Effect of a single application of silver diamine fluoride on root caries after 12 months in institutionalised older adults-A randomised clinical trial.

OBJECTIVE: Silver diamine fluoride (SDF) has been shown to be highly effective against caries, in particular for arresting root surface caries and for dentine caries in primary teeth. SDF may complement fluoride varnish routines for treatment of root caries in nursing home residents. The aim of this randomised, single-blinded, placebo-controlled trial was to evaluate the additive effect of a single annual application of SDF for prevention and treatment of incipient root caries in older adult nursing home residents. METHOD: Four hundred older adult nursing home residents (≥70 years old) with at least one exposed root surface (on teeth 15, 14, 13, 23, 24, or 25) were identified during routine dental examination visits in the domiciliary dental care setting. Eligible patients, who were able to understand the implication of consenting to the study, were invited to participate. Their cleaned root surfaces were randomly allocated to treatment with SDF (Advantage Arrest Silver Diamine Fluoride 38%, Advantage Arrest, LLC, Redmond, OR 97756, USA, Lot 16 152) or with placebo (tap water), each for 1 minute. RESULTS: Of the 400 eligible individuals, 42 declined to participate and two forms were destroyed. The remaining 356 participants (89.0%; mean age 87.7 years) were randomly allocated, with 174 going to the SDF group and 182 to the placebo group. At 1 year, 273 participants (76.7%) were available for assessment: 135 in the SDF group and 138 in the placebo group. By that time, 109 individuals (39.9%) demonstrated root caries progression or regression. Among those 118 (16.7%) of the 708 included root surfaces had developed caries There were no statistically significant differences in the primary outcome related to treatment with SDF or placebo, at either patient or root surface level. CONCLUSION: Based on the finding of this clinical trial, it is concluded that a single SDF application to complement a risk-based preventive programme including fluoride varnish applications did not have a statistically significant additional preventive effect on root caries development in a group of older adult nursing home residents with limited caries activity and cognitive capacity to cooperate in oral care activities.

Incidence and risk factors for medication-related osteonecrosis after tooth extraction in cancer patients-A systematic review.

OBJECTIVES: Antiresorptive medication has been reported to be associated with medication-related osteonecrosis of the jaw (MRONJ). This systematic review aims at investigating the incidence of and risk factors for MRONJ after tooth extractions in cancer patients treated with high-dose bisphosphonate and denosumab (BP and DS). MATERIAL AND METHODS: The protocol followed the PRISMA statement list and was registered in PROSPERO. Searches were performed for literature published up to April 2021 in the electronic databases PubMed, Embase, Web of Science, and CINAHL and then supplemented by manual research. RESULTS: The search process resulted in 771 identified articles, of which seven studies fitted the population, intervention, comparison, and outcome framework. All were observational studies and four had control groups. A total of 550 patients treated with BP and DS were identified of whom 271 had received tooth extractions after medication onset. Due to significant heterogenicity in the collected data, only a qualitative analysis was performed. The MRONJ incidence after tooth extractions varied between 11% and 50% at the patient level. MRONJ occurred up to 3 years after the tooth extraction. Teeth affected by inflammation before the extraction and additional osteotomy during the surgical procedure were identified as risk factors. CONCLUSIONS: Reliable methods of diagnosing MRONJ and adequate follow-up periods are important factors in obtaining the actual incidence of MRONJ after tooth extractions in patients treated with high-dose BP and DS.

Evaluation of upper labial frenectomy: A randomized, controlled comparative study of conventional scalpel technique and Er:YAG laser technique.

OBJECTIVES: Abnormalities in the maxillary frenum may lead to esthetic or functional limitations and need to be corrected with a surgical intervention called frenectomy. The aim of the study was to compare frenectomies performed using Er:YAG laser technology with those using a conventional scalpel technique. Comparisons were of patients' experiences, treatment times, bleeding during treatment and wound healing. MATERIAL AND METHODS: The trial was performed as a prospective, randomized and controlled, single-blind investigation. A total of 40 patients requiring frenectomy were randomly assigned to groups which underwent either conventional or Er:YAG laser treatment. Patients' experiences, treatment time, bleeding and wound healing were evaluated immediately after surgery and 5 days, 12 days and 3 months after surgery. RESULTS: Significant increase in time spent in surgery and bleeding was seen with conventional scalpel surgery. Directly after surgery the wound area was significantly larger in the laser group but at the 5-day evaluation no difference could be observed between the groups. Finally, patients were satisfied with both methods, giving them the same assessments. CONCLUSION: In the frenectomy procedure, laser surgery is faster and causes less bleeding and may be advantageous in frenectomies.

Oral health and dental care of older persons-A systematic map of systematic reviews.

OBJECTIVES: To examine the current knowledge on oral health status and dental care of older persons through a systematic mapping of systematic reviews of low or moderate risk of bias. BACKGROUND: Geriatric dentistry covers all aspects of oral health and oral care of older persons. Oral health is part of general health and contributes to a person's physical, psychological and social wellbeing. METHODS: A literature search was performed in three different databases (PubMed, The Cochrane Library and Cinahl) within 12 domains: Dental caries, periodontitis, Orofacial pain and temporomandibular joint (TMJ) pain, mucosal lesions, oral motor function, dry mouth, halitosis, interaction between oral status and other medical conditions, ability to interrelate and communicate, quality of life, ethics and organisation of dental care for older persons. Systematic reviews were identified and scrutinised, highlighting scientific knowledge and knowledge gaps. RESULTS: We included 32 systematic reviews of which 14 were judged to be of low/moderate risk of bias. Most of the domains lack systematic reviews with low or moderate risk of bias. In two of the domains evidence was identified; in institutionalised people aged 65 or older, effective oral hygiene can prevent pneumonia. Furthermore, there is an evidence of a relationship between malnutrition (protein energy-related malnutrition, PEM) and poor appetite and edentulousness. CONCLUSIONS: There is an urgent need for further research and evidence-based knowledge within most domains in geriatric dentistry and in other fields related to oral health and dental care for older persons striving for multi-disciplinary research programmes.

A Randomized Controlled Trial Comparing Er:YAG Laser and Rotary Bur in the Excavation of Caries - Patients' Experiences and the Quality of Composite Restoration.

OBJECTIVE: The aim of this study was to evaluate patients´ experiences of two excavation methods, Er:YAG laser and rotary bur and time required by the methods as well as objective assessments of quality and durability of restorations over a two-year period. METHODS: A prospective, single-blind, randomized and controlled investigation was performed. Patients aged 15 to 40 years with at least two primary caries lesions, which had been radiographically assessed as of the same size, were recruited. In each patient, one cavity was excavated using rotary bur and one using Er:YAG laser technique. The time required for excavations and, where applicable, local anaesthesia, was measured during the treatments. Patient experiences were measured using questionnaires. The quality and durability of restorations were assessed over a two-year period in accordance with modified Ryges criteria and radiographs. Twenty-five patients (mean age 22.6 years) participated in the study. In total, 56 cavities were included of which 28 were treated with Er:YAG laser and 28 were treated with a rotary bur. RESULTS: The patients associated the laser method with less discomfort. The mean time for excavation by laser was three times longer than by rotary bur (13.2 min vs. 4.3 min, P<0.0001). Over a two-year period, no statistically significant differences with regard to quality or durability could be seen between the restorations associated with the methods. CONCLUSION: The Er:YAG laser technique was more time-consuming than the rotary bur. Despite this, the laser technique caused less discomfort and was preferred as an excavation method by patients.

Patient Experiences of Therapeutic Jaw Exercises in the Treatment of Masticatory Myofascial Pain: A Qualitative Study.

AIMS: To investigate patients' experiences of therapeutic jaw exercises for treating masticatory myofascial pain. METHODS: A total of 10 patients were selected for the interview study. All patients had received treatment with jaw exercises at a specialist clinic. Semi-structured interviews were conducted in a nonclinical environment according to an interview guide with 10 domains. The interviews were transcribed and translated into English. Systematic text condensation (STC) was used to arrange and analyze the text material. RESULTS: In the systematic process of analyzing the qualitative data, four main themes were identified: "Patient Adherence," "Symptoms," "Treatment Effect," and "Participation." Most informants were initially skeptical of the jaw exercises due to their simplicity. Later on, the simplicity of the exercises and the fact that they did not need more advanced treatment were valued most by a majority of patients. Some informants suspected serious disease behind their symptoms. Treatment effects on pain and physical impairment were reported. To do the jaw exercises in conjunction with an already established routine seemed important to enhance adherence. Trust in the caregiver and being able to remedy their pain by themselves were also important to the informants. CONCLUSION: Jaw exercises are a useful treatment valued by patients due to their simplicity and effectiveness. However, before the treatment, patients should be informed about the cause of the symptoms, and any skepticism should be addressed. Results from this qualitative study cannot be generalized, but the study design and the selected population allow the results to be transferable to similar contexts.

Oral health status in older immigrants in a medium-sized Swedish city.

AIM: The aim of the study was to investigate oral health and oral care habits among older immigrants to Sweden from countries outside the Nordic region. METHOD: Participants ≥60 years of age from senior social centers for immigrants were invited to attend oral examinations. Data was collected on the number of teeth, dentures, caries, periodontal status, saliva secretion, and plaque scores. Participants also described their general health and oral care habits. RESULTS: Fourteen men and 28 women, median age 71.5 years, participated. Seventeen percent were edentulous, women often than men. Three out of four had caries and 63% had gingival bleeding. Two-thirds brushed their teeth twice per day and 60% had visited dental services in the last 2 years. CONCLUSION: The group had a high prevalence of oral diseases and discomfort. They used dental services and brushed their teeth less frequently than Swedish populations of the same age.

Self-reported changes in using fluoride toothpaste among older adults in Sweden: an intervention study.

OBJECTIVE: The aim of the study was to investigate the possibility of increasing knowledge about the caries-reducing effects of fluoride (F) toothpaste and to increase the use of F toothpaste among older adults through an intervention. MATERIALS AND METHODS: 63-67-year-olds in Sweden, who 2 years earlier had answered a questionnaire about their knowledge of F toothpaste, toothbrushing and toothpaste habits and who had shown less favourable habits with regard to toothpaste use, were invited to participate. The 20-min intervention, performed at a Public Dental Clinic, was implemented by a dental hygienist (author OJ) and consisted of individual information and instruction on the use of F toothpaste. The questionnaire was repeated 4 months after the intervention and a population in another city in Sweden served as control. RESULTS: In the intervention group, 68 individuals responded and 151 in the control group. Knowledge of the benefits of F toothpaste in the intervention group had improved between the times of the first and second questionnaires, but the same effect was also noted in the control group. After the intervention, a clear improvement concerning the use of F toothpaste was reported: the individuals brushed for a longer time, used more toothpaste and used less water during and after brushing. In the control group, there were no changes of habits between the first and second occasions. CONCLUSION: Individually-based interventions performed by a dental hygienist had a positive effect on changing the way older adults used F toothpaste.

Dental hygienists working in schools - a two-year oral health intervention programme in swedish secondary schools.

PURPOSE: To investigate the possibility of influencing adolescents' caries incidence, knowledge and attitudes to oral health and tobacco through a school-based oral health intervention programme. MATERIALS AND METHODS: Four schools in a county in Sweden were randomised to one intervention and one control group. At the intervention schools, two dental hygienists worked 4 h every week for two years. Health education and preventive measures, such as fluoride varnish treatments every 6 months, were performed. The control group had no intervention. The study included a total of 534 participants aged 12-16 years. Outcome variables of the study were 1) caries incidence assessed on bite-wing radiographs and 2) knowledge and attitudes measured through questionnaires. RESULTS: The intervention programme impacted on the incidence of enamel caries, while no effect on dentin caries could be seen. Data from the questionnaires showed that the adolescents considered their teeth as important. Adolescents in the intervention group had better knowledge about oral health and oral hygiene compared to the control group after the two years, but no impact on attitudes toward tobacco could be seen. A majority of the adolescents were positive to the education about oral health and tobacco and they believed that the dental hygienists would help them improve their oral health. CONCLUSIONS: Although the effects of the intervention as regards to caries incidence, knowledge and attitudes were limited, the presence of dental hygienists in school was appreciated by the adolescents and seemed to increase their interest in their oral health.

Implementation of laser technology and treatment at county level in the Swedish Public Dental Service.

The aim of this study was to obtain an understanding of the factors that affected the way new technology and methods were used in dentistry after a training program. A qualitative research method was used to collect data. Nine dentists working in the Public Dental Service (PDS) in Uppsala County in Sweden agreed to be interviewed in the study. They worked in five different clinics, all with laser equipment, and had received training in the use of lasers. The interviews were tape recorded and transcribed, and were analysed using manifest and latent qualitative content analysis. The categories in this study were identified as "Prerequisites and obstacles to imple- mentation", "Attitudes to laser technology and treatments" and "Laser technology in the future'". The dentists described working with lasers as complicated and problematic. They had concerns about the method relating to the working environment, evidence of efficacy of treatment, costs, and benefits for patients and dentists. The main finding was that the decision to adopt the technology seemed to be based on individual perceptions of the value of lasers compared to other ways of achieving the same goal. They provided uniform proposals regarding how an organization should implement new methods, including an emphasis on the importance of preparation and having opportunities to be able to test and evaluate the technology. Another important factor was support from surrounding staff, colleagues and management. Despite all the barriers, the respondents were positive about working with lasers in the future, mainly due to their belief that patients would demand laser treatment. In conclusion both individual and organizational factors affected the extent to which the respondents used the laser. The main finding was the individual perception of the value of lasers compared to other methods which could achieve the same goal.

Adverse events in Public Dental Service in a Swedish county--a survey of reported cases over two years.

Adverse events cause suffering and increased costs in health care. The main way of registering adverse event is through dental personnel's reports, but reports from patients can also contribute to the knowledge of such occurrences. This study aimed to analyse the adverse events reported by dental personnel and patients in public dental service (PDS) in a Swedish county. The PDS has an electronic system for reporting and processing adverse events and, in addition, patients can report shortcomings, as regards to reception and treatment, to a patient committee or to an insurance company. The study material consisted of all adverse events reported in 2010 and 2011, including 273 events reported by dental personnel, 53 events reported by patients to the insurance company and 53 events reported by patients to the patient committee. Data concerning patients' age and gender, the nature, severity and cause of the event and the dental personnel's age gender and profession were collected and analysed. Furthermore the records describing the dental personnel's reports from 2011 were studied to investigate if the event had been documented and the patient informed. Age groups 0 to 9 and 20 to 39 years were underrepresented while those between the ages 10 to 19 and 60 to 69 years were overrepresented in dental personnel's reports. Among young patients delayed diagnosis and therapy dominated and among patients over 20 years the most frequent reports dealt with inadequate treatments, especially endodontic treatments. In 29% of the events there was no documentation of the adverse event in the records and 49% of cases had no report about patient information. The majority of the reports from dental personnel were made by dentists (69%). Reporting adverse events can be seen as a reactive way of working with patient safety, but knowledge about frequencies and causes of incidents is the basis of proactive patient safety work.

Simplified methods of topical fluoride administration: effects in individuals with hyposalivation.

The aim was to compare fluoride (F) levels in individuals with normal salivary secretion and hyposalivation in connection with their use of F solutions and toothpaste. Seven individuals with normal salivation and nine with hyposalivation rinsed with 0.2% NaF solution for 1 minute. In addition, individuals with hyposalivation performed the following: (i) 0.2% NaF rinsing for 20 seconds, (ii) rubbing oral mucosa with a swab soaked with 0.2% NaF solution, and (iii) brushing with 5,000 ppm F (1.1% NaF) toothpaste. Subjects characterized by hyposalivation reached approximately five times higher peak values of F concentrations in saliva after 1 minute rinsing with the F solution and higher area under the curve (AUC) values. The simplified methods exhibited the same AUC values as did 1 minute of rinsing. Brushing with 5,000 ppm F toothpaste resulted in higher AUC values than did the simplified methods. The F concentrations reached higher levels in individuals with hyposalivation compared to those with normal salivation. The simplified methods tested showed similar effects as conventional methods.

Oral health-related quality-of-life in homebound elderly dependent on moderate and substantial supportive care for daily living.

OBJECTIVES: To describe the oral health-related quality-of-life in homebound elderly dependent on moderate and substantial supportive care for daily living. MATERIALS AND METHODS: A total of 302 selected persons in three counties in Sweden over 65 years of age and in need of daily support from society participated in the study. Half of the participants had moderate needs of support, defined as supportive care of 15-50 h per month and half had substantial needs of supportive care, i.e. 3-times a day with a night overview. An oral examination was performed and structured questions were asked about general health and living conditions, medication, oral care routines and quality-of-life, using the instrument GOHAI (Geriatric Oral Health Assessment Instrument). RESULTS: Cardiovascular disease was common and an average of seven prescription drugs was used. More than half of the participants had dentures. The strongest correlation with GOHAI was the total number of teeth. There was a significant difference between individuals with moderate and substantial needs according to GOHAI, irrespective of gender. More elderly people with substantial needs of support had low GOHAI values. Decayed teeth, DT/T, root remnants and dry mouth were negatively correlated to GOHAI among individuals with substantial needs. CONCLUSIONS: This study found that elderly homebound individuals with substantial needs of supportive care had a lower quality-of-life than elderly homebound individuals with moderate needs of supportive care, although both medical and odontological variables were similar in the groups.

Oral status, oral hygiene, and patient satisfaction in the elderly with dental implants dependent on substantial needs of care for daily living.

Using osseointegrated implants to replace teeth is a routine procedure today. This study investigated oral status, oral hygiene habits, and patient satisfaction in elderly with dental implants who were dependent on substantial support for daily living. Twenty-six persons over the age of 65 who were dependent on supportive care were examined. Data collected included the number of teeth and implants, plaque scores, bleeding on probing, and oral hygiene habits. Self-perceived knowledge about managing their implants and satisfaction with the implants was recorded. Subjects had a total of 148 natural teeth and 144 implants. Only a few signs of oral disease were found and the tissues around implants were healthier than around natural teeth. No correlations between oral hygiene habits and plaque scores or bleeding were found. A majority of the subjects were satisfied with their implants. Dental implants have satisfactory function even in individuals who are elderly and have substantial needs for supportive care.

Is the use of fluoride toothpaste optimal? Knowledge, attitudes and behaviour concerning fluoride toothpaste and toothbrushing in different age groups in Sweden.

OBJECTIVES: The most effective method to prevent caries is the regular use of fluoride toothpaste. The aim of this study was to evaluate self-care routines in a population by identifying knowledge, attitudes and behaviour relating to fluoride toothpaste and toothbrushing habits. METHODS: A questionnaire was sent to 3200 individuals in two municipalities in Sweden. Four age groups representing different life stages were chosen: 15-16, 31-35, 61-65 and 76-80 years of age. The participants were selected from the population register by random selection of birth dates. RESULTS: Totally 2023 (63%) individuals answered the questionnaire. The majority (84-94%) in all age groups brushed their teeth twice a day or more often. Good toothpaste behaviour identified as brushing at least twice a day, using at least 1 cm toothpaste, brushing 2 minutes or longer and using a small amount of water when rinsing was reported by only 10% of the respondents. The factors that increased the odds for having good caries-preventive behaviour were: (i) being female, (ii) being younger than 35 years, (iii) having knowledge about fluoride, (iv) finding use of fluoride toothpaste important and (v) rating own oral health as good. CONCLUSIONS: The population seems to have embraced regular toothbrushing with fluoride toothpaste to a large extent. However, regarding techniques for using fluoride toothpaste effectively, there was great potential for improvement, especially among the older respondents.

Oral status in home-dwelling elderly dependent on moderate or substantial supportive care for daily living: prevalence of edentulous subjects, caries and periodontal disease.

OBJECTIVES: The aim of this study was to compare the prevalence of edentulous subjects, caries and periodontal disease among the home-dwelling elderly with moderate and substantial needs of support for daily living. MATERIALS AND METHOD: A sample of 302 randomly selected elderly with moderate or substantial needs of supportive care were examined in Sweden. Several oral clinical variables were registered: number of teeth, dentures, caries, probing pocket depth, gingival bleeding and Eichner's index. RESULTS: Both in general and in oral health, the differences were small when comparing elderly with moderate and substantial care needs for daily living. Those with substantial needs had more caries lesions (p < 0.01) and more gingival bleeding (p < 0.05), while the number of teeth and prevalence of edentulous subjects did not differ in relation to the need of daily support. The elderly had, on average, 9.8-11.7 teeth, one-third of whom had no natural teeth. According to Eichner's index, half of the elderly in both groups had no opposing tooth contacts. Fifty-five per cent used dentures. CONCLUSIONS: Elderly people with needs of supportive care have lost many teeth before they become dependent. Health promotion should be a priority in early ageing populations to prevent oral diseases and tooth loss.

Oral status, oral hygiene habits and caries risk factors in home-dwelling elderly dependent on moderate or substantial supportive care for daily living.

OBJECTIVES: Elderly people with disabilities have an increased risk of developing oral diseases as compared with the healthy elderly. The aim of this study was to investigate oral hygiene habits, clinical variables related to oral self-care and caries risk in elderly individuals living at home with moderate and substantial needs of home care. METHODS: A random sample of 151 elderly people with moderate needs and 151 with substantial needs of home care were examined. Data concerning general health, social conditions and oral hygiene habits were collected using a questionnaire. Data showing the prevalence of caries, plaque scores and gingival bleeding were obtained through clinical examinations. RESULTS: Elderly subjects with substantial needs of home nursing had more active caries (P < 0.01) and more often gingival bleeding (P < 0.05), as compared with elderly people with moderate needs. Forty-nine per cent of the elderly with moderate needs performed acceptable self-care, as compared with 25% of the individuals with substantial needs. Good self-care was associated with women, low plaque scores, less bleeding and less caries. Factors increasing the risk of having caries were low saliva secretion, high plaque scores and a large number of fillings, while having a dentist and good oral hygiene habits increased the chance of not developing caries. CONCLUSIONS: Good oral hygiene habits were associated with less prevalence of plaque and oral disease in the elderly irrespective of extent of needs of home nursing. However, the elderly with moderate needs more often performed good self-care, indicating that the possibilities of strengthening self-care and learning new routines are better when functions are less affected.

Clinicians' preventive strategies for children and adolescents identified as at high risk of developing caries.

BACKGROUND: Clinicians handle diagnosis and treatment planning of caries in different ways, and the underlying factors leading to management of risk and choice of treatment strategies are poorly understood. AIM: The aim of this study was to investigate dentists' and dental hygienists' choices of preventive strategies for children and adolescents identified as at high risk of developing caries. DESIGN: A sample of dental records from 432 of a total of 3372 children in a Swedish county identified as at high risk of developing caries, aged 3-19 years, was randomly selected for analysis in the study. Information of importance for the therapists' choice of caries management strategies were obtained from the dental records. RESULTS: The results showed that therapists considered tooth brushing instruction and fluoride treatment at the clinic to be of primary importance as treatment given in 60% of the cases, respectively. Fluoride treatment at home and diet counselling were both chosen in half of the cases. Fissure sealant therapy was used in 21% of the cases, and 15% of the patients did not receive any preventive treatment at all. The results also showed that girls more often received fluoride treatment, tooth brushing instruction and oral hygiene information than boys. CONCLUSIONS: In the majority of the children and adolescents, several preventive measures were given. The more background factors included in the risk assessment, the more preventive measures were given. The differences between the treatments given to girls and the boys need to be further investigated.

Fluoride toothpaste and toothbrushing; knowledge, attitudes and behaviour among Swedish adolescents and adults.

The most effective way to administer fluoride is through the regular use of fluoride toothpaste. Adolescents and adults seem to have low awareness of toothbrushing procedures and use of fluoride toothpaste despite frequent dental care. The aim of this study was to describe knowledge, attitudes and behaviour concerning toothbrushing and use of fluoride toothpaste in three age groups in a Swedish population. A qualitative study design was used with the purpose of achieving a deeper understanding of the issue. Data were collected through interviews. A manifest and latent analysis of the text was performed using qualitative content analysis (Grounded theory). The informants were selected strategically to obtain the greatest possible variation in the data. Three age strata representing different stages in life were chosen: 15-16, 30-35 and 60-65 years. Informants were interviewed with support from an interview guide. Open-ended questions were used to focus on the individual's knowledge, attitudes and behaviour concerning toothbrushing and fluoride toothpaste. Five people from each age group were interviewed in the study. The content areas were knowledge, attitudes and behaviour and the latent analysis identified the areas of empowerment, driving force and guidance as categories. Although the informants showed little knowledge about the reasons for and techniques of using fluoride toothpaste effectively, they described toothbrushing as important and the habit as a priority, giving the theme of this study: toothbrushing with fluoride toothpaste was a priority, despite the lack of knowledge about how to use toothpaste effectively and its positive effects on oral health. In conclusion the state of knowledge concerning toothbrushing and fluoride toothpaste needs to be improved. In addition, people's desire for a fresh-feeling mouth and to fit in socially must be affirmed and utilized by dental staff in health promotion.