a ‘modern’ disease.
veloped and many are practiced. The pre- Dentists are lucky that teeth survive the lon-
*The author is Professor emeritus, Newcastle University. No support was provided for the preparation of this paper.
117
Acta Medica Academica 2013;42:117-130
gest of any tissue after death: we do not have den of dental caries, it remains one of man’s
to rely on contemporary accounts of disease most prevalent diseases (2). Elsewhere in
prevalence, we dig up our ancestors. The re- the world, dental caries experience has in-
sults of these archaeological surveys reveal creased (Figure 1) so that, for children for
that experience of dental caries was low until example, the global average has remained
the nineteenth century, when it rose sharply almost unchanged for 30 years.
in several European countries. This steady The effect of dental caries is cumulative
increase during the century 1850 to 1960 co- with age, and Petersen and colleagues (3)
incided with increasing importation of cane point out that the worldwide average for peo-
sugar from the Americas. In Britain, a de- ple aged 65 years or more, is 22 teeth either
fining moment occurred around 1900 when decayed, missing or filled (out of 32 teeth).
‘poor teeth’ was the most important cause of Dental caries is the most important oral dis-
rejection of volunteers for military service. ease and is of medical, social and economic
This became a ‘wake-up call’ for those con- importance. It is now recognised that dental
cerned with public health. For much of Eu- caries cannot be considered in isolation – its
rope and other ‘developed’ countries, 1960 occurrence and control depends on social
to 1970 became the turning-point; after environment and behaviour, at the levels of
1970 the epidemic of dental caries reduced the individual and the broader community.
considerably (1). As will be discussed be- It is recognised increasingly that oral diseas-
low, this decline has been due largely to the es have negative impacts on general health.
widespread use of fluoride. Although there Table 1 shows that, in an area of north-east
has been a very welcome decline in the bur- England without water fluoridation, over a
Figure 1 Dental caries severity (decayed, missing and filled teeth) in 12-year-olds between 1980 and 1998, in
developed countries (top line), all countries (middle line) and developing countries (bottom line) (2).
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Andrew Rugg-Gunn: Dental caries prevention
Table 1 Percentage of 5-year-old children living in Urban and Rural areas in north-east England in who had
(a) one or more dental abscess at the time of examination (point prevalence), (b) lifetime experience of one
or more episode of toothache, or general anaesthetic for dental extraction. Data collected in Non-fluoridated
(<0.1 mg F/litre) and Fluoridated (1 mg F/litre) communities in 1975 (4)
Urban Rural
Experiences
Non-fluoridated Fluoridated Non-fluoridated Fluoridated
Dental abscess (%) 3 1 5 0
Toothache (%) 40 22 38 17
General anaesthetic (%) 34 18 22 7
third of 5 year-olds had experienced tooth- es in Europe, the first summary point was:
ache and a quarter to a third had had one “Oral diseases remain a major public health
or more general anaesthetics for dental ex- issue for high-income countries, where ex-
tractions due to dental decay (4). In many penditure on treatment often exceeds that
countries, tooth extraction because of dental for other diseases, including cancer, heart
caries is the most common reason for gen- disease, stroke, and dementia. This is dis-
eral anaesthetics in childhood. turbing, given that much of the oral disease
At the Sixtieth World Health Assembly burden in high-income countries is due to
in May 2007, a Resolution, confirmed by the dental caries and its complications, and this
Member States, emphasised that oral disease is preventable through the use of fluoride
is a serious public health problem and that and other cost effective measures”. The re-
its impact on individuals and communities port estimates that the annual cost in 2011
in terms of pain and suffering, impairment of dental treatment within the 27 member
of function and reduced quality of life, is states of the current EU was about €79 bil-
considerable (5). Oral disease is the fourth lion. Dental disease is one of the frequent
most expensive disease to treat. Globally, reasons for absence from school. The aeti-
the greatest burden of oral diseases lies on ology of these diseases is very well known,
disadvantaged and poor populations. The yet they are not yet prevented because of the
first action point in the Resolution – “urges seemingly insurmountable hurdles of com-
Member States to adopt measures to ensure mercial pressure, politics, local environ-
that oral health is incorporated as appropri- ments and personal behaviour.
ate into policies for the integrated preven-
tion and treatment of chronic noncommu-
Pathogenesis
nicable and communicable diseases, and
into maternal and child health policies.” Ancient civilizations in China, Mesopota-
This acknowledges that most oral disease mia and Greece believed that dental decay
and chronic diseases have common risk fac- was caused by worms and therefore had to
tors, for example, unhealthy environments be treated by fumigation. This view per-
and behaviours, particularly widespread use sisted up to the time when Antony van Leu-
of tobacco and excessive consumption of al- wenhoek observed, through his newly de-
cohol and sugar. veloped microscope, little worms (bacteria)
More locally, a recent report on ‘The state in material taken from a carious tooth. Pas-
of oral health in Europe’ (6) summarised the teur showed that sugars could be fermented
impact of oral diseases within the EU. Dis- to acids by micro-organisms, and Magitot
cussing the economic impact of oral diseas- demonstrated that the acids produced by
119
fermentation of sugars were capable of de- tential for remineralisation of demineralised

stroying tooth enamel in vitro. In 1890, WD enamel, cover enamel surfaces so as to put a
Miller published his chemo-parasitic theory barrier between dental plaque and enamel.
of caries aetiology. This remains the simple All of these, and more, have been tried.
explanation of the caries process: bacteria in Toothbrushing is an accepted social hab-
dental plaque metabolise dietary sugars to it, making teeth more attractive, removing
acids which then dissolve dental enamel and mouth odours and helping to prevent peri-
dentine. A modern refinement is that the odontal disease. If done very well, tooth-
process is not continuous but cyclical. Peri- brushing is able to remove plaque sufficient-
ods of acid attack and mineral loss are in- ly to reduce caries development. But the
terspersed with periods of remineralisation, majority of people do not achieve this stan-
and major tooth destruction (a cavity) only dard and studies have shown that brushing
occurs if mineral loss is greater than healing. teeth, per se, does not reduce caries devel-
The major force to remineralise tooth tissue opment; it is the fluoride in the toothpaste
is saliva, which is supersaturated with cal- used which has the caries-preventive effect
cium. This becomes clinically evident in pa- (7) (vide infra).
tients with very low salivary flow (hyposali- Unlike classical infectious diseases,
vation) – perhaps due to radiation to the which are caused by microbial pathogens,
head and neck or drugs – who suffer rapid, dental caries is caused by the resident oral
severe dental caries. The most important ac- microflora. There are contrasting opinions as
tion of fluoride is to encourage reminerali- to the use of chemical agents in the preven-
sation of demineralised enamel and dentine. tion and treatment of dental caries. Those in
Although the phrase ‘dental plaque’ is still favour believe that chemical agents can be an
used extensively, it is more correct to use the adjunct to toothbrushing and dental flossing,
term ‘dental biofilm’ – the important thing is while those opposed argue that such agents
that it is 70% bacteria, forms within days if may disturb the ecological balance within
teeth are not cleaned, and adheres very well the oral cavity and that resistant strains may
to tooth surfaces, thus keeping acid metabo- emerge (8). Nevertheless, many chemical
lites close to the tooth surface. agents have been studied, the most successful
being chlorhexidine. This cationic antiseptic
Possible approaches to caries is bacteriocidal and, being strongly surface-
active, is particularly good at preventing mi-
prevention
crobial colonisation of clean enamel. Com-
Since the pathogenesis of dental caries is mercial mouthrinses commonly contain
well understood, strategies to prevent car- 0.2% chlorhexidine. Although such mouth-
ies development would seem to be relatively rinses are effective in aiding plaque control,
simple. Either the attacking forces can be they are not used extensively because they
reduced or the host resistance can be en- discolour teeth and some tooth-coloured
hanced. Ways to decrease to attacking forces restorations, and alter taste sensations.
include: removal of dental plaque (dental Other approaches have been the use of
biofilm), alteration of dental plaque so that probiotics and immunisation. Probiotics are
it is less able to metabolise dietary sugars “live microorganisms which, when adminis-
to acids, neutralise the acids within plaque, tered in adequate amounts, confer a health
and remove or reduce dietary sugars. Ways benefit on the host” and many species and
to enhance host resistance include: reduce strains have been studied in relation to oral
enamel’s solubility in acid, increase the po- health (9). Their action is to interfere with
120
attachment and colonisation of cariogenic plaque to metabolise sugars to acids. The

bacteria and to inhibit sugar fermentation, various ways in which fluoride can be used
and there is some evidence that they confer in caries prevention are discussed below.
some benefit. The vehicle used is commonly If you can make saucepans ‘non-stick’,
milk and it is fortunate that the action of pro- why not teeth? Of the various ‘coatings’
biotics and fluoride are additive (10). There studied, ‘fissure-sealants’ have stood the test
was much work on immunisation against of time and are used extensively. The key to
dental caries about 30 years ago but virtually their success was the development of the ‘ac-
none during the past 15 years. Partial protec- id-etch’ technique in the 1950s (13) whereby
tion only was achieved in monkeys following the enamel surface is etched, washed and
quite extensive courses of inoculation, but the dried before resin is flowed onto the etched
possibility of cross-reaction with heart tissues enamel and set hard. It is only practical to
made further research uninviting. A central seal the fissures and pits in teeth since these
problem is that no one plaque organism is are the most at risk sites. It is an exacting
uniquely cariogenic. The approach of reduc- technique carried out by professional staff
ing dietary sugars will be discussed below. and is thus relatively expensive (compared
Research into increasing enamel’s resis- with home care or community preventive
tance to dental caries is nearly a century old. methods) but the large number of trials in-
Eighty years ago, during the golden era of dicate high retention rates for sealants and,
vitamin research, it was believed that dental thus, substantial caries prevention.
caries was a deficiency disease, and dietary In conclusion, a great number of ap-
vitamins and minerals have been studied ex- proaches to caries prevention have been
tensively (11). There is some evidence that tried. At the present time, only three are of
vitamin D is protective and some evidence practical importance – control of dietary sug-
that caries development is inversely related ars, fluoride and fissure-sealing. Currently,
to hardness of water, but any of these effects research into genetic factors associated with
is dwarfed by the positive effect of fluoride. dental caries is active: certain genes have
The unique ability of fluoride to protect been shown to be associated with protection
against caries seems to be, in part, because against caries (14) but the practical signifi-
it acts in several ways, all beneficial (12). cance of these findings is, as yet, uncertain.
First, the appropriate dose of fluoride dur-
ing tooth development in childhood renders Dietary control of dental caries
the enamel more acid-resistant – fluorapa-
tite is less soluble than hydroxyapatite. Sec- Diet advice to prevent and control dental
ond, there is some evidence that fluoride al- caries has a long history. For example, the
ters the shape of the fissures in tooth crowns ancient Greeks warned against eating over-
during tooth formation: this is somewhat ripe figs. However, the last century has seen
controversial and likely to be unimportant. much research in this area.
Third, an adequate concentration of fluo-
ride within plaque helps to reduce demin- Dental caries a deficiency disease?
eralisation and enhance remineralisation of
enamel during the dynamic caries process: Advice about healthy eating, about fifty
this ability to encourage remineralisation is years ago, urged mothers to give their young
now thought to be fluoride’s most important children diets rich in calcium and vitamin
action. Fourth, adequate concentrations of D, so that they would form strong healthy
fluoride within plaque reduce the ability of bones and teeth: the inference was that these
121
‘strong teeth’ would be less likely to decay. fed conventionally. In the second experiment
Although this is sound advice as far as the (16), rats were fed a cariogenic diet but half
skeleton is concerned, there has always been of them were kept germ-free while the other
little evidence to substantiate the view that half lived conventionally with a mixed micro-
good nutrition in early life helps to prevent bial flora. No caries developed in the germ-
dental decay by a systemic effect. This cer- free rats in contrast to extensive decay in the
tainly does not mean that good nutrition conventionally reared animals. Thus, it be-
should be discouraged, it merely reflects came quite clear that caries development de-
the current view that, in developed coun- pended on microflora and food in the mouth.
tries, diet has a much greater effect locally A third important series of experiments was
in the mouth on erupted teeth than it does published by Stephan, initially in 1940 (17).
pre-eruptively (11). The evidence support- Figure 2 shows what has become known as
ing the pre-eruptive role of diet now centres the ‘Stephan curve’. Laboratory experiments
around just two aspects – vitamin D and flu- had shown that enamel dissolves when the
oride (11) (vide infra). Under-development pH falls below about 5.5. Stephan showed
of salivary glands in malnourished children that the pH within dental plaque falls rapidly
results in hyposalivation which, in turn, in- after exposure to sugar, from a resting value
creases risk of dental caries – but this is a of about 7, to values below 5.5, taking about
post-eruptive effect. 40 minutes to return to its resting value. The
Two key experiments were published in slow rise back to the resting value is due to
the 1950s. In the first experiment (15), rats saliva, both removing the sugars and neu-
were fed a cariogenic (caries-inducing) diet tralising the acids, as became apparent when
either conventionally or by stomach tube. salivary glands were cupped. Variations of
Those fed by stomach tube did not develop Stephan’s curve experiments are still being
dental caries, even in a sub-group whose sal- used, albeit using more advanced methods
ivary glands had been removed, in contrast of recording pH within plaque, to test the
to extensive caries development in the rats cariogenic potential of foods (vide infra).
Sugars and dental caries – types of study

providing the evidence
One of the key publications which turned
opinion away from ‘caries is a deficiency
disease’ to the modern view that dietary
sugar is of paramount importance in car-
ies development appeared in 1940 (18).
Since then, much research has confirmed
this view. Because this has been disputed
by the sugar and sugar-related industries,
the evidence base will be reviewed briefly.
There are six types of study providing evi-
dence on the relationship between diet and
Figure 2 The Stephan curve. Plot of the pH within the development of dental caries (Table 2).
dental plaque at time-points after exposure to sug-
ar. The interrupted horizontal line at pH 5.5 marks
The best source of evidence is studies of the
the critical pH below which enamel is at risk of dis- occurrence of caries in human populations
solution. in relation to their diet. These studies are ei-
122
ther observational (epidemiological) studies oral medicines long-term – these have been
or interventional studies. The later provide observed to have high caries experience.
stronger evidence but are fewer in number There have been a large number of observa-
because of the practical and ethical difficul- tional studies relating caries experience with
ties of inviting large groups of subjects to diet in free-living children and adults. Most
adhere to strict diets for a long enough time of these have been cross-sectional stud-
for an effect on caries increment to be ob- ies where caries experience and diet have
served: this time period would normally be been recorded concurrently once only. This
two to four years. There have been a large is a relatively weak design since dental car-
number of observational studies and, since ies usually develops slowly over many years
the widespread use of computers, control- and diet may change from the time-period
ling for known confounding factors has be- when it was influencing caries initiation to
come routine. The findings of these studies the time, several years later, when the diet
in human subjects (11) will be summarised. was recorded. A better design is a longitu-
dinal observational study (lasting a mini-
Table 2 Types of investigation which provide
mum of two years) where development of
evidence on the relationship between diet and the
development of dental caries (11) caries during that time-period is recorded
and compared with diet recorded frequently
Observational human studies during the same period of time. Possible
Interventional human studies confounding factors, such as use of fluorides
Animal experiments and socio-economic status, can be recorded
Enamel slab experiments and included in data analysis. The vast ma-
Plaque pH experiments jority of these studies have recorded positive
Incubation (laboratory) experiments associations between caries experience or
development, and sugar intake – the latter
There are many examples of populations may be specified as weight of sugar ingested,
who have traditionally had diets low in sug- frequency of sugar ingestion, or consump-
ar but were then exposed to sugar through tion of specific sugar-rich food groups such
importation – for example, the Inuit, Bantu, as confectionery and sugared drinks.
east and west Africa, the island of Tristan da The Vipeholm study (11) is one of the
Cunha, and England. Dental caries experi- most famous in dental literature: it was car-
ence was very low before exposure to sugar ried out in a mental institute in Sweden be-
but high after exposure. There are groups of tween 1945 and 1953. There were eight test
people who have had to consume diets low groups and one control group – the most
in sugar. An example is those with heredi- aggressive regime was 24 toffees each day.
tary fructose intolerance who have to avoid The study would now be considered un-
consumption of fructose and sucrose: their ethical. Caries development was very rapid
caries experience is very low. During the in the groups consuming high amounts of
Second World War, consumption of sugar sugar confectionery. In contrast, the Turku
was much reduced in several countries: re- (Finland) study tested the effect of substitut-
cords show that caries experience fell and ing normal dietary sugar (mainly sucrose)
then rose in parallel with sugar availability. with fructose in one group and with xylitol
In contrast, there are groups of people who in another group (11). The study lasted two
have habitually consumed diets high in sug- years, 1972-74, and showed that caries de-
ar – for example, workers in the confection- velopment was virtually absent in the group
ery industry, and children taking sugared consuming xylitol compared with the fairly
123
high caries increment in the reference group periments and valuable in the past for screen-
who consumed their usual diet and the fruc- ing foods for their ability to produce acids in
tose group who developed slightly less decay the presence of plaque bacteria and the ability
than the reference group. Both the Vipe- of minerals (e.g. calcium) to prevent dissolu-
holm and the Turku studies are examples of tion of enamel during exposure to acid.
intervention studies (11). In summary, the evidence that consump-
Most of the many animal experiments tion of sugars causes dental caries is over-
into the relation between diet and caries de- whelming: several types of study contribute
velopment were conducted before 1980. As to this body of evidence. Three aspects of
mentioned above, they provided crucial evi- sugar-eating will be discussed briefly.
dence that sugar in the mouth is essential for
caries development. In addition, they indi-
Type of Sugar
cated that frequency of ingestion of sugars,
independent of the amount of sugar per day, The most common dietary sugars are su-
is strongly positively related to caries sever- crose, glucose, fructose, maltose and lac-
ity. Conversely, they also provided evidence tose. The sugar most commonly associated
that the amount of sugar ingested per day, with dental caries is sucrose and, indeed,
independent of frequency, is positively re- it has been labelled “the arch criminal of
lated to caries severity. dental caries” (11). Some, but not all, of the
‘Enamel slab experiments’ involve volun- many studies have suggested that sucrose is
teer subjects wearing intra-oral appliances the most cariogenic sugar; certainly, none is
into which are inserted small pieces (slabs) more cariogenic than sucrose. There is ex-
of enamel: caries development in these slabs tensive evidence that lactose is the least car-
is measured when the subjects are asked to iogenic sugar, and the cariogenicity of galac-
consume a variety of diets. The advantage is tose is likely to be similar to lactose. From
that very early carious changes can be ob- the practical viewpoint, there is probably
served (by a variety of instruments) so that little to be gained by substituting glucose,
experiments last only a few weeks. These fructose or maltose, for sucrose.
experiments have added to the literature on
the importance of frequency of exposure,
Frequency of consumption and the total
different sugars and sugar-substitutes, and
amount consumed
concentration of sugars.
Plaque pH studies are relatively simple to There is good evidence that frequency of
conduct and have been valuable in empha- ingestion of dietary sugars influences the
sising the risk of frequent sugar ingestion. severity of caries development. From the
They have also shown, for example, how curve shown in Figure 2, it can be under-
the harmful effect of sugar ingestion might stood that demineralisation of enamel can
be negated by ingestion of cheese, since in- occur each time sugar is ingested – if there
gestion of cheese raises plaque pH rapidly. are 10 sugar intakes a day, enamel stands to
Fast-flowing saliva is alkaline (~ pH 7.5) be attacked 10 times a day. The main conclu-
and plaque pH experiments have shown sion from the Vipeholm study (vide supra)
that chewing sugarless gum induces salivary was that caries severity was strongly related
flow and raises plaque pH, thus encouraging to frequent ingestion of sugar. However,
remineralisation of demineralised enamel. there is also much evidence that the amount
Incubation experiments are the simplest of sugar ingested per day is positively related
type of study. They are laboratory-based ex- to caries severity. Most of the large number
124
Figure 3 Plot of frequency of intake per day against the Figure 4 Dietary sugars intake in 12-14 year-old chil-
weight consumed per day, of confectionery, by 405 dren living in north-east England (21). Mean daily
12-14-year-old children in north-east England (11). intake of all sugars was 118 g.
of observational studies mentioned above, intake (90 g out of 118 g) were non-milk in-
recorded amount of sugar, or sugar-rich trinsic sugars as can be seen in Figure 4 (21).
foods, rather than frequency of ingestion. Table 3 shows where these 90 g of non-
Carefully controlled animal experiments milk extrinsic sugars came from: 60% came
indicate that both variables – frequency and from just two sources – confectionery and
amount – are important. However, from the soft drinks. It should be noted that both of
practical point of view, it probably does not these are marketed for frequent consump-
matter if advice is to cut down frequency or tion (snacking) and it is therefore not sur-
amount since, in free-living people, there prising that these two are targeted heavily in
is a close relation between frequency and health promotion.
amount. Figure 3 is a plot of frequency of
daily intake of confectionery against amount Table 3 Mean daily intake of non-milk extrinsic
of confectionery consumed – the correlation sugars (19) (‘free sugars’ (20); ‘added sugars’) from
was +0.77. various dietary sources (as grams and as percentage)
in a survey of 379 12-year-old English children in
1990 (21)
Sources of dietary sugars
Various dietary sources Added sugars (g; %)
When giving advice about how to reduce Confectionery 30 (33)
sugar consumption, it is useful to know Soft drinks 24 (27)
which part of the diet to target. First, it Table sugar 11 (12)
should be appreciated that some foods con- Biscuits and cakes 10 (11)
tain sugars naturally – these include milk
Sweet puddings 5 (6)
(lactose), fruit and vegetables. Much sugar,
Breakfast cereals 5 (5)
though, is added to foods. These distinctions
Syrups and preserves 2 (2)
are important and have led to the definition
of three types of sugar (19): (i) ‘intrinsic sug- Other sources 3 (4)
ars’ – those within the structure of the food All sources 90 (100)
– e.g. fresh fruit and vegetables, (ii) ‘milk
sugars’ – lactose, and (iii) ‘non-milk extrinsic Dietary starch and dental caries
sugars’ – sometimes called ‘added sugars’ and
by WHO ‘free sugars’ (20). In a study of UK It is not uncommon to see advice that dental
adolescents, over two-thirds of total sugars caries is caused by ‘dietary carbohydrates’.
125
This is convenient for those promoting 125 mg/100 ml) and proteins, particularly
sugar products, as it takes the spotlight off casein. The result is that milk is classed as
dietary sugars. Dietary carbohydrates are, in non-cariogenic. In some experiments, milk
broad terms, sugars and starches (excluding has been shown to prevent dental caries and,
‘fibre’). A review of the evidence shows that indeed, WHO (20) classifies the strength of
dietary starches are not cariogenic, certainly evidence relating milk to ‘decreased risk’ of
compared with dietary sugars (11). If finely caries as ‘possible’. Thus, neither fruit nor
ground and heat-treated, starch can cause milk are seen as a threat to oral health, and
dental caries, but the amount is less than this is the reason for classifying them sepa-
that caused by sugars. Cooked staple starchy rately (as ‘intrinsic’ and ‘milk’ sugars) from
foods, such as rice, potatoes and bread are non-milk extrinsic sugars.
of low cariogenicity. This view is supported
by the WHO (20) who, when considering
Non-sugar sweeteners
the strength of the evidence linking diet to
dental caries, stated: (a) the evidence was A number of confectionery companies have
‘convincing’ for ‘increased risk’ of caries tried to overcome the problem of sugar-
from ‘amount of free sugars’, and ‘frequency containing (and therefore cariogenic) prod-
of free sugars’, and (b) there was ‘no relation- ucts by substituting non-sugar sweeteners for
ship’ between dental caries and ‘starch in- sugars. Foremost amongst these have been
take (cooked and raw starch foods, such as manufacturers of chewing gum. The sweet-
rice, potatoes and bread)’. The advice for oral eners used include sorbitol, xylitol, manni-
health and general health are in agreement tol and maltitol (11). Evidence indicates that
– increase consumption of staple starchy these sweeteners are non-cariogenic. It would
foods and decrease consumption of ‘free’ appear that xylitol has better dental proper-
(‘added’ or non-milk extrinsic) sugars. ties compared with the other sweeteners (22).
The dental benefits of chewing sugarless gum
(commonly containing xylitol) have been in-
Fruit and milk
vestigated extensively in Scandinavia, partic-
Fruit and milk contain sugars and, thus, ularly Finland (23). This is promoted because
could be considered cariogenic. To sum- the chewing stimulates saliva flow, thus en-
marise the evidence (11): as eaten by hu- couraging remineralisation of dental enamel.
mans, fresh fruit appears to be of low car- WHO (20) classifies the strength of evidence
iogenicity; sugared, fruit-flavoured drinks for ‘decreased risk’ of caries for ‘sugars-free
when used as a comforter are a significant chewing gum’ as ‘probable’. Manufacturers
cause of dental caries in young children; and of carbonated soft drinks have marketed
there is insufficient evidence regarding pure ‘sugar-free’ or ‘no calorie’ drinks for many
fruit juice and caries, most of the studies years. These contain intense sweeteners,
looked at sugar-containing fruit-flavoured which are non-cariogenic (11). However,
drinks. The WHO (20) classified the evi- these drinks are acid and are strongly linked
dence as ‘no relation’ between ‘whole fresh to erosion of dental enamel.
fruit’ and dental caries.
Cow’s (bovine) milk contains about 4.8 g Summary and implications for health
lactose per 100 g, thus having the potential policies
to cause dental caries. However, milk also
contains factors which protect teeth; these It is clear from the above brief review that
are mainly the high calcium content (about what we eat dictates whether or not we de-
126
velop dental caries. Consumption of foods certainly due to the increased use of fluo-
and drinks rich in sugar increases risk con- ride, particularly the introduction of fluo-
siderably. Staple starchy foods, fresh fruit, ride toothpastes. The story of the recogni-
vegetables and milk are not a threat to teeth. tion and exploitation of fluoride’s ability to
Dietary fat and protein are not metabolised prevent, partially, caries development is long
to acids within the mouth. Thus, dietary ad- and interesting (12). The 1930s and early
vice for oral health is completely compatible 1940s was a time when the inverse rela-
with dietary advice for general health (20). tionship between fluoride concentration in
There is growing evidence that non-milk ex- drinking water and dental caries experience
trinsic sugars increase risk of diseases other became apparent, and the first water fluori-
than dental caries, either independently or dation scheme began in the USA in 1945.
via increased risk of obesity (20). Strategies The subsequent story of water fluoridation
to reduce sugar consumption need to be ro- is the subject of an article in this issue (27).
bust because there are strong forces encour- It wasn’t long before fluoride was added
aging consumption of foods and drinks high to vehicles other than water, leading to much
in sugar: the advertising budgets for the con- research and the production of many effec-
fectionery and soft drinks manufacturers tive fluoride agents. The course of research
are very large. There are signs that diets of was not always easy, as the first fluoride-con-
children are improving (24) and it is worth taining toothpastes were ineffective due to
mentioning the following initiatives. First, the incompatibility between the added fluo-
food and drink in school should conform to ride (as sodium fluoride) and the calcium-
standards: confectionery is not sold and the based abrasives (12). Alternative abrasives
only drinks allowed are water, milk and pure and fluoride compounds (e.g. sodium mono-
fruit juice. Second, advertisements on televi- fluorophosphate) overcame these difficulties.
sion displayed at times when children may Another line of research was the application
be watching, should not encourage purchase of concentrated solutions to tooth surfaces
and consumption of high sugar foods and to make them more resistant to caries attack.
drinks. Third, foods and drinks for sale must At the same time, the success of water fluo-
be labelled for nutrient content including ridation led to experiments adding fluoride
sugars content. In addition, manufacturers to domestic salt, milk, flour and even sugar
should agree to their food products carry- – only salt and milk have stood the test of
ing ‘traffic-light’ labels, indicating whether a time, and these are discussed in detail in later
product is high (red) or low (green) in fat, articles in this issue (28, 29).
salt, sugar, and energy. A tax on products Table 4 lists the fluoride vehicles current-
high in sugars has been discussed but not ly in use: these are grouped as those which
yet implemented. Further information may provide fluoride ‘automatically’, those suit-
be obtained from published reviews of diet able for home care by the individual, and
and dental disease (25, 26). those which require application by a health
professional. Water, salt and milk fluorida-
Fluoride tion are suitable for community prevention.
Their advantages include low cost and little
It was stated in the first section of this ar- if any personal effort by the individual ben-
ticle that, in many countries, caries sever- efitting from the programme. To some ex-
ity reached its zenith around the 1950s and tent, they can be targeted at communities
1960s, and then declined, markedly so in most in need. These advantages have been a
several countries. This decline was almost tremendous help in trying to combat health
127
inequalities. The concentration of fluo- plications are infrequent (two to four ap-
ride in water, salt or milk is decided taking plications per year), and you know that the
background fluoride exposure and climate application has been done. Disadvantages
(since water consumption increases in hot include: the cost is high as professional time
climates) into account. is used, and effort to attend the appointment
is needed. Professional fluoride applications,
Table 4 Methods of delivering fluoride therefore, tend to be targeted at those in
greatest need. Home-based and professional
Automatic Home care Professional care
fluoride use will be discussed in a later ar-
Water Toothpaste Solutions
ticle in this issue (30).
Salt Mouthrinse Gels
Milk Tablets Varnishes
- - Slow-release devices
Concluding comments
From the above discussions, it can be seen
These three vehicles differ from the other that dental caries can be prevented. The fact
vehicles (Table 4), in that the fluoride in wa- that it remains a prevalent, expensive disease,
ter, salt and milk is ingested. This may bring of medical and social importance, is deeply
added benefit but it means that only one of frustrating. This preventable disease is not
these so-called ‘systemic’ methods should be yet prevented. In theory, dietary control of
used in any community. An example of this, sugar could assign caries to the ‘rare disease’
and the way they can be used appropriately category, as it was in millennia past. But sug-
on a population basis, can be seen in Chile. ar consumption has become integral to our
Here, the national policy is for water fluori- daily life, encouraged by massive marketing.
dation and 70% of the Chilean population But progress is being made: health promo-
receives fluoridated water. In many rural ar- tion in many countries has made people
eas, water fluoridation is not technically pos- aware of the desirability of reducing sugar in-
sible, and the national policy is for children take and it is now less socially-acceptable to
in these communities to receive fluoridated ‘take sugar’. An important step was that rel-
milk in school. In this way, the whole popu- evant health professionals – medical, dental
lation is covered. In addition, of course, the and dietetic – agreed what dietary messages
whole population is encouraged to use fluo- should be. Governments have made well-
ride-containing toothpastes, since the sepa- documented and authoritative statements
rate preventive effects of fluoride in water about nutrition and diet, which have been
and fluoride in toothpaste are additive. applied at national, community and individ-
The groupings in Table 4 are somewhat ual levels. For once, the sugar industries are
flexible. For example, fluoride mouthrins- ‘on the back foot’. Progressive, coordinated
ing has been used, and still is, in several effort will be needed to continue progress to
countries as a community preventive mea- better diets in many countries.
sure – children rinsing daily or weekly in The picture of dental caries in the 1950-
school. Likewise, there are school-based 60s was bleak, particularly in northern Eu-
toothbrushing programmes. School-based rope and Australia; the wave continued in
fluoride tablet programmes were common, other European countries and South Ameri-
especially in Eastern Europe, but there are ca. The widespread use of fluoride has much
few such programmes now. reduced this epidemic. This issue will discuss
Professional application of fluoride has its use and its future. There is no doubt that
a long history (12). Advantages are that ap- fluoride is underused. Toothpaste use is less
128
than half what would be required if all den- Conflict of interest: The author declares that he has
tate people brushed their teeth twice a day. no conflict of interest.
Water fluoridation is a low-cost, very effec-
tive, socially-equitable preventive measure
yet, for a variety of reasons, it is very much References
underused in Europe. It is important that
each country has a strategy to decrease the 1. Marthaler TM. Changes in dental caries 1953-
2003. Caries Res. 2004;38:173-81.
burden of dental caries through nutritional
2. Petersen PE. The World Oral Health Report 2003:
policy and appropriate use of fluorides. continuous improvement of oral health in the 21st
Nutritional policy and appropriate use of century – the approach of the WHO Global Oral
fluorides is best decided at the national level. Health Programme. Community Dent Oral Epi-
Nutritional policy for oral health is wholly demiol. 2003;31(Suppl 1):3-24.
compatible with nutritional policy for gener- 3. Petersen PE, Kandelman D, Arpin S, Ogawa
H. Global oral health of older people – call for
al health, as indicated above, and it is impor-
public health action. Community Dent Health.
tant that national authorities deciding such 2010;27(Suppl 2):257-68.
policy include expert(s) on nutrition and oral 4. Rugg-Gunn AJ, Carmichael CL, French AD, Fur-
health. Part of that policy should be to en- ness JA. Fluoridation in Newcastle and Northum-
sure that dental personnel in that country are berland: a clinical study of 5-year-old children. Br
Dent J. 1977;142:395-402.
fully aware of policy, their role in promoting
5. Petersen PE. World Health Organization global
good nutrition in the population and know
policy for improvement of oral health – World
how to give nutritional advice to patients of Health Assembly 2007. Int Dent J. 2008;58:115-21.
all ages. The success of these policies needs to 6. Patel R. The state of oral health in Europe. Report
be monitored by regular surveillance of ac- commissioned by the Platform for Better Oral
tivities of dental personnel and by assessing Health in Europe; 2012. [cited 2013 January 25].
Available from: http://www.oralhealthplatform.
the dietary habits of the population.
eu/sites/default/files/field/document/Report%20
Decisions regarding national fluoride -%20the%20State%20of%20Oral%20Health%20
policy will depend on disease levels, exist- in%20Europe.pdf
ing fluoride exposure and resources avail- 7. Nyvad B. The role of oral hygiene. In: Fejerskov O,
able: these need to be assessed. Countries Kidd EAM, editors. Dental caries. Oxford: Black-
with large urban populations usually have well Munksgaard; 2003. p. 171-7.
8. Scheie AAa. The role of antimicrobials. In: Fejer-
centralised piped water supplies, and these
skov O, Kidd EAM, editors. Dental caries. Oxford:
would be more economic to fluoridate than Blackwell Munksgaard; 2003. p. 179-88.
water supplies for small, rural communities. 9. Meurman JH. Probiotics and oral health. In: Wil-
The implementation of fluoridation of water, son M, editor. Food constituents and oral health.
salt and milk, and the resources needed for Cambridge: Woodhead; 2009. p. 421-32.
each, will be discussed in subsequent articles 10. Petersson LG, Magnusson K, Hakestam U, Baigi
A, Twetman S. Reversal of primary root caries le-
in this issue. When community preventive
sions after daily intake of milk supplemented with
schemes are introduced, it is important that fluoride and probiotic lactobacilli in older adults.
adequate resources are identified to mea- Acta Odont Scand. 2011;69:321-7.
sure the effectiveness of these programmes: 11. Rugg-Gunn AJ. Nutrition and dental health. Ox-
WHO recommends that 10% of the budget ford: Oxford Medical Publications; 1993.
is devoted to evaluation. It is important to 12. Murray JJ, Rugg-Gunn AJ, Jenkins GN. Fluorides
in caries prevention. 3rd ed. Oxford: Butterworth-
recognise that efforts to improve nutrition
Heinemann; 1991.
and maximise the appropriate use of fluo- 13. Rugg-Gunn AJ. Dental caries. In: Welbury RR, ed-
ride are not alternatives; both are important itor. Paediatric dentistry. 2nd ed. Oxford: Oxford
to the improvement of oral health. Medical Publications; 2001. p. 95-114.
129
14. Wang X, Willing MC, Marazita ML, Wendell 22. Maguire A, Rugg-Gunn AJ. Xylitol and caries
S, Warren JJ, Broffitt B, et al. Genetic and envi- prevention – is it the magic bullet? Br Dent J.
ronmental factors associated with dental caries 2003;194:429-36.
in children: the Iowa fluoride study. Caries Res. 23. Mäkinen KK. Oral care gum products. In: Wil-
2012;46:177-84. son M, editor. Food constituents and oral health.
15. Kite OW, Shaw JH, Sognnaes RF. The prevention Cambridge: Woodhead; 2009. p. 433-54.
of experimental tooth decay by tube-feeding. J 24. Fletcher ES, Rugg-Gunn AJ, Matthews JNS, Hack-
Nutrit. 1950;42:89-103. ett A, Moynihan PJ, Mathers JC, et al. Changes
16. Orland FJ, Blayney JR, Harrison RW, Reyniers JA, over 20 years in macronutrient intake and body
Trexler PC, Wagner M, et al. Use of the germ-free mass index in 11- to 12-year-old adolescents living
animal technic in the study of experimental dental in Northumberland. Br J Nutr. 2004;92:321-33.
caries. J Dent Res. 1954;33:147-74. 25. Moynihan PJ. Dental Disease. In: Geissler CA,
17. Stephan RM. Changes in hydrogen-ion concen- Powers HJ, editors. Human nutrition. 11th ed. Ed-
tration on tooth surfaces and in carious lesions. J inburgh: Elsevier; 2005. p. 461-76.
Am Dent Ass. 1940;27:718-23. 26. Moynihan PJ. Dietary advice in dental practice. Br
18. Jay P. The role of sugar in the etiology of dental Dent J. 2002;93:563-8.
caries. J Am Dent Ass. 1940;27:393-6. 27. Harding MA, O’Mullane DM. Water fluoridation
19. Department of Health. Dietary sugars and human and oral health. Acta Med Acad. 2013;42:131-39.
disease. Report on health and social subjects 37. 28. Marthaler TM. Salt fluoridation for the prevention
London: HMSO; 1989. of dental caries – its role and potential. Acta Med
20. World Health Organization. Diet, nutrition and Acad. 2013;42:140-55.
the prevention of chronic diseases. Report of a 29. Bánóczy J, Rugg-Gunn AJ, Woodward M. Milk
joint WHO/FAO expert consultation. WHO tech- fluoridation for the prevention of dental caries.
nical report series 916. Geneva: WHO; 2003. Acta Med Acad. 2013;42:156-67.
21. Rugg-Gunn AJ, Adamson AJ, Appleton DR, Butler 30. Rugg-Gunn AJ, Bánóczy J. Fluoride dentrifices
TJ, Hackett AF. Sugars consumption by 379 11-12 and fluoride mouthrinses for home use. Acta Med
year old English children in 1990 compared with Acad. 2013;42:168-78.
results in 1980. J Hum Nutr Diet. 1993;6:419-31.
130
Fluoride and caries prevention
Review article
Acta Medica Academica 2013;42(2):131-139
DOI: 10.5644/ama2006-124.81
Water fluoridation and oral health
Máiréad Antoinette Harding1,2, Denis Martin O’Mullane1
1
Oral Health Services Research Centre Water fluoridation, is the controlled addition of fluoride to the wa-
Cork University Dental School and ter supply, with the aim of reducing the prevalence of dental caries.
Hospital, Wilton, Cork, Ireland Current estimates suggest that approximately 370 million people in
2
HSE-South, Dental Clinic, Health Centre 27 countries consume fluoridated water, with an additional 50 million
Innishmore, Ballincollig, Co Cork, Ireland consuming water in which fluoride is naturally occurring. A pre-erup-
tive effect of fluoride exists in reducing caries levels in pit and fissure
Corresponding author:
surfaces of permanent teeth and fluoride concentrated in plaque and
Máiréad Antoinette Harding
saliva inhibits the demineralisation of sound enamel and enhances the
Oral Health Services Research Centre
remineralisation of demineralised enamel. A large number of studies
Cork University Dental
conducted worldwide demonstrate the effectiveness of water fluorida-
School and Hospital
tion. Objections to water fluoridation have been raised since its incep-
Wilton, Cork, Ireland
tion and centre mainly on safety and autonomy. Systematic reviews
m.harding@ucc.ie
of the safety and efficacy of water fluoridation attest to its safety and
Tel.: + 353 214 901 210
efficacy; dental fluorosis identified as the only adverse outcome. Con-
Fax.: + 353 214 545 391
clusion: Water fluoridation is an effective safe means of preventing
Received: 28 February 2013 dental caries, reaching all populations, irrespective of the presence of
Accepted: 18 April 2013 other dental services. Regular monitoring of dental caries and fluo-
rosis is essential particularly with the lifelong challenge which dental
Copyright © 2013 by
caries presents.
Academy of Sciences and Arts
of Bosnia and Herzegovina.
Key words: Water fluoridation, Effectiveness, Dental caries, Fluorosis.
E-mail for permission to publish:
amabih@anubih.ba
Introduction hood factors such as where we live and the

foods and the fluorides we have access to, all
Dental Caries (tooth decay); a transmissible
infectious disease with a multifactorial aeti- exert an impact on the development of the
ology has affected individuals for centuries disease (2). Dental caries is still a major oral
at least since the seventh century and the health problem in many established econo-
Iron Age (1). Change in the distribution of mies, affecting 60-90% of schoolchildren
dental caries intra-orally has occurred, as and the vast majority of adults. It is also a
has the dominant paradigm in managing prevalent oral disease in several Asian and
dental caries. A much greater emphasis is Latin-American countries, while it appears
now being encouraged towards prevention to be less common and less severe in many
rather than curative care. Community fac- African countries (3). In the US it has been
tors are currently the focus of considerable described as the most common chronic
research internationally. Social gradients disease of childhood (4). Untreated dental
in caries are demonstrated and neighbour- caries can lead to pain, infection, impaired
131
function, poor aesthetics, and diminished pioneering public health city of Grand Rap-
quality of life, which equate to a significant ids, Michigan (13). In the second part of the
human, financial, psychological and emo- 20th century, to address the high prevalence
tional cost. of dental caries water fluoridation was intro-
Water fluoridation is described as the duced to many countries, including Ireland,
controlled addition of fluoride to the water Australia, Hong Kong, Israel, New Zealand,
supply with the aim of reducing the preva- Singapore, and the UK.
lence of dental caries. Fluoride can also oc-
cur naturally in some water supplies. Cur-
Mode of Action
rent estimates are that 370 million people
in 27 countries are currently supplied with The mode of action of fluoride in the preven-
artificially fluoridated water and 50 million tion of dental caries is predominantly post-
around the world are drinking naturally flu- eruptive; however, the pre-eruptive effect of
oridated water (5). ingested fluoride is also important. Findings
This paper will discuss water fluoridation from Australia, the Netherlands and Mary-
under the following headings: Background, land support the pre-eruptive effect of fluo-
the mode of action, the effectiveness, the ride in reducing caries levels in pit and fis-
risks and benefits, the monitoring of water sure surfaces of permanent teeth. Research
fluoridation and the legislative nature of pro- has also indicated that exposure to fluori-
viding communities with water fluoridation. dated water from birth produces the maxi-
In the review baseline and subsequent mum benefit (14, 15). What is clear is that
national oral health surveys conducted in a constant low level of fluoride ion in saliva
Ireland are included to demonstrate the ef- and plaque fluid reduces the rates of enamel
fectiveness of water fluoridation and the demineralisation during the caries process
challenges to water fluoridation; in the Re- and promotes the remineralisation of early
public of Ireland (RoI) 73% of the popula- caries lesions (16, 17). Fluoride concentrated
tion presently benefit from water fluorida- in plaque and saliva inhibits the deminer-
tion. Thus providing an appropriate example alisation of sound enamel and enhances the
for Europe (6, 7, 8). remineralisation of demineralised enamel.
The terms part per million, ppm and
mg/l are used rather than the SI unit for flu-
oride in water μg/ml, to conform to previous
The effectiveness of water fluoridation
research. The Centers for Disease Control and Pre-
vention (CDC) have recognised water fluo-
Background ridation as one of the ten great public health
measures of the twentieth century (12). The
Water fluoridation is an ideal public health extensive international research demon-
measure in reducing dental caries; since its strating the effectiveness of water fluorida-
effectiveness does not require conscious tion is summarised in a number of impor-
daily cooperation from individuals (9) The tant texts (18, 19), recently Rugg-Gunn and
beneficial effects of natural water fluorida- Do (20) presented the international studies
tion in caries prevention was identified in attesting to the effectiveness water fluorida-
the first part of the 20th century and is un- tion published between 1990 and 2010, the
doubtedly a significant landmark in den- reader is referred to these sources for a re-
tistry (10, 11, 12), culminating in the intro- view of the many international studies. The
duction of artificial water fluoridation to the number of studies which were conducted
132
Máiréad Antoinette Harding et al.: Water fluoridation and oral health
since 1990 has declined; newer studies have implementation of the Act a baseline survey
tended to be pragmatic with the statistical of caries levels among children and adoles-
analyses taking account of confounding fac- cents would be undertaken (6). The Act also
tors (20, 21). Despite an overall reduction importantly stipulated that regular caries
in the number of countries and studies rep- surveys be undertaken “whenever and as of-
resented the number of studies from Brazil ten as the Minister requires” to monitor the
and Australia had increased, both countries effectiveness of fluoridation of water sup-
having extensive water fluoridation (5, 20). plies in controlling dental caries.
All studies demonstrate a similar positive The baseline surveys conducted prior to
reduction in per cent caries reduction. water fluoridation indicate a high caries ex-
Sources suggest that water fluoridation is perience; this was recorded as the number of
not only effective in childhood but also into teeth which were decayed, missing or filled
adulthood (22, 23). Water fluoridation com- because of tooth decay. They were recorded
bined with toothpaste use could be more ef- using the dmf/DMF index for both the pri-
fective than either alone (24). mary (baby teeth) (dmf), and permanent
(adult) (DMF) dentitions in 5-year-old to
15-year-old children (6, 28) (Table 1). Once
Water fluoridation in Ireland the fluoridation of water supplies com-
The fluoridation of water supplies in Ireland menced the concentration of fluoride in wa-
is indicative of the effectiveness, the ben- ter was set in the range 0.8 to 1.0 ppm, with
efits of, the required monitoring and chal- a target of 0.9 ppm.
lenges that may occur after implementation
(25). In the mid twentieth century the RoI National survey of children’s oral health
required a solution to the effects of wide- (Republic of Ireland) – 1983-84
spread dental caries and introduced water
fluoridation to Dublin on July 15th 1964, and In 1982 the Department of Health in the
to Cork in May 1965 the planned introduc- RoI commissioned a National Survey of
tion being delayed by some four years due Children’s Dental Health, the primary aim
to legal challenges in both the High and of which was to measure the effectiveness of
Supreme Courts (26). By 1970 the majority water fluoridation on a countrywide basis, it
of cities and larger towns were fluoridated. was also decided that levels of enamel fluo-
Under the legislation directing water fluori- rosis would be recorded, using internation-
dation (27) provision was made that, before ally accepted indices (28, 29). Random sam-
Table 1 Mean dmft* in five-year-olds, and DMFT* in 15-year-olds, in fluoridated communities (full Fl) in the
Republic of Ireland in 1984 and 2002, and in non-fluridated communities (non Fl) in the Republic of Ireland
and Northern Ireland in the 1960s, 1983-84 and 2002 (6, 7, 8)
5-Year-Olds 15-Year-Olds
Year Full Fl Non Fl Full Fl Non Fl
RoI RoI NI RoI RoI NI
1960 - 5.6 4.8 - 8.2 10.6
1983 – 1984 1.8 3.0 4.5 4.1 5.4 9.2
2002 1.3 1.7 1.8 2.1 3.2 3.6
Fl = fluoridated; RoI = Republic of Ireland; NI = Northern Ireland; dmf = decayed missing filled primary (teeth). DMF refers to permanent teeth.
133
ples of children who were lifetime residents The North south survey of children’s oral
of either fluoridated or non-fluoridated areas health – 2002
and aged five, eight, 12 or 15 years-old were
In 2000 under a contract for the evaluation
examined by 10 examiner/recorder teams (7).
of oral health services the Department of
The criteria adopted for dental caries exami-
Health commissioned a further national sur-
nation were similar to those used in the base-
vey of children’s dental health, with the aim
line studies of 1961-1963 (6) thus permitting
of monitoring the effectiveness of water fluo-
comparison. The results indicated a decline in
ridation (8).The study included a contem-
caries levels for children in both fluoridated
poraneous survey of children’s dental health
and non-fluoridated areas; the decline be-
in Northern Ireland (NI), where water fluo-
ing considerably greater in fluoridated areas,
ridation has not been introduced (31). The
fluorosis was measured using Dean’s index of diagnostic criteria for both caries and dental
fluorosis, the teeth scored for fluorosis were fluorosis were the same as used in the 1984
the upper permanent incisors (29). The chil- study (7). It was seen that in the period from
dren who were resident in non-fluoridated ar- 1983-1984 to 2002 there was a substantial re-
eas had a significantly higher dmf/ DMF than duction in dental caries in both fluoridated
those in fluoridated areas (Table 1). and non-fluoridated communities in the
The observed downward trend in den- RoI, and in the non-fluoridated population
tal caries has been noted in many inter- of NI; the reduction in the period from 1983-
national studies; the advent of fluoridated ‘84 to 2002, is greater in fluoridated com-
toothpastes in the 1970’s providing a valued munities. In the five-year-old age group, the
contribution (30). In the national survey in mean dmft among the lifetime residents of
1983-’84 (7) the prevalence of fluorosis was fluoridated communities in the RoI declined
low, with 94% of children in fully fluoridat- from 1.8 in 1983-’84 to 1.3 in 2002, the cor-
ed communities having normal enamel ac- responding figures for five-year-old children
cording to Dean’s Index (29), compared with in non-fluoridated areas in the RoI were 3.0
98% among eight-year-old children in non- and 1.7, and in NI were 4.5 and 1.8 respec-
fluoridated communities (Table 2). Only tively. Similar trends are apparent in the fig-
fluorosis grades of ‘questionable’ and ‘very ures recorded for caries among 15-year-olds
mild’ were recorded in the survey (7, 8, 31). in both jurisdictions (Table 1).
Table 2 Dean’s Index of Fluorosis*- % of eight-year-olds affected according to fluoridation status in the
Republic of Ireland and Northern Ireland in 2002 and 1984 (7, 8)
Full Fl Non Fl Full Fl Non Fl Non Fl

Eight-Year-Olds RoI RoI RoI RoI NI
1984 (a) 1984 (b) 2002 (c) 2002 (d) 2002 (e)
Normal 94 98 76 90 90
Questionable 5 2 11 7 6
Very Mild 1 0 8 2 3
Mild 0 0 4 0 0
Moderate 0 0 0 0 0
Severe 0 0 0 0 0
*Scores relate to permanent maxillary incisor teeth; RoI= Republic of Ireland; NI= Northern Ireland; The difference between a and c, c and d and
c and e were significant (p<0.0001).
134
The inverse occurred with the prevalence ment of teeth. It is a hypomineralisation of

of dental fluorosis and fluorosis increased in enamel characterised by an increased sur-
the RoI between 1983-1984 and 2002, par- face and subsurface porosity causing opac-
ticularly in residents of communities with ity, pitting or staining of the enamel (38).
water fluoridation. In 1983-’84, ninety-four However water fluoridation since its ini-
percent of children residing in fluoridated tiation has attracted hostile publicity, those
communities in the RoI had normal enam- who do not put a value on water fluoridation
el; this figure had reduced to 76% in 2002 caution that it is; costly and not effective,
(Table 2). The figures for ‘questionable’, ‘very that it impacts negatively on general health;
mild’ and ‘mild’ fluorosis in 1983-1984 were causes objectionable dental fluorosis and
5%, 1% and zero, respectively; these figures that it is a violation of medical ethics and the
had increased in 2002 to 11%, 8% and 4%, rights of the individual (39). Thus the very
respectively. The increasing prevalence of core of its capacity to promote prevention to
fluorosis was also identified internationally the whole population is challenged.
(32, 33). All of the reviews conducted on water
fluoridation have acknowledged that fluoro-
sis occurs to some degree with water fluo-
The benefit of water fluoridation ridation, and fluorosis was identified as the
Water fluoridation has been the subject of only adverse effect of fluoridation (33). The
rigorous reviews of late and has been rec- likelihood of fluorosis occurring was iden-
ognised as safe and as the most effective tified at the very outset, for it was McKay’s
method of reaching the whole population observation of the Colorado ‘brown stain’
irrespective of access to dental services in that led to the identification of the benefi-
this way each individual can benefit without cial effect of fluoride in the prevention of
the need for active participation (24, 34, 35). dental caries and was acknowledged in the
In addition the review of McDonagh et al. work of Dean and the ‘21 cities study’ (10).
(24) suggested water fluoridation conferred The environmental concerns which have
a benefit over and above the use of fluoride been raised with regard to fluoride were re-
containing toothpastes alone. The process of cently addressed in the report of the Euro-
water fluoridation has been endorsed by the pean Commission’s Scientific Committee on
world’s leading science and health organisa- Health and Environmental Risks (SCHER)
tions including the WHO (36), IADR (In- (40). The committee did not identify any
ternational Association of Dental Research) evidence of negative environmental impacts
and FDI (World Dental Federation), with from community water fluoridation. Ethi-
the benefits available to both child and adult cal concerns were addressed by the Nuffield
(22, 23). Griffin et al. (37) showed that for Council on Bioethics (41, 42, 43). Reviews
the US water fluoridation delivered signifi- conducted in the US, Australia, and Canada
cant cost savings. arrived at similar conclusions (35, 44, 45).
Nevertheless it is crucial that on-going sur-
veillance of general health be maintained in
The risk of water fluoridation fluoridated and non-fluoridated communi-
ties. The structured use of health registers,
Dental fluorosis is recognised as a conse-
for example cancer and hip fracture regis-
quence of consuming fluoridated water sup-
ters, are an important source of information
plies.
for this purpose.
It arises as a result of a long-term intake
of fluoride during the preeruptive develop-
135
Monitoring 0.7 mg/l (ppm), rather than the previous range

0.7mg/l – 1.2 mg/l, (ppm) to take account of
The studies conducted in Ireland (7, 8) es- other sources from which communities may
tablished there was a decline in dental caries receive fluorides (50). In Canada the concen-
after the fluoridation of water supplies and tration of 0.7 mg/l (ppm) of fluoride has been
also an increase in dental fluorosis. Good set moving from the previous range of 0.8 to
practice recommends the recording of the 1.0 mg/l (ppm) (51) while in Australia, levels
fluoride concentration in water supplies on have remained unchanged, since the current
a regular basis, daily, weekly, monthly and research in Australia into caries prevention
strategies must be in place to notify the rel- and fluorosis suggests maintaining the status
evant authorities of the measurements that quo. Some Asian, tropical and sub-tropical
are recorded. Audit is possible when the regions have reviewed the concentrations at
agency fluoridating supplies is not the same which water is fluoridated and have agreed an
agency. In Ireland the sanitary authori- upper and lower limit of 1mg/l and 0.5 mg/l
ties have responsibility for the addition of (ppm) respectively.
fluoride to water supplies while the health Naturally occurring high fluoride water
authorities and environmental protection supplies occur around the world and defluo-
agency have responsibility for monitoring ridation if required is possible (18), some of
the concentration of fluoride in supplies (26, the methods which can be used for defluori-
46). This also ensures agencies are compliant dation are to blend waters with high fluoride
with legislation and regulation. concentration with waters of low concentra-
Regular monitoring has led to changes tion in addition technologies such as reverse
in fluoride concentration internationally. osmosis, electrodialysis and distillation are
When the prevalence and severity of fluoro- available in the market. The fluoridation
sis between the two national surveys (7, 8) plants must have an effective fail-safe system
was compared in Ireland (7, 8), (Table 2), the with well-defined limits for the precision
prevalence had increased. Consequent on of measurements (52). A concentration of
these findings in 2007 the level of fluoride in 1.5mg/l (1.5 ppm) is accepted as the Maxi-
drinking water was reduced from a range of mum Acceptable Concentration (MAC) of
0.8 to 1.0 ppm, with a target of 0.9 ppm, to a artificially fluoridated supplies.
range of 0.6 to 0.8 ppm, with a target of 0.7
ppm (47). In addition, recommendations for
Legislation
the use of fluoride toothpaste by infants and
young children were also introduced (34). Legislation providing for water fluoridation
Recommendations with regard to tooth- can be of two types. It may be mandatory,
paste were made as the inappropriate use of requiring a ministry of health or communi-
fluoride toothpaste in young children who ties of a certain size to fluoridate their pub-
may not be able to expectorate it adequately lic water supplies if it is below the accepted
is a major risk factor in fluorosis (38, 48, 49). fluoride level; this is the type of legislation in
A downward revision of the concentra- Ireland. Alternatively, it may be of the per-
tion of fluoride in water supplies has oc- missive or enabling type, empowering the
curred in other jurisdictions to balance the ministry of health or a local government to
availability of fluorides from other sources, institute fluoridation. Some countries and
such as fluoridated toothpastes. The Depart- jurisdictions require consultations with the
ment of Health and Human Services in the community and to consider such consulta-
US has recommended water fluoridation at tions prior to proceeding, such as in the UK.
136
Discussion Future research must consider the challeng-

es in reporting appropriate outcomes for
In this article the authors have brought to- both dental caries and dental fluorosis and
gether the experience of and the challenges the means of overcoming the challenges in
to water fluoridation using the experiences the design, conduct and reporting of future
in the RoI for examples. They have also con- work.
sidered why it remains an effective compo-
nent of prevention and oral health policy. Authors’ contributions: Conception and design:
Emerging evidence suggests that the declin- DOM, MH; Acquisition, analysis and interpretation
of data: DOM, MH; Drafting the article: DOM, MH;
ing caries levels which excited oral health Revising it critically for important intellectual content:
professionals through the nineties and early DOM, MH.
2000’s may have plateaued. Internationally
established economies are tending towards Conflict of interest: The authors declare that they
have no conflict of interest.
a more energy dense, refined carbohydrate
diet, which may become more challenging
in the delicate balance in preventing dental References
caries and dental fluorosis, and promot-
1. Moore WY. The distribution of dental car-
ing oral health. The National Health and ies in ancient British populations. Caries Res.
Medical Research Council in Australia (35) 1973;(7):139-53.
concluded: the existing body of evidence 2. Sgan-Cohen HD, Evans RW, Whelton H, Vil-
strongly suggests that water fluoridation lena RS, Mac Dougall M, Williams D. IADR-
is beneficial at reducing dental caries’. For GOHIRA Steering and Task Groups. IADR
Global Oral Health Inequalities Research Agenda
most studies the consistent measure of effect (IADR-GOHIRA®). A call to action. J Dent Res.
to indicate the effectiveness of water fluori- 2013;(92):209-11.
dation is the dmf/DMFT index (20), scien- 3. World Health Organisation. Oral disease burdens
tifically this makes sense and permits com- and common risk factors: WHO; 2012. [cited 2013
parison with relative ease. Perhaps going Jan 31]. Available from: http://www.who.int/oral_
health/disease_burden/global/en/index.html.
forward ways of demonstrating effectiveness
4. Oral Health in America. A Report of the Surgeon
in terms of the distress and misery avoided, General. Rockville, MD: US Dept. of Health and
capturing children’s ability to develop a pos- Human Services, National Institutes of Health,
itive association with oral health should be National Institute of Dental and Craniofacial Re-
considered. The emotional impact of dental search; 2012. p. 2.
caries is significant and apparent on a daily 5. British Fluoridation Society (BFS): One in a mil-
lion – the facts about water fluoridation, 3rd ed.
basis to a significant number of families and [cited 2013 Jan 19]. Available from: http://www.
dental personnel. bfsweb.org/onemillion/onemillion2012.html.
6. Minister for Health: Reports on the incidence of
dental caries in school children and on the analyses
Conclusion of public piped water supplies in the different coun-
ties, 1961-1965. Dublin: Stationery Office; 1965.
Water fluoridation is an effective safe means 7. O’Mullane DM, Clarkson J, Holland T, O’Hickey
of preventing dental caries, reaching all pop- S, Whelton HP. Children’s Dental Health in Ire-
ulations, irrespective of the presence of oth- land 1984. Dublin: Stationery Office; 1986.
er dental services. The monitoring of dental 8. Whelton H, Crowley E, O’Mullane D, Harding M,
caries and dental fluorosis is the cornerstone Guiney H, Cronin M, et al. North South Survey
of Children’s Oral Health in Ireland 2002. Dublin:
of good public health practice and is essen- Brunswick Press Ltd; 2006 [cited 2013 Jan 20].
tial particularly when the lifelong challenge Available from: www.dohc.ie/publications/oral_
which dental caries presents is considered. health.html.
137
9. Centers for Disease Control and Prevention 23. Slade GD, Sanders AE, Do L, Roberts-Thomson K,
(CDC). Populations receiving optimally fluoridat- Spencer AJ. Effects of fluoridated drinking water
ed public drinking water-United States. MMWR on dental caries in Australian adults. J Dent Res.
Morb Mortal Wkly Rep. 2002;(51):144-7. 2013;(92):376-82.
10. Dean HT, Arnold FA, Elvove E. Domestic water 24. McDonagh MS, Whiting PF, Wilson PM, Sutton
and dental caries. Additional studies of the rela- AJ, Chestnutt I, Cooper J, et al. Systematic review
tion of fluoride domestic waters to dental caries of water fluoridation. BMJ. 2000;321(7265):855-9.
experience in 4,425 white children aged 12-14 25. O’Grady P. In the public good. J Ir Dent Assoc.
years of 13 cities in 4 states. Public Health Rep.
2012;58(3 Suppl)S4-5.
1942;(57):1155-79.
26. Clarkson J, McLoughlin J, O’Hickey S. Water fluo-
11. Dean HT, Arnold FA, Jay P, Knutson JW. Studies
ridation in Ireland – A success story. J Dent Res.
on mass control of dental caries through fluorida-
2003;(82):334-7.
tion of the public water supply. Public Health Rep.
1950;(65):1403-8. 27. Health (Fluoridation of Water Supplies) Act, 1960.
12. Centers for Disease Control and Prevention Dublin: Stationery Office; 1960.
(CDC). Achievements in public health, 1990- 28. Klein H, Palmer E, Knutson JW. Studies on Den-
1999: fluoridation of drinking water to pre- tal Caries: Dental status and dental needs of el-
vent dental caries. MMWR Morb Mortal Wkly ementary school children. Public Health Rep.
Rep.1999;(48):933-40. 1938;(53):751-65.
13. Centers for Disease Control and Prevention 29. Dean HT. The investigation of physiological ef-
(CDC). CDC Honours 65 Years of Community fects by the epidemiological method. In: Moulton
Water Fluoridation; 2010. [cited 2013 Jan 16]. FR, ed. Fluorine and dental health. Washington
Available from: http://www.cdc.gov/fluorida- DC: American Association for the Advancement
tion/65_years.htm. of Science; 1942. p. 23-71.
14. Groeneveld A, Van Eck AA, Backer-Dirks O. 30. Petersson G, Bratthall D. The caries decline: A review
Fluoride in caries prevention: is the effect pre- or of the reviews. Eur J Oral Sci. 2007;(104):436-43.
post- eruptive? J Dent Res. 1990;69 Spec No: 751-
31. Whelton H, Crowley E, O’Mullane D, Donald-
5:820-3.
son M, Cronin M, Kelleher V. Dental caries and
15. Singh KA, Spencer AJ, Brennan DS. Effects of enamel fluorosis among the fluoridated popula-
water fluoride exposure at crown completion and tion in the Republic of Ireland and non-fluoridat-
maturation on caries of first permanent first mo- ed population in Northern Ireland in 2002. Com-
lars. Caries Res. 2007;(41):34-42.
munity Dent Health. 2007;(23):37-43.
16. Fejerskov O, Thylstrup A, Larsen MJ. Rational use
32. Fomon SJ, Ekstrand J, Ekhard E, Ziegler D. Fluo-
of fluoride in caries prevention: A concept based
ride intake and prevalence of dental fluorosis:
on various cariostatic mechanisms. Acta Odontol
Trends in fluoride intake with special attention
Scand. 1981;(39):241-9.
to infants: Review and commentary. J Pub Health
17. Featherstone JD. Prevention and reversal of dental
Dent. 2000;(60):131-9.
caries: role of low level fluoride. Community Dent
Oral Epidemiol. 1999;(27):31-40. 33. Pendrys DG, Haugejorden O, Bardsen A, Wang
18. World Health Organisation. Appropriate use of NJ, Gustavsen F. The risk of enamel fluorosis and
fluorides for human health. Geneva: World Health caries among Norwegian children: implications
Organisation; 1986. for Norway and the United States. J Am Dent As-
soc. 2010;(141):401-14.
19. Murray JJ, Rugg-Gunn AJ, Jenkins GN. Fluorides
in caries prevention, 3rd ed. Oxford: Butterfield- 34. Report of Forum on Fluoridation. Dept. of Health.
Heinemann; 1991. [cited 2013 Feb 11]. Available from: http://www.
20. Rugg-Gunn A and Do L. Effectiveness of water dohc.ie/publications/pdf/fluoridation_forum.pdf.
fluoridation in caries prevention. Community 35. National Health and Medical Research Council. A
Dent Oral Epidemiol. 2012;40(Suppl 2):S55-64. systematic review of the efficacy and safety of fluo-
21. O’Mullane DM, James P, Whelton H, Parnell C. ridation. Canberra, Australian Government; 2007.
Methodological issues in oral health research: in- [cited 2013 Feb 11]. Available from: http://www.
tervention studies. Community Dent Oral Epide- nhmrc.gov.au/_files_nhmrc/publications/attach-
miol. 2012;40(Suppl 1):S15-20. ments/eh41_1.pdf.
22. Neidell M, Herzog K, Glied S. The Association 36. Petersen PE. The World Oral Health Report 2003:
between community water fluoridation and adult continuous improvement of oral health in the 21st
tooth loss. Am J of Pub Health. 2010;(100):1980-5. century – the approach of the WHO Global Oral
138
Health Programme. Community Dent Oral Epi- mittee on Health and the Environment. Ottawa,
demiol. 2003;(1):3-23. Ontario; 2010. [cited 2013 Feb 3]. Available from:
37. Griffin SO, Jones K, Tomar SL. An economic eva- http://www.hc-sc.gc.ca/ewh-semt/alt_formats/
luation of community water fluoridation. J Public hecs-sesc/pdf/pubs/water-eau/2011-fluoride-
Health Dent. 2001;(61):78-86. fluorure/2011-fluoride-fluorure-eng.pdf.
38. Browne D, Whelton H, O’Mullane D. Fluoride me- 46. European Communities (Drinking Water) (No.2)
tabolism and fluorosis. J Dent. 2005;(33):177-86. Regulations S.I. No. 278 / 2007). Government of
39. Melbye MLR, Armfield JM The dentist‘s role in Ireland; 2007. [cited 2013 Aug 07]. Available from:
promoting community water fluoridation: A http://www.irishstatutebook.ie/2007/en/si/0278.
call to action for dentists and educators. JADA. html.
2013;(144):65-75. 47. Fluoridation of Water Supplies Regulations. S.I.
40. EU Scientific Committee on Health and Environ- No. 42/2007. Government of Ireland; 2007. [cited
mental Risks (SCHER). Critical review of any new 2013 Jan 24]. Available from: http://www.irishstat-
evidence on the hazard profile, health effects, and utebook.ie/2007/en/si/0042.html.
human exposure to fluoride and the fluoridating 48. Pendrys DG, Stamm JW. Relationship of total flu-
agents of drinking water; 2011 [cited 2013 Feb oride intake to beneficial effects and enamel fluo-
4]. Available from: http://ec.europa.eu/health/ rosis. J Dent Res. 1990;69(Special Issue):529-38.
scientific_committees/environmental_risks/in- 49. Harding MA, Whelton H, O’Mullane DM, Cronin
dex_en.htm. M, Warren JJ. Primary tooth fluorosis in 5-year-
41. Nuffield Council on Bioethics. Public Health: old schoolchildren in Ireland. Eur J Paediatr Dent.
Ethical Issues. London: Nuffield Council on 2005;(6):155-61.
Bioethics; 2007. 50. Centers for Disease Control and Prevention
42. Mullen J. History of water fluoridation. BDJ. (CDC), Division of Oral Health, Changes pro-
2005;(199);1-4. posed to national fluoridation level. [cited 2013
43. Mullen J. Defending fluoridation. J Ir Dent Assoc. Feb 11]. Available from: http://www.cdc.gov/oral-
2012;58(3 Suppl):S9. health/.
44. Centers for Disease Control and Prevention CDC 51. Findings and recommendations of the Fluo-
Oral Health Division. Oral Health Resources; ride Expert Panel. Health Canada; 2007. [cited
2013. [cited 2013 Feb 3]. Available from: http:// 2013 Feb 2]. Available from: http://www.hc-sc.
www.cdc.gov/oralhealth/. gc.ca/ewh-semt/pubs/water-eau/2008-fluoride-
fluorure/index-eng.php.
45. Guidelines for Canadian Drinking Water Quality.
Guideline Technical Document Fluoride. Federal- 52. Fawell J, Bailey K, Chilton J, Dahi E, Fewtrell L,
Provincial-Territorial Committee on Drinking Magara Y. Fluoride in drinking water. WHO. Lon-
Water of the Federal-Provincial-Territorial Com- don: IWA Publishing; 2006.
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Strategies for caries prevention

Dental caries: Strategies to control this preventable disease

Introduction ventable is not yet prevented. The aim of this

fermentation of sugars were capable of de- tential for remineralisation of demineralised

attachment and colonisation of cariogenic plaque to metabolise sugars to acids. The

Sugars and dental caries – types of study

Water fluoridation and oral health

Máiréad Antoinette Harding1,2, Denis Martin O’Mullane1

Introduction hood factors such as where we live and the

Full Fl Non Fl Full Fl Non Fl Non Fl

The inverse occurred with the prevalence ment of teeth. It is a hypomineralisation of

Monitoring 0.7 mg/l (ppm), rather than the previous range

Discussion Future research must consider the challeng-

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