School-based caries prevention and fluoridation in Switzerland Thomas M. Marthaler Prof. emeritus of Preventive Dentistry University of Zurich

School dental services Principles, methods and results regarding caries prevention

From 1900 to 1960, school dental services were introduced in various Western European countries Until , they had two main principles: 1. one free dental examination per year for recording all carious lesions Dentistry of public schools 2. offer to parents for caries treatment with fillings (even crowns in severe cases) Cost of treatment: paid by the state: Scandinavia. Partial payment only: Switzerland, Netherlands.

From 1955 to 1970 preventive programs for children were developed and scientifically tested (Scandinavia, Switzerland) New priorities: 1. Prevention in schools, free of charge Role of public schools 2. Yearly examination for caries 3. Offer to parents for caries treatment Payment for treatment: in Scandinavia continued. Reduced payment in Continental Europe (mostly).

Introduction of school programs for Caries prevention Canton of Zurich; start in Role of schools: Switzerland Six supervised toothbrushing exercises per year using a concentrated fluoride preparation (F-gel) Discussions with the children aided by posters demonstrating the main reasons for caries Basic program:

In the Canton of Zurich, large numbers of schoolchildren were examined in 1964 in 16 sample communites dispersed over the entire Canton Follow-up examinations were carried out every four years in the same 16 communities, that is in 1968, 1972, 1976, , 2000, 2004 Average DMFT numbers per child were:

1980: Slovenia was still part of Yugoslavia and had a good school dental service. After 1986, prevention began to be introduced in the public schools using topical fluorides. In 1987, 1993 and 1998, large samples of Schoolchildren in Slovenia at age 12, 15, 18 years were examined. From these data, the average numbers of DMF-teeth were computed.

School prevention programs: Western Austria Federal State of Vorarlberg: Toothbrushing exercises at school since 1988, using methods adopted from Switzerland (Bischof, unpublished data) % DMFT Results obtained from 1988 to 2003

Conclusions The introduction of school-based caries preventive programs using topical fluoride resulted in conspicuous caries declines Early examples: Norway, Finland, Sweden, Denmark, Switzerland Later cases: Slovenia, Vorarlberg (Austria) School-based prevention using fluorides

Fluoridation The main caries preventive uses of fluoride are: Water fluoridation, and salt or milk fluoridation; water fluoridation brought the first success of public caries prevention on a public health scale Topical fluorides applied to erupted teeth in the oral cavity greatest success of public caries prevention in those countries where people can afford toothbrushes and toothpastes and are using them

Since ≈ 1995, F- toothpastes are regarded as the - most important measure of caries prevention - if used at least twice a day WHY? - In the industrialized countries where children have used F-toothpastes twice a day for at least 10 years a strong decline took place - But in less industrialized countries of Central and Eastern Europe where F- toothpastes have been available since 1992, there is little evidence of a decline as seen in the industrialized world: the majority of families have low incomes Fluoride in toothpaste, F-toothpastes

FDI-Commission, Renson et al DMFT at age 12 FW FW: widespread use of F-water

Fluorite, CaF 2 F-salt in Spain a German brand Use of fluoridated salt for caries prevention

DMFT-results of the Colombian fluoride study

Table taken from Jones et al. (2005), Bulletin of the WHO, 83(9) with reference to Estupinan-Day et al. (2001) Salt fluoridiatoin and dental caries in Jamaica. Comm Dent Oral Epidemiol 29: Universal salt fluoridation introduced in 1986 Salt fluoridation costs were minimal: 0.03 EURO / person / year

DMFT reductions obtained in children at age 12 after use of fluoridated salt Mexico YearDMFT Reduction 45 % Irigoyen && Caries Res. 2000;34: 303;Miinisterio de Salud Publica 1999 Uruguay YearDMFT Reduction 40 %

Costa Rica4 millions (>95%) since 1986 Jamaica 2.6 mill. (>98%) since 1987 Colombia43 millions (>80%) since 2002 Mexico40 millions in low F-water regions In addition: Ecuador, Uruguay, Venezuela Salt fluoridation, Central / Latin America Number of users (% of populaton) F-level: mostly mgF/kg Users of fluoridated salt in millions (America & Europe) Year User, millions

Fluoride in drinking water or salt? Fluoride in water: scientifically established effectiveness, useful for large water works (>100,000) Fluoride in salt: method chosen in Switzerland, began in 1955, on the national level since 1983, is by far the cheapest method, effectiveness demonstrated

Swiss Army Recruits, age 20 Decayed Teeth + Missing Teeth + Filled Teeth = DMFT, average per recruit YearDMFT Reduction due mainly to the prevention in schools started in and to F-salt = 80% red.

The three pillars of caries prevention Fluoride, systemic use - in salt OR water, intended F-intake Fluoride, topical use direct contact with teeth - in toothpastes most important, also in rinses, gels, varnishes (Small children sometimes ingest small amounts of F) Oral hygiene, toothbrushing with F-toothpaste Dietary changes: less sugared food, more toothfriendly sweets (not fermented)

Reasons for caries decline in Swiss children of school age and recruits +(+) More frequent / better toothbrushing: intensified contact of fluoride toothpaste with erupted teeth in the mouth, less plaque +++Fluorides in toothpastes, since Topical fluorides in school, brushing exercises, since (+) Fluoride in salt, since 1983

I thank you very much for your attention Thomas Marthaler