Critique of the review of 'Water fluoridation for the prevention of dental caries' published by the Cochrane Collaboration in 2015.

The Cochrane Review on water fluoridation for the prevention of dental caries was published in 2015 and attracted considerable interest and comment, especially in countries with extensive water fluoridation programmes. The Review had two objectives: (i) to evaluate the effects of water fluoridation (artificial or natural) on the prevention of dental caries, and (ii) to evaluate the effects of water fluoridation (artificial or natural) on dental fluorosis. The authors concluded, inter alia, that there was very little contemporary evidence, meeting the Review's inclusion criteria, that evaluated the effectiveness of water fluoridation for the prevention of dental caries. The purpose of this critique is to examine the conduct of the above Review, and to put it into context in the wider body of evidence regarding the effectiveness of water fluoridation. While the overall conclusion that water fluoridation is effective in caries prevention agrees with previous reviews, many important public health questions could not be answered by the Review because of the restrictive criteria used to judge adequacy of study design and risk of bias. The potential benefits of using wider criteria in order to achieve a fuller understanding of the effectiveness of water fluoridation are discussed.

Dental Caries Status, Socio-Economic, Behavioral and Biological Variables among 12-Year-Old Palestinian School Children.

UNLABELLED: There are currently inadequate data regarding the prevalence of dental caries and its associated variables, among Palestinian children. AIM: To determine the current prevalence of dental caries and related variables, among Palestinian children in East Jerusalem. STUDY DESIGN: A stratified sample of 286 East Jerusalem Palestinian children was selected, employing randomly chosen sixth grade clusters from three pre-selected socio-economic school groups. Dental caries was recorded according to WHO recommendations. Salivary flow, pH, buffer capacity and microbial parameters, were recorded according to previously employed methodologies. RESULTS: The mean level of caries experience, by DMFT, was 1.98 ± 2.05. This level was higher than those found among Israeli children, but lower than several other Middle Eastern countries. In uni-variate analysis, significant associations were revealed between caries and school categories, which indicated lower, middle and higher socio-economic position(SEP), mothers' employment, home densities, dental visits, tooth brushing, Streptococci mutans (SM), Lactobacilli (LB), and saliva pH. CONCLUSION: According to a linear logistic regression model, children learning in lower SEP schools, with higher SM levels and more acidic saliva, had a higher chance of experiencing dental caries. These findings should be considered in the planning of services and dental health care programs for Palestinian children.

Dental caries among children in Georgia by age, gender, residence location and ethnic group.

OBJECTIVE: To provide prevalence data for dental caries in Georgia. METHODS: This World Health Organization pathfinder survey was conducted among 1,351 (6, 12 and 15 year-old) Georgian children, representing the main ethnic groups in urban and rural locations. Caries was analysed at univariate and multivariate levels, according to age, gender, urban/rural locality and ethnic group. RESULTS: Caries experience levels among 6-year-olds were dmft = 4.57, sd 3.42 (14.8% caries-free); DMFT = 2.04 (sd 2.02) among 12-year-olds (31.1% caries-free); and DMFT = 3.51 (sd 3.14) for the 15-year-olds (17.7% caries-free). Urban children at ages 6 and 12 years were more likely to be caries-free and have both lower levels of caries-experience and higher levels of filled or restored teeth. In multivariate regression analyses, most age groups showed a significant contribution from residence location. No differences were found by age and no consistent differences were detected by ethnic group. CONCLUSION: These data should provide the baseline for formulating and conducting public oral health efforts in Georgia, with emphases on rural residence locations.

Dental erosive wear assessment among adolescents and adults utilizing the basic erosive wear examination (BEWE) scoring system.

OBJECTIVES: To investigate erosive tooth wear and related variables among adolescents and adults in Israel, utilizing the new basic erosive wear examination (BEWE) scoring system, in an attempt to contribute to the ongoing review, evaluation, and further development of an international standardized index. MATERIAL AND METHODS: A cross-sectional, descriptive, and analytic survey was conducted among 500 subjects of five age groups. Dental erosion was measured according to the new BEWE scoring system. Independent variables included gender, age, origin, education, employment status, and diet. A backward stepwise linear regression model was applied to identify significantly associated variables. RESULTS: Fifty percent of the survey subjects demonstrated erosive tooth wear; among them, 10 % had distinct erosion of over 50 % of the dental surface. Total BEWE score differences by age groups were statistically significant; as the age increased, the mean total BEWE scores increased (p < 0.001). The association between acidic foods and erosion was evident among the younger population (p = 0.038). In a multiple regression model, age (p < 0.001) and diet (p = 0.044) achieved statistical significance as variables associated with dental erosive wear. CONCLUSIONS: Our study is one of the first to use the BEWE scoring system in an epidemiological survey among adolescents and adults. It was found that the BEWE index is straightforward, easy to conduct, and comfortably accepted by the examinees. CLINICAL RELEVANCE: The present findings, together with further international research, should contribute toward continued evaluation of the BEWE system as an international standard and thereby, toward more optimal understanding, evidence-based treatment, and prevention of dental erosive wear.

[Community dentistry in practice: four decades of activity among the Ethiopian community].

The immigration absorption of the Ethiopian community poses a great Zionist challenge to the State of Israel. The Department of Community Dentistry established a long and ongoing relationship with this unique population on a variety of levels. We revealed an alarming deterioration of their oral health status since their arrival to Israel. Concurrently, we explored the association between oral health and psychosocial variables among these immigrants. Accordingly, we implemented a holistic community oral health care program (prevention, treatment, dental, medical, social, psychological), with the participation of a multidisciplinary team of Ethiopian born professionals. In addition, as part of the integration process in the Israeli society and workplace, our department educated and trained individuals of this community as dental assistants and dental hygienists in courses held at the Hadassah Medical Organization. We strongly believe that this model of relationship and support should be implemented on a national level.

Religiosity, spirituality, social support, health behaviour and dental caries among 35- to 44-year-old Jerusalem adults: a proposed conceptual model.

The aim of this study was to assess the relationship between religiosity and dental caries, and whether oral health-related behaviours, spirituality and social support are included in the potential pathways which explain the association between religiosity and dental caries. The present cross-sectional study employed a stratified sample, according to religiosity level (33.1% secular, 33.1% religious and 33.9% orthodox), of 254 Jewish adults in Jerusalem. The objective was to examine the pathway between religiosity, spirituality and social support and its effect on oral health outcomes by DMFT, controlling for socio-economic position and health behaviour determinants. Religiosity was determined and validated by self-definition. Social support was assessed by the Multidimensional Scale of Perceived Social Support. Spirituality was estimated by the Hebrew version of the SpREUK Questionnaire for Religiosity, Spirituality and Health. The mean caries experience (DMFT) was 10.75. Secular people revealed significantly higher DMFT than their religious and orthodox counterparts (78.0 vs. 43.9 and 39.3%, respectively, p < 0.01). A conceptual logistic regression model revealed a possible pathway, wherein a higher level of religiosity was distally associated with superior dental health outcomes, mediated by high spirituality, strong social support and positive oral health behaviours. The present study identified a strong statistical association between caries experience and religiosity. The direction of the association suggested that being religious had a protective effect on caries experience. Our conceptual hierarchical approach suggests a pathway to explain the association between the level of religiosity and dental caries experience. In this study this association was mediated by extrinsic (i.e. social support) and intrinsic (i.e. spirituality) pathways.

Trends and distribution of oral and pharyngeal lymphoma in Israel.

OBJECTIVES: To describe the distribution and trends of oral and pharyngeal lymphoma cases in Israel. METHODS: Incidence rates were derived from the Israel National Cancer Registry and included all registered data from 1970 to 2006. Oral lymphoma included the tongue, mouth, salivary glands, tonsils, and pharynx. Morphological description was according to WHO classification of lymphoid neoplasms. RESULTS: A total of 670 cases were diagnosed, mean age 59.5 years, half were over 65 years old. Tonsils were the most prevalent site of involvement (36.0%), followed by the pharyngeal region and salivary glands. Over the years, the prevalence of lymphoma in salivary glands increased by 49%, whereas in tonsils lymphoma decreased by 28.6%. The overall 5-year survival rate was 57% with best rates among young people. CONCLUSION: The correlation of survival, type of lymphoma and age, was similar to extra-oral lymphoma. A trend of increased cases in the parotid region, dissimilar to other oral sites, raises a question of possible external factors or an increase in autoimmune diseases. Head and neck clinicians should be aware of different sites, types, and prognoses for the different age groups.

The social and behavioural pathway of dental caries experience among Jewish adults in Jerusalem.

AIMS: To report dental caries status, related health behaviours and social determinants among a representative sample of adults residing in Jerusalem. METHODS: This cross-sectional study was conducted using a stratified sample of 254 Jewish and married adults aged 35-44 years in Jerusalem. Dental caries status was examined according to DMFT, percentage of caries-free persons and of people maintaining all their natural teeth (no teeth missing due to caries). The results were analysed by the independent variables and interpreted by weighted caries scores for the total Jerusalem population. RESULTS: The mean age was 38.63 years. Weighted DMFT was found to be 10.59; 6.8% of the population were caries-free; 67.1% demonstrated maintenance of all natural teeth. Level of education was the distal factor, associated with number of natural teeth, DMFT and untreated decay. Mediating behavioural determinants included dental attendance, plaque level and sugar consumption. DISCUSSION: The findings of this study demonstrated that caries experience among Jewish married adults in Jerusalem was moderate with low unmet dental caries needs. Additionally, data confirmed that a low level of education was a strong distal social determinant of caries experience, which affected dental health status via a pathway mediated by behavioural factors.

Is religiosity related to periodontal health among the adult Jewish population in Jerusalem?

BACKGROUND AND OBJECTIVE: Religiosity may be a relevant protective factor for periodontitis, as it is for other chronic systemic diseases. The objective of the present study was to assess the relationship between periodontitis and religiosity, and whether oral health-related behaviours, spirituality and social support are included in the potential pathways that explain the association between religiosity and periodontitis. MATERIAL AND METHODS: Cross-sectional data were part of a retrospective study. The stratified random-sampling technique was limited to the Jerusalem Jewish population. Conceptual hierarchical data analysis modelling was adopted, assuming that socio-economic position was the most distal determinant, age and gender were confounders, and social support, spirituality and oral health behaviours were mediators in the relationship between religiosity and periodontitis. RESULTS: Kappa intra-examiner values (0.89) were satisfactory. Response rate was 88.0%. The final sample included 123 men and 125 women. The mean age was 38.6 years (SD 3.25 years), with 33.9% declared to be 'orthodox', 33.1% 'religious' and 33.1% 'secular'. Higher levels of religiosity (p=0.01), support of internal life through spirituality (p=0.03), higher family social support (p=0.02) and low levels of plaque (p=0.05) were related to lower levels of periodontitis. Religiosity led to higher family social support and support of internal life through spirituality, which was related to plaque level and periodontitis. CONCLUSION: Religiosity had a protective effect against periodontitis through extrinsic and intrinsic pathways. This should be considered as part of aetiology and prognosis, in potential prevention and care of periodontitis.

Lip cancer: incidence, trends, histology and survival: 1970-2006.

BACKGROUND: High levels of lip cancer have been reported among Israelis over the last four decades. Epidemiological descriptions and analyses for this region have not previously been presented. OBJECTIVES: To establish the incidence, trends and histology of lip cancer and associated demographic variables in Israel over time. METHODS: Data for 1970-2006 were derived from the Israel National Cancer Registry. Incidence and trends over time and analyses by lip site, sex, age, origin, histology and 5-year survival were studied. RESULTS: Of 4337 new cases, most were found among men (61.4%), people aged over 53 years (75.5%), and those with lighter skin (62.6%). Lip cancer cases were 40 times more prevalent in the external than in the inner lip. The dominant tumour type was squamous cell carcinoma at the external lower lip and intraoral lip mucosa (predominantly in men) and basal cell carcinoma (originating from skin) at the external upper lip (predominantly in women). Minor salivary gland tumours, melanoma and metastases were also reported. Slight increases in the trend of upper lip cancer and decreases for lower lip cancer were reported. CONCLUSIONS: Men, fair-skinned individuals and those over 53 years of age were at higher risk for lip cancer. A higher incidence of external lip cancer, compared with internal, may indicate a major role for sun exposure rather than smoking. The effect of public awareness campaigns as well as occupational changes, both related to sun exposure, should be studied carefully as potential factors in the changing incidence of lip tumours.

Changing dental caries levels in the 1980's, 1990's and 2005 among children of a Jerusalem region.

OBJECTIVE: To study caries levels and related variables among first grade and fourth grade schoolchildren in one Jerusalem geographic region in 2005, and possible changes in caries levels over three decades: the 1980s, 1990s and finally in 2005. METHODS: Dental caries was examined, within schools, employing the DMFS and defs indices, for permanent and deciduous teeth respectively. RESULTS: Data indicate a consistent decline in disease: a reduction from 1.64 to 0.32 to 0.16 for DMFS, and 13.95 to 8.09 to 5.07 for defs (1983, 1992, 2005, respectively), among first grade children; and from 3.50 to 2.50 to 1.07 for DMFS, and 13.88 to 7.26 to 4.16 for defs, (1983, 1992, 2005, respectively), among fourth grade children. CONCLUSIONS: A consistent decrease in caries has been detected over three decades. Specific causal factors were not ascertained.

Dental status among native and immigrant young Israeli adults.

BACKGROUND: New immigrants, originating from different cultures, often demonstrate dental health, behavior and treatment levels, which are different to native born populations. Immigrants are often classified as 'high-risk' populations. The goals of this study included comparing caries prevalence levels and different modes of treatment and dental health behavior, among immigrants from the former USSR and Israeli born young adults. METHODS: 581 young adults (average age 18 years) answered a questionnaire and were clinically examined. RESULTS: Socio-demographic variables were significantly different: number of siblings and years of schooling were higher among the Israeli born population; father's occupation was less professional among the immigrants. Untreated caries and lower father's occupation were significantly associated. Most immigrants reached the dentist's office only when they suffered pain, in contrast to the Israelis who were more regularly taken care of. Smoking was more prevalent among immigrants and significantly associated with caries levels. The caries prevalence among the Israelis was: DMFT = 4.7 +/- 4.13, D = 1.09 +/- 1.81, M = 0.11 +/- 0.37, F = 3.51 +/- 3.85, and among the immigrants: DMFT = 5.98 +/- 4.66, D = 2.78 +/- 2.77, M = 1.01 +/- 0.51, F = 2.70 +/- 3.22. These differences were statistically significant (p<0.005). CONCLUSIONS: Immigrants should be considered as a high risk group and demand a specific call for public health action.

[Oral health promotion for children in boarding schools].

INTRODUCTION: In Israel there are approximately 9,000 "sheltered" children who are lodged in several boarding schools. These children have been removed from their parents' guardianship, some with their parents permission and some by court order, usually due to neglect or abuse. This article describes these children and the efforts implemented regarding oral health: dental care insurance, a preventive program which has been conducted for approximately 10 years among 80 boarding schools and family care shelters, evaluation of these services and caries levels among the children. METHODS: A sample of 123 children was examined in four Israeli boarding schools. The DMF(T) index was employed according to WHO guidelines, by one examiner, using a torch, plane dental mirror and probe when required. RESULTS: An average DMF(T) level of 4.62 was detected among 12 year olds. Among all the children from ages 1-18 years, only 30% were caries free. The rate of caries-free children decreased with age. CONCLUSIONS: Caries prevalence among this population was higher than levels reported in Israel and abroad. There is a clear need for oral health promotion among this community.

A review of satisfaction with dental service at a Jerusalem community clinic serving elderly patients.

AIM: The audit of dental satisfaction and its association with the reported outcome of a dental health care programme for elderly patients. DESIGN: A telephone survey of 162 patients in a Jerusalem municipal dental clinic for geriatric patients, who had completed a treatment course in oral rehabilitation. RESULTS: The average age of the respondents was 73.2 +/- 8.45 years, over 80% of who were very satisfied or satisfied with the treatment given by the dental clinic staff. Only 1.8% were not satisfied (the remaining 17.9% were unable to answer the question). Among those who responded, 91.6% were currently using their full dentures, 80.4% reported an improvement in chewing ability, and 82.3% an improvement in appearance. Respondents who reported daily use of dentures and improved chewing and appearance, also reported higher levels of satisfaction with the clinic. CONCLUSIONS: These results indicate a potentially important role of satisfaction with dental staff in optimal compliance and success of a geriatric oral health care programme.

[Optimal fluoride level in drinking water and public health].

Water fluoridation is a safe, efficient, and well-proven way of preventing dental decay in the community. In countries such as Israel, where dental care is not covered by the national insurance law, this has an important role in reducing social inequalities in health care. For toddlers and children, water fluoridation is the only way of promoting dental health without a need for regular visits to dental clinics, and without regard to parent awareness and motivation. The other methods of fluoride supplementation do not succeed in reaching the level of safety and cost-efficiency of water fluoridation, and their use is successful only among upper socio-economic classes. Water fluoridation has been defined by the US CDC as one of the main achievements in health care during the 20th century. In spite of the legal difficulties raised by various activist groups, the use of water fluoridation is growing steadily among developed as well as third world countries. The Israeli bylaw of national water fluoridation that is in effect will enable the safe improvement of the overall dental health status of the population at an extremely low cost.

[The fight over water fluoridation in Israel].

Water fluoridation in Israel was initially introduced on a municipal level in 1981. Legislation in favor of national water fluoridation was approved in 1998. Over the last year an increasing campaign against the fluoridation project has become more and more evident. The material published by the opponents to fluoridation, distributed in pamphlets, daily journals and mass media resources, illustrate as in the USA, an endless and unrestrained "duel" between opponents and supporters of fluoridation. In Israel, in contrast to the USA, referenda are unprecedented, therefore, the political "battle field" is transferred to the municipal authorities and the Knesset. The pivotal component of the Israeli opponents to fluoridation regards the public's health and safety. Unscientific publications appear regularly in the daily journals and electronic mass media with no reference of supporting studies ever mentioned. The inevitable question addressed in this article is what are the best ways of action to be taken by the supporters of fluoridation is Israel. The main and most important mode of action against this campaign is, undoubtedly, continuous persuasion. Nevertheless, the continuous daily struggle of the supporters must be in a world-wide frame and be adjusted to the different target groups of the public. An effective confrontation should include nation-wide available publications (internet, daily papers and multimedia) with special emphasis on the important subjects (e.g. evidence based care, significance of toxic doses and the value of social justice), in a format comprehensible to the public and its leaders. The American experience helps us to understand that the opposition to water fluoridation will not diminished but, on the contrary, is expected to strengthen. We must look forward with no illusions and establish ways of action and cooperation by learning from past experience and from that of our collaborators. This will serve as the basis for the ongoing frank and persuasive efforts, derived from a deep and honest belief in the justice of our way.

Community-oriented oral health promotion for infants in Jerusalem: evaluation of a program trial.

OBJECTIVES: This study sought to measure the effect of a community health education program on reported infants' bottle-feeding practices and infants' toothbrushing behavior, with or without distribution of toothpaste and toothbrushes. METHODS: In this quasi-experimental comparison group design study conducted in mother and child health centers in Jerusalem, parents of 727 children were surveyed by telephone at baseline and six months later. The cohort of infants was aged 6-12 months at baseline. The program group received structured health education. The control group received no organized educational intervention. Within the program and control groups, half of the centers were randomly given toothpaste and toothbrushes. RESULTS: Parents' reports revealed a secular 32.5 percent increase in toothbrushing for infants with no intervention, 45.1 percent for infants only receiving toothpaste and toothbrushes, 43.7 percent for infants only receiving the health education program, and a 60.4 percent increase for infants receiving health education together with toothpaste and toothbrushes (chi-square, P = .0002). Modification of bottle-drinking practices, in this program, was unsuccessful. CONCLUSION: The free distribution of toothpaste and toothbrushes, together with an oral health education program, is recommended as a potentially practical and effective method of promoting early oral hygiene practices.

Relationship of blood glucose level to community periodontal index of treatment needs and body mass index in a permanent Israeli military population.

BACKGROUND: The goal of this study was to find a possible link between blood glucose levels and periodontal disease. METHODS: In a prospective study the dental health of 10,590 military service men and women was examined. The relationships of periodontal condition, expressed as CPITN index, and blood glucose levels were tested. The effect of gender, body mass index (BMI), and smoking was also evaluated. RESULTS: Blood glucose levels were significantly and positively associated with severe periodontal disease, men, and higher BMI. Smoking did not affect blood glucose levels. CONCLUSIONS: Blood glucose levels might be associated with severe periodontal disease.