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1994: Year of Oral Health

Dr. David Barmes, Chief Oral Health Program, WHO


Half a Century of Prevention and Research on Oral Health

Evaluations state how much we have developed in terms of oral health. The results show a promising perspective of health in general for the following 50 years.

From its early days as a professional career dentistry has promoted dental hygiene, although the scientific basis for this were scarce and sometimes hazy. Later on, came efforts to limit the consumption of sugar and/or its effects by cleaning shortly after consumption. Then came fluorides and the beginning of massive changes in health status and the profession dedicated to improve it.

The early trials of fluorides as a community preventive measure against dental caries led to the introduction of fluoridation of public water supplies. The potential success of water fluoridation as well as the controversy that surrounded its implementation gave the impetus for extensive and successful research into a wide range of methods for using fluorides. The success achieved through the fluoridation of public water supplies was clear in 1973 and till today benefits continue to occur in many industrialized countries as well as in a few developing ones. Consequently, new preventive vehicles were made available to populations, such as fluoride bearing toothpaste, rinses, solutions, varnishes and gels for topical administration, besides fluoridation of salt, milk and fluoride bearing tablets for systemic administration. Fundamentally significant for assessing oral health status as well as success or failure of prevention has been development, testing and implementation of better methodologies for surveys, clinical trials and, more recently, clinical records.

As a result of all this research and promotion of prevention as an essential of healthy lifestyles, another success, perhaps even more far reaching than fluorides per se, is the acceptance and practice of oral hygiene as part of total bodily hygiene. The application of fluoride through toothbrushing has become arguably the most effective way of preventing dental caries, while achieving by the same action reduction in the severity of periodontal diseases and in the premature loss of teeth.

While these preventive successes and related public health procedures were happening, there were vast improvements in treatment modalities and management in every area of oral health practice. Apart from those relevant to the common oral diseases, there has been a broadening of the dental profession's approach to care of the wide range of rarer oral conditions occurring primarily in the oral cavity or as a manifestation of systemic disease. A powerful stimulus for this development has been the advent of HIV infection for which there is a large list of oral conditions which may be associated with HIV infection, including some conditions which had virtually disappeared.

Consistent with these developments there have been huge changes in the education of dental personnel, both professional and auxiliary. These developments have passed through stages of a broadening biological base for routine conservative, restorative, surgical and medical procedures, massive improvements in dental materials and equipment and increasing emphasis on prevention, risk assessment, tissue conservation and preservation of a functional dentition back to an even broader approach to and reorientation of dental education. Growing acceptance of the health sciences and extended career development approach is a very important recent development as are computer assisted learning techniques.

The symbiosis of dentistry professionals with the oral health industry, guided by the philosophy of prevention and promotion of oral health and supported by continuous re- searches on fluorides, has led to the production of a wide range of preventive and restorative materials of the dental surface. Sealants, re-mineralizing agents, glass ionomers, improved amalgam, infection control equipment and materials are some of these results.

Informatics and telematics have exploded onto the scene as a fundamental impact on information management, on analysis of quality care, on assistance for diagnosis and treatment and on education of personnel involved in oral health and care.

For all of these reasons WHO feels optimistic and believes in a promising future for oral health and health in general during the next 50 years. Researches succeeding in such areas as microbiology, immunology and genetic engineering have produced preventive procedures, notably in control of the flora, vaccination, dietary improvements, all based on the philosophy of prevention and promotion of oral health, within a healthy lifestyle.

From 1958 to the Year 2000 - The Contribution of WHO to the Promotion of Oral Health

Since the creation in 1958 of Expert Committees to cover the main areas of concern in oral health, expert opinion and guidance from WHO has been covering the main areas of Dentistry, specially since 1970, when the Oral Health Program (ORH) intensified and diversified its activities.

Under a policy of mass control and prevention since 1969, the first researches on water fluoridation were supported, along with the creation of the Global Oral Data Bank (GODB), which would serve as a dynamic indicator of the oral health status in many countries. This collection of epidemiological data was promoted in general and, specifically, by offering data analysis free of cost to all who used the standard methods and forms of the Oral Health Surveys: Basic Methods (OHS). Especially for areas with minimal resources of personnel and money, OHS enabled administrators to obtain working estimates of oral health status at minimal cost in time and money from which to develop national oral health plans.

Incentive to strategies based on national oral health plans with prevention as a top priority was given through the supply of know-how to establish and control the goals of these plans. As an example we can mention the global oral health strategy for the year 2000, which was proposed in 1979. This proposal was accepted as an indicator of the quality of national programs and it has enlarged oral health strategies almost all over the world. These strategies were extended to ages 6, 18, 35 to 44 and 65 to 74, developed by IDF and WHO working groups, where the latter three age groups deal with tooth loss rather than dental caries.

With the creation of standardized methods of data collection, WHO embarked in 1970 on an international study of oral health delivery systems. The study title in full was the International Collaborative Study of Dental Manpower Systems, but it is now more conveniently referred to as ICS I, as it has been followed 15 years later by ICS II, which has the modified full title of the International Collaborative Study of Oral Health Outcomes. The basis for these studies has been the combination of clinical and sociological data collection in a standard form and the inclusion of data from care providers and administrators. The main objective was to ascertain what different delivery systems, or parts of such systems had and could achieve in the hope of helping not only participating nations to improve their delivery systems, but also to provide guidance drawn from the study to other Member States.

During the period from 1970 to the present a number of Joint Working Groups (JWG) were developed with the World Dental Federation. These dealt with a large variety of topics:

Further development of the Community Periodontal Index of Treatment Needs/CPITN (JWG 1) and approaches to management of periodontal diseases (JWG 10),

Biostatistics applied to oral health (JWG 2),

Development of a standard measurement system for dento-facial anomalies (JWG 3),

Curriculum development for all categories of oral health personnel (JWG 4),

Trends in the common oral diseases (JWG 5) and development of a system for estimating oral health personnel needs (JWG 6),

Curriculum (JWG 7) and equipment (JWG 8) development for Latin America,

Development of a system for standard measurement of the economic aspects of oral health care, both prevention and treatment (JWG 9),

Criteria for classification of dental products (JWG 11) for Latin America,

Oral health status of young adults (JWG 12), the role of oral health personnel in the campaign against HIV infection, with special on oral manifestations of the infection (JWG 14),

International collaborative oral health research (JWG 15).

Outcomes from these working groups have been plentiful. The major ones have been:

The final definition, testing and evaluation of the CPITN, its uses and effects on the management of periodontal diseases care,

The emergence of the DAI as a standard measure of need for orthodontic care, a development which eventually occurred outside the work of JWG 3, but which had its international beginnings in that JWG,

Confirmation of the reducing trends in caries intensity which had been repeatedly reported from the GODB and the need for the dental profession to reorient itself to this fundamental change,

A guidance manual for production of oral health personnel appropriate to the changing needs,

Preparation of a manual and computer program on planning under the title of "Health through Oral Health" for estimating oral health personnel needs for changing and planned situations,

Provision of an instrument for data collection on economic aspects of oral health care,

Development of a standard package for collection of data on oral manifestations of HIV infection and guidance materials on epidemiology, health promotion, infection control and treatment related to HIV and the oral health facility,

Definition of priority research areas for international collaborative research.

AIDS

Epidemiological methodology applied to the oral manifestations of HIV infection is the subject of material which is in proof to be followed shortly by material on education, infection control, data collection and treatment which is now in the advanced draft stage.

A special project is developing to address the problem of noma or cancrum oris and its possible relation of HIV infection, by combining a primary prevention approach with a moderately complex treatment availability locally and a referral system for very complex care. It is hoped that this project in helping to manage this maiming and killing disease will demonstrate one way in which the dental profession can broaden its approach consonant with changing oral health status.

Research leads to more research

Research projects have always had a privileged place. Starting with projects embodying from basic researches up to definitions of priority areas for international cooperation, a plan for delivering health services was carried out with the objective to find new ways to transfer knowledge to establish oral health services. In this plan one of the studies focused on the performance concept as it related to both practice and training. Close collaboration with the Universities of Maryland and British Columbia in this study meant that the system was studied simultaneously in industrialized and remote village communities. The latter participated in the study through the Intercountry Center for Oral Health in Chiang Mai. Training of personnel who had very little formal schooling was achieved in an amazingly short time to perform high quality routine care to the level of scaling and to bring adequate coverage to village communities through school and health centers at low cost. The success of the study pertained not to the acceptance of the system as a whole but to the expanding use of the most practical elements of the system, notably non-invasive care provided with simple, low cost equipment and using practical ergonomic procedures.

Presently, there is much activity in updating or producing new methodologies. The fourth edition of the Oral Health Surveys: Basic Methods is in final draft form as is the third edition of the International Classification of Diseases: Application to Dentistry which is compatible with the tenth revision of the parent classification. A manual on collection of data from clinical records is in the advanced draft stage and is aimed at improving data availability for better management and planning of oral health services right from the practice to the national level. Computer assisted learning methodology and documents on specifications for oral health settings, instruments, materials and drugs are being produced to help those trying to provide services in a cost-effective way.

Caries

The development of a study named Atraumatic Restorative Treatment (ART) of dental caries is in progress now which uses many of the elements described in the Maryland/British Columbia plan. Clinical trials and community preventive programs in collaboration with industry promise to reveal ART as a very effective means of achieving better coverage of deprived communities.

Many projects have been undertaken and much effort is continuing to demonstrate effective prevention at community level. Current projects are using milk fluoridation, fluoride bearing toothpaste and sealants bearing preventive agents in an attempt to extend the preventive choice and to convince communities of the prime importance of prevention.

International Collaboration: Steps to Global Health

In the 80's the International Collaborative Oral Health Development Program (IDP) was developed to respond to specific requests from WHO Member States. The concept is simple, the usual steps being a national situation analysis performed with or without external help, followed by a national plan from which areas which require expertise not nationally available are identified. At that stage WHO's role is to link the requesting country with a Member State or institution which is willing and able to help. Countries like France, Japan, Netherlands, Denmark, Sweden and USA gave contributed significantly.

All these activities lead us to the most pressing need to orchestrate a fundamental change in the oral health sub-sector appropriate to changes in oral health status. At all levels there is the need for much greater integration with all other health services than presently exists. Training is the key to that process and WHO strongly focuses on the health sciences approach for oral health personnel involved in promoting and delivering oral health and care. Use of computer assisted learning methodologies is emphasized as the only practical way of achieving these changes in a rapid and efficient manner.

It is important to mention that all that was achieved so far and all the plans for the future have only been made possible by the concerted efforts of all the Member States of WHO and the collaboration of the health and other professions. Whether it concerns methodology development or data for the GDB or study and application of new preventive and treatment programs nothing could be achieved without that involvement and support.

What will be the specific outcomes which WHO will aim to produce or promote as a concerted effort of the whole dental world?

Prevention

A compendium will be produced with a large graphic component to show what proven preventive methods are available, what can be achieved by each method, how to choose for different situations and what is in prospect.

Special posters and videos on specific preventive items will be produced, areas to be considered being salt and milk fluoridation, oral hygiene including a range of toothpaste and a special effort to relate to hygiene in general, healthy lifestyles promoted by oral health personnel, HIV and oral health, deprivation and oral health, non-invasiveness and oral health, 3rd party payment and oral health and orthodontic care and the DAI.

A set of brochures on self care in oral health taking the broad canvas view.

Education

A protocol for the development of an international health sciences curriculum in oral health outlining the whole concept and the proposed first generation curriculum.

40 multimedia self-training packages.

Quality of Care

State of the art guidelines on the use of new materials such as implants and adhesives and on rehabilitative care in general.

State of the art guidelines on tooth loss and restorative care.

A computer program for assessing the quality of care and enhancing practice management from aggregated clinical records.

A compendium of accepted and innovative settings related to oral health practice integrated with health services in general.

A document on equipment and instruments specifications in various settings plus lists of materials and drugs.

Special Projects

The first ICS II monograph.

Three videos on oral manifestations of HIV infection in French and English.

Two IBM versions, one low and one high technology, of the Computer Assisted Learning on the Oral Manifestations of AIDS (CALOMA) program which is available on Mackintosh.

A version of CALOMA in book form.

A video on noma and the campaign to contain its destructive impact.

A self learning manual and video on ART.

A video on cross infection, especially in relation to minimal acceptable levels in low resource communities.

Research

A WHO Technical Report Series publication from an Expert Committee meeting to be held late in 1993.

A paper on main thrusts of the International Collaborative Oral Health Research Agenda.

A protocol for etiologic research on ANUG/noma.

A protocol for epidemiological research on ANUG/noma.

A review on demographic changes in relation to their impact on research priorities.

Methodology

The 4th edition of OHS:BM.

The 3rd edition of the ICD-DA.

A series of booklets on health education, infection control, epidemiology and treatment related to oral manifestations of HIV infection plus visual supporting material.

The first edition of the Oral Care Management Systems manual.

The first edition of a manual linking sociological data to the OHS:BM.

A manual on calibration of examiners.

What can other organizations, charitable trusts, industry and countries do in relation to the list of intended outcomes or on their own initiative?

In spite of all the success achieved, we are still far away from the effective control over caries and, specially, over the periodontal diseases. Management of oral cancer, oral manifestations of systemic diseases and a long list of oral mucosal diseases are more distant still from being satisfactorily prevented and controlled. It must also not be forgotten that hit her to unknown health risks may appear, which herald a more complex basis for oral health care. Demographic changes are posing the three way problems of increased numbers, increased lifespan and a shift in the percentage distribution towards the elderly which introduces a further complicating factor into regular oral health care. Additionally, success itself is posing a potential problem because the situation for dental caries and what is preventable, for periodontal diseases is fundamentally different to other forms of complete (for example smallpox) or large scale prevention. Unless preventive behavior is maintained long after the target oral diseases are no more than a vague memory they will reappear in abundance and set up a vicious cycle of repair and prevention phases. With those thoughts in mind potential collaborative activity is discussed under the four categories named in the title of this section.

International Organizations

In referring to the four organizations listed below, it is not intended to be exclusive, but only to link obvious areas of interest. Other interested bodies are very welcome to participate, one which has already expressed its enthusiasm being the International Association of Dental Students. Suggestions for main theme interests follow:

International Association of Dental Research - this body should take the theme on focused research and decide what activities and promotion it would engage in for the World Health Day and/or the Year of Oral Health in collaboration with its regional divisions and specific national research bodies. From the list of specific outcomes it might take the lead in preparing the paper on main thrusts and in providing expertise for the WHO Expert Committee on research and in the etiological research on ANUG and noma and any relations with HIV (see item Research).

International Dental Federation - quality of care should be the main thrust of this body and, whereas there may be many items which the headquarters office, the regional organizations and the member associations wish to concentrate upon, an important contribution to the restorative part of the paper on tooth loss would seem to be very appropriate. The European Regional Organization might well be specially interested on material on oral health developments in European Member States which were formerly socialist economies and also in the computer program on clinical records. The American Dental Association may have a special interest in the ICS II continuation beyond the sites included in the monograph.

International Federation of Dental Education Associations - the international health sciences curriculum on oral health is of fundamental interest for this federation. It could take a prominent role in both preparation of the paper and in promoting production of computer assisted learning modules.

Its component bodies from Europe, Latin America and the USA may wish to add initiatives in the field of dental education.

International Federation of Dental Hygienists - the theme on prevention is of special interest to this body and especially the compendium, several of the poster and video subjects and the paper on self care (see item Prevention).

These main theme interests do not preclude the four organizations from exercising their interest in other named or unnamed themes. They are welcome to propose items for the celebration of World Health Day at WHO HQ, Geneva, to participate on that occasion in a prominent role and to participate in as many as possible of the celebrations in the 186 Member States of WHO.

Charitable Trusts

A specific example of such a trust is the Borrow Dental Milk Foundation which may well wish to develop material on milk fluoridation in collaboration with WHO. However, there is the American Fund for Dental Health and trusts with general interests like the Carter Foundation which are likely to have a lively interest in the WHD program and in the YOH.

Industry

The wholehearted involvement of industry in these celebrations is both highly desirable and well earned. There is something in each of the themes to interest various areas of the dental industry and there are no doubt other themes which members of different corporations might wish to propose and pursue. In some areas industry might wish to take the lead, for example in producing certain parts of the preventive compendium and some of the poster and video material or in items under quality of care dealing with dental settings, equipment and materials.

Countries

It is hoped that many, if not all nations will develop programs for the WHD. They should have at their disposal all the materials we are hoping to produce in the whole collaborative effort described in this paper and they should be encouraged to produce items special to their own cultures and interests. Their celebrations might take the form of special media coverage over the whole year or for specific periods, oral health months, weeks, the actual WHD on 7 April, special services to promote better oral health behavior or life styles in general, or any other special initiative that can be developed in one or several countries.

The network of WHO Collaborating Centers will be an important resource at national and international levels. Also, there are many national bodies, some of them WHO Collaborating Centers, which have important international as well as national roles that could give strong support to the WHD and the YOH. Those that spring readily to mind are the National Institute of Dental Research, American Association of Public Health Dentistry, Centers for Disease Control, American Fund for Dental Health and American Association for World Health in the USA, the Union Française Santé Bucco-Dentaire in France and the British Dental Health Foundation in the UK.

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