Population-wide Strategies for Oral Health Rory Hume School of Dentistry

What we were, what we are now We evolved to have healthy mouths Agriculture changed that The sugar industry changed it more The tobacco industry made things worse Low-cost, high-sugar manufactured foods are now creating additional challenges

Eight oral diseases and risks 1.Dental caries (tooth decay) 2.Periodontal (gum) disease 3.Pre-cancer and cancer 4.Developmental disorders

5.Dry mouth (drugs, Sjögren’s, post-irradiation) 6.Oral effects of HIV/AIDS 7.Oro-dental trauma 8.Dental corrosion (erosion)

Three population-wide strategies for improving oral health, each spaced 50 years apart…

1920 New Zealand. The whole country. A massive problem with dental caries. Plenty of money. All children of school age, at no cost to the child or family. A logical approach. Brush teeth after meals to remove food More fruit and vegetables for better nutrition Fillings – the state-of-the-art in care

1920 New Zealand. The whole country. A massive problem with dental caries. Plenty of money. All children of school age, at no cost to the child or family. A logical approach. Brush teeth after meals to remove food More fruit and vegetables for better nutrition Aggressive fillings – the state-of-the-art in care

Outcomes Decayed-missing-filled numbers increased Each child received, on average, about 35 fillings by age 16; many were replacements Many had their teeth extracted in their 20s 70% of NZ 60-year-olds had no teeth 60 years later, the world’s highest rate of edentulism It failed, absolutely, to meet expectations

Why did it fail? New Zealand. The whole country. A massive problem with dental caries. Plenty of money. All children of school age, at no cost to the child or family. A logical approach. Brush teeth after meals to remove food More fruit and vegetables for better nutrition Aggressive fillings - the state-of-the-art in care

1970 South Australia. The whole State. A massive problem with dental caries. Plenty of money. All children of school age, at no cost to the child or family. Still a logical approach. But by then the science was different…. so the approach to care was different.

Clean teeth daily to remove biofilm (plaque) Family and school dietary counseling, to decrease simple carbohydrate amount and frequency; fully-explained, food and drinks Systemic fluoride by tablets or community water supply; topical by office and toothpaste Fissure sealants, using resin-based adhesion Cautious restoration of advanced defects

Outcomes Decayed-missing-filled numbers fell, fast – from 12 at 12 years to 0.5 at 12 years by 1990 Those who had low caries at age 12 still have low caries – and are excellent dental patients 45 years later edentulism is very rare; most dental schools no longer teach full dentures Absolute success; expectations met; and dentistry did it alone, as a solo profession

Clean teeth daily to remove biofilm (plaque) Family and school dietary counseling, to decrease simple carbohydrate amount and frequency; fully-explained, food and drinks Systemic fluoride by tablets or community water supply; topical by office and toothpaste Fissure sealants, using resin-based adhesion Cautious restoration of advanced defects

The 1970 model was adopted in a few other places, focused on caries in children, and it continued to work well It required a particular political mindset, and it was expensive – initially about $1,000 per child per year in today’s dollars, falling to about $200 when the restorative backlog had gone - a lot of money across a whole population

The 1970 model was adopted in a few other places, focused on caries in children, and it continued to work well It required a particular political mindset, and it was expensive – initially about $1,000 per child per year in today’s dollars, falling to about $200 when the restorative backlog had gone - a lot of money across a whole population

The 1970 model was adopted in a few other places, focused on caries in children, and it continued to work well It required a particular political mindset, and it was expensive – initially about $1,000 per child per year in today’s dollars, falling to about $200 when the restorative backlog had gone - a lot of money across a whole population

2020 Some questions, some observations, and some suggestions What can be done now, for whole populations? For caries in children, for caries in adults and the elderly, and for the other major oral diseases?

2020 – caries in children The political climate is different in most places; few societies would now feel that they can afford the 1970 level of cost, despite good outcomes. Disease patterns are now different, socio- economically. The burden is now greater among disadvantaged groups in many societies. The science is more advanced. We could get even better outcomes, faster, at lower cost.

2020 – caries in children What can we do now to prevent and cure caries? All that we did before – daily biofilm removal, dietary understanding and control, topical fluoride, fissure seals, conservative restoration…

2020 – caries in children What can we do now to prevent and cure caries? All that we did before – daily biofilm removal, dietary understanding and control, topical fluoride, fissure seals, conservative restoration…

2020 – caries in children What can we do now to prevent and cure caries? All that we did before – daily biofilm removal, dietary understanding and control, topical fluoride, fissure seals, conservative restoration…

2020 – caries in children What can we do now to prevent and cure caries? All that we did before – daily biofilm removal, dietary understanding and control, topical fluoride, fissure seals, conservative restoration… Delay S. mutans infection, maternal education Assess caries risk, and reduce it Remineralize before or instead of restoring

2020 – caries in children What can we do now to prevent and cure caries? All that we did before – daily biofilm removal, dietary understanding and control, topical fluoride, fissure seals, conservative restoration… Delay S. mutans infection, maternal education Assess caries risk, and reduce it Remineralize before or instead of restoring

It is still a logical strategy for population-wide oral health first to prevent caries in children. Teeth are at very high risk of caries for the first several years - newly-formed enamel is much less completely mineralized than it will be. Clear evidence that low caries children become low caries adults.

Are these strategies useful for caries prevention and cure at other ages? Yes, with one exception, S. mutans transmission So it may be beneficial to societies to educate population-wide about these things

Are these strategies useful for caries prevention and cure at other ages? Yes, with one exception, S. mutans transmission So it may be beneficial to societies to educate population-wide about these things

2020 – other oral diseases Periodontal disease? Biofilm, nicotine, uncontrolled diabetes, immune deficiency Oral cancer? Tobacco, burned or chewed; alcohol Developmental; folic acid, maternal smoking Trauma; awareness, mouth guards Dry mouth; preventive education, management Corrosion; preventive education, management

2020 – other oral diseases Periodontal disease? Biofilm, nicotine, uncontrolled diabetes, immune deficiency Oral cancer? Tobacco, burned or chewed; alcohol Developmental; folic acid, maternal smoking Trauma; awareness, mouth guards Dry mouth; preventive education, management Corrosion; preventive education, management

2020 For most oral diseases, preventive community-wide education therefore appears to be a logical, primary method of management. It’s logical to assess effectiveness of preventive intervention by measurement of outcomes – which requires initial measurement as well. In some cases, treatment will also be needed.

2020 So it appears that much good could now be done through population-wide education 1:1 education is likely to be much more effective than population-wide, as a general principle… But it is also much, much more expensive. So it’s well worth consider developing population- wide preventive educational technologies....

2020 ….and measuring the effectiveness of these technologies by having good epidemiological data before, during and after. Also, measuring knowledge, behaviors, and early indicators of disease such as risk status, not just levels of disease.

2020 Could we leverage the effort? We could do much more than oral health only, using similar educational technologies. A broad range of other possible health risks – whatever would make sense together. Find partnerships, share effort, share technology development, share costs.

2020 Population-wide health education, including oral health education, leveraging other health messages when that makes sense Using varied technologies suited to different ages Supported by clinical service delivery, in whatever way is most efficient and most effective in particular social circumstances

2020 Population-wide health education, including oral health education, leveraging other health messages when that makes sense Using varied technologies suited to different ages Supported by clinical service delivery, in whatever way is most efficient and most effective in particular social circumstances

2020 What does dentistry have that will draw other professions to us, so that they will want to work with us towards common goals? A proven record of effective, population-wide interventions to reduce disease burden.

Last thoughts - from global to local Economics must be considered, here and now Cost recovery on a fee-for-service model for community health education? Hard to imagine But if well-leveraged, the costs will be low, and philanthropic and research opportunities strong Increased business will accrue through routine service paths for those seen as actively engaged

Thanks for your attention, and I look forward to questions and comments