Early childhood caries--a synopsis.

All the papers presented at the conference are reviewed and comparisons are made with past beliefs on the topic. Early childhood caries (ECC) is a serious public health problem in disadvantaged communities in both developing and industrialized countries in which under-nutrition is common. ECC involves the maxillary primary incisors within months after their eruption and spreads rapidly to involve other primary teeth. The early implantation of mutans streptococci, the use of a feeding bottle containing sugary solutions and prolonged breast-feeding, especially at night, are important predisposing factors. Attention is drawn to the need for more research into the factors which determine the resistance of the enamel and particularly the elucidation of the relationship established in several countries between early enamel caries, enamel hypoplasia, and perinatal under- or malnutrition. Primary preventive measures should be applied during the ante- and immediate post-natal periods. Secondary preventive measures include the use of chemotherapeutic agents such as fluoride, and antimicrobials. The most appropriate tertiary preventive measure is the atraumatic restorative technique (ART). Broadly based committees should be established by governments to address the issues of caries risk in young children. Parents and all personnel involved in infant health and welfare should be shown how to recognize early signs of the condition, as well as to promote early intervention and referral.

Use of proteinase K for RT-PCR of cytokine mRNA in formalin fixed tissue.

Fresh tissue from cases of sudden infant death syndrome is becoming increasingly scarce and therefore researchers interesting in studying the aetiology of this syndrome have had to resort to archival tissue, usually in the form of paraffin wax sections. A simple method for isolating mRNA from formalin fixed, paraffin wax embedded material of sufficient purity for reverse transcription (RT)-PCR is described. Proteinase K treatment of formalin fixed, wax embedded tissue followed by RNA STAT-60 extraction was successful in isolating mRNA suitable for RT-PCR. Interleukin (IL)-1alpha, IL-6 and tumour necrosis factor (TNF) transcripts were amplified successfully from heart, but not thyroid, kidney or liver tissue, of a patient who died following rejection of a transplanted heart, and IL-1alpha, but not IL-6 or TNF, transcripts from lung tissue of a six month old baby who died of viral pneumonia. Transcripts of a housekeeping gene were detected in all tissues. This method should be useful for examining gene expression in archival material.

Prevalence of developmental enamel defects and dental caries in rural pre-school Thai children.

The prevalence of developmental enamel defects and dental caries was assessed in 344 Karen children aged 1-4 years who were chronically (70 per cent) and acutely malnourished (9.3 per cent) The teeth were cleaned with gauze to facilitate detection of hypoplastic lesions on labial surfaces of maxillary incisors. At least one tooth with defective enamel was seen in 31.9 per cent of children, while enamel hypoplasia was present in 22.7 per cent of children. Enamel defects were found in 21.2 per cent of teeth, with hypoplasia and opacities occurring in 14.6 and 6.6 per cent of teeth, respectively. Gender did not alter the prevalence of defects. The upper central incisors were affected more than lateral incisors. The prevalence of dental caries was 31.9 per cent with a mean dt of 1.1. The prevalence of caries associated with enamel hypoplasia was significantly greater than that associated with opacities and sound enamel (P < 0.0005).

The community care model of the Intercountry Centre for Oral Health at Chiangmai, Thailand.

The Intercountry Centre for Oral Health opened in Chiangmai, Thailand, in November, 1981. In 1984, as part of its mandate to promote new approaches to the delivery of oral health care, it initiated a demonstration project known as the Community Care Model for Oral Health. Logistic, financial and organisational difficulties prevented the full implementation of the original plan. Nevertheless, consideration of the strengths and weaknesses of the Model has provided valuable suggestions for adoption by national and international health agencies interested in adopting a primary health care approach to the delivery of oral health services. Important features which could be appropriate for disadvantaged communities include: integration into the existing health service infrastructure; emphasis on health promotion and prevention; minimal clinical interventions; an in-built monitoring and evaluation system based on epidemiological principles, full community participation in planning and implementation; the establishment of specific targets and goals; the instruction of all health personnel, teachers and senior students in the basic principles of the recognition, prevention and control of oral diseases and conditions; the application of relevant principles of Performance Logic to training; and the provision of a clear career path for all health personnel.

A new approach to the training and education of oral health personnel.

An innovative curriculum has been designed for the Fiji School of Medicine to enable dental personnel to proceed through a sequence of educational modules on a career path leading from a dental assistant through other auxiliary grades to a dentist with a BDS degree. The courses for each grade are formulated to be relevant to the pattern of oral diseases in Fiji and the Pacific Islands; be designed in accordance with specified job-descriptions; have a strong community orientation, with emphasis on prevention and the promotion of oral health; permit exit and re-entry at each level; incorporate, where appropriate, the principle of problem-based learning; and incorporate procedures to ensure early establishment of clinical skills. Details of the first year and an outline of the structure of the course for the subsequent years are presented.

Dental caries and periodontal disease in Fiji.

A national oral survey was conducted in Fiji in 1985/86. The results showed that the prevalence of caries was generally low and most commonly affected pit and fissure surfaces. Comparisons with previous surveys in 1948 and 1965 showed that the prevalence had fallen in primary teeth but remained relatively constant in permanent teeth. There were significant variations in prevalence between residential locations but not between ethnic groups. Periodontal disease was found to be a major public health problem. Except for the percentage of young children with caries-free dentitions, the current status of oral health in Fiji was generally better than that proposed in the WHO goals for the year 2000. The training of dental hygienists to help in the prevention of both dental caries and periodontal disease is discussed.

Primary oral health care for developing countries.

A model for the delivery of oral health care in rural areas of developing countries has been derived from studies in Papua New Guinea and Thailand. It gives special attention to self-help and self-reliance at village level; it provides for training of each category of personnel, with a clearly defined career structure, and can be adapted to respond to diverse epidemiological, demographic, social and economic circumstances.

Attitudes to oral health, preventive practices and dental services in a Thai population.

1500 subjects aged 15-18 and 35-44 years, providers of oral health care and village headmen from 6 north Thailand districts with different dental services were interviewed about their knowledge of and attitudes to oral health, preventive practices and oral health services. Current oral symptoms mentioned by the 1500 subjects included pain (20.7 per cent), holes in teeth (10.5 per cent), ulcer, lump or swelling (5.9 per cent), loose teeth (5.2 per cent), calculus (2.9 per cent) and bleeding gums (1.3 per cent). Those complaining of holes in teeth had a significantly higher mean number of DMFT (2.05) than those who had no current problem (0.60). There was a general lack of appreciation of periodontal disease as a clinical problem. 57.5 per cent of those with a current problem did nothing about it because of lack of time or because they did not know where to go. 98 per cent said they used a toothbrush and 75.1 per cent used it two or more times a day. 58 per cent said that oral disease was preventable. Virtually all methods mentioned referred to dental caries which was a minor problem in this age group. A significant number had received advice on oral health from primary health care workers. In two districts primary oral health care workers trained at the Intercountry Centre for Oral Health for two weeks to do superficial tooth scaling provided care for 110 subjects, 85-88 per cent of whom were satisfied with the care received. Village headmen were sceptical about preventing oral disease and wanted more frequent visits from mobile dental units. The dentist and dental nurses were unable to cope with the range of work required and wanted additional training. Sub-district health workers and primary oral health workers were frustrated by the limitations of their work and wanted additional training to do fillings and extractions.

Periodontal status and treatment needs in the Chiangmai/Lamphun provinces of Thailand.

As part of an oral health survey concerned with the evaluation of a collaborative primary oral health care program, the CPITN system was used to determine the periodontal status and treatment needs of 2009 Thai people aged 12-44 yr. Calculus dominated the CPITN scores. The percentage of persons with healthy periodontal tissues was small, ranging from 0.7% at age 35-44 to 4.1% at age 12. Ranges for other highest scores were bleeding-0.4% at age 35-44 yr to 6.1% at age 12 yr; calculus-62% at age 35-44 yr to 92.6% at age 17-18 yr. Pocketing did not occur to any significant extent until age 35-44 where 23.9% had 3-5 mm pockets and 12.8% had pockets 6 mm or deeper. 15-18-yr-olds who had received prior care from a Village Scaler had a significantly higher number and proportion of healthy sextants than those who had not received such care. No such effect was demonstrated in 35-44-yr-olds. The need for caution in the interpretation of this result is stressed. Attention is drawn to the desirability of differentiating between supra- and sub-gingival calculus in the CPITN scoring system and to the excessive treatment requirements that arise from classifying everyone with calculus as requiring prophylaxis and scaling. A great deal of improvement will need to be affected if the Thai national and global goals for periodontal health are to be achieved in the districts covered by this survey.

Dental caries experience in the Chiangmai/Lamphun provinces of Thailand.

Thailand has a highly developed system of primary health care. Using the criteria and methods recommended by W.H.O., an oral health survey was undertaken of 2111 subjects from six districts with different types of dental service including two with no systematic service and two with ICOH-trained primary oral health care personnel - examiners, health educators and village scalers. Significant differences between districts, unrelated to the type of dental service, were found in the percent of children with caries-free primary teeth and in mean dmft at ages 5 and 6; and at ages 5-6, 12, 17-18 and 35-44 (but not 15-16) in the percent of subjects with caries-free permanent teeth. The prevalence of DMFT was uniformly low ranging from 0.0 at age 6 to 1.18 at age 35-44. There was an inverse relationship between CFI and DMFT in subjects aged 12-18 and a direct relationship between dental fluorosis and the fluoride content of well-water used for cooking and drinking. The most conspicuous feature of the data was the much greater prevalence of caries in the primary dentition with heavy involvement of the maxillary incisors. Comparisons with the Thai and International Goals for Oral Health by the Year 2000 show that all except two districts have already achieved the Thai, but not the FDI/WHO, Goal for 5-6-yr-olds with caries-free primary teeth and, except for one district, all of the national and international goals with respect to the status of the permanent dentition have also been achieved.

The Danish oral health care service for children: an evaluation.

An evaluation of the children's oral health care service was performed by an international assessment team who undertook a field programme in Denmark. Three counties were visited, one metropolitan, one urban and one rural. Data on dental health costs were collected and dental services in six municipalities selected at random were examined. Opinions of administrators at all levels and those of clients and providers were obtained and interviews also took place with staff and students at the two dental schools. The service was considered effective insofar as active dental disease was closely controlled by restorative care and a high level of dental awareness was instilled in all sections of the child population. The service was also clearly adequate since participation of schoolchildren was almost universal. However, resource expenditure on both professional personnel and clinical facilities was considered high and the efficiency of the service was possibly rendered less than optimal by a degree of over-provision in 'passive' prevention and orthodontics. The appropriateness of devoting so much resource to children at the expense of the population as a whole was also regarded as questionable as was the lack of a fluoridation programme. Client groups wholeheartedly supported the service as a result of the high quality of care and the attractive, considerate image projected by clinics and staff. The overall excellence of the service was a matter of satisfaction to administrators, of gratification to clients and of pride to the providers whose morale was high.

The Danish oral health care service for children: an international appraisal.

The Danish children's oral health care service has been so successful in achieving its objectives that it will need to change and adapt in order to survive. It is suggested that the service should gradually become community-based rather than child-based. This process can be commenced by introducing treatment for the elderly, the handicapped and the indigent, converting the school clinics to municipal oral health units. Although it is important that private practice is maintained, private dentists should be encouraged to work in the system part-time, leading teams of supporting auxiliary personnel trained within an integrated system. Eventually, the facilities could form the basis of primary health care centres. The lessons to be learnt from the Danish experience have a wider application to other countries. In developing countries it is obvious that they should first place limited dental resources into public health prevention and only invest in expensive treatment clinics as funds become more available. Manpower planning should ensure that personnel are not overtrained for the needs of the community. In developed countries, increasingly more resources will need to be channelled into adult dental care, and dental education must lead the profession into this new era. Difficult though these changes will be, the stable relationships that have developed between the various arms of the service under the guidance of the Danish Dental Association, will ensure that the profession will survive and flourish for the benefit of the Danish people.

The Danish oral health care service for children: a comparison with alternative systems.

Aarhus in Denmark, Adelaide in Australia, Saskatchewan in Canada, Bristol in England and Limerick in Ireland were chosen as representing five different systems for improving the dental health of children. Fluoridation apart, the system of dental care delivery seems to have little influence on the level of dental disease, but appears to have remarkable cost implications. The most expensive system employs salaried dentists to carry out all the operative procedures. Employing dental therapists to do the simple operative procedures reduces costs materially, but utilizing private dentists in an insurance scheme that encourages efficient practice may be less expensive still. The results of this study highlight the need for more detailed comparison of delivery systems, in order to advise public dental health authorities on the most effective and efficient systems for children.