1. National Survey on School-based Fluoride Mouth Rinsing Program in Japan - Regional Spread Conditions in Various Kinds of Schools - Kazunari Kimoto * 1, Katsuhiko Taura 2, Akihiro Yoshihara 3, Satoru Kazunari Kimoto * 1, Katsuhiko Taura 2, Akihiro Yoshihara 3, Satoru Haresaku 4, Yuichi Ando 5, Hirohisa Arakawa 1 and Osamu Sakai 6 Haresaku 4, Yuichi Ando 5, Hirohisa Arakawa 1 and Osamu Sakai 6 1 Division of Oral Health, Department of Health Science, Kanagawa Dental College, Japan 1 Division of Oral Health, Department of Health Science, Kanagawa Dental College, Japan 2 Dental Care Center attached to Tohoku University Hospital, Miyagi, Japan 2 Dental Care Center attached to Tohoku University Hospital, Miyagi, Japan 3 Division of Preventive Dentistry, Department of Oral Health Science, Graduate school of Medical 3 Division of Preventive Dentistry, Department of Oral Health Science, Graduate school of Medical & Dental Sciences, Niigata University, Japan & Dental Sciences, Niigata University, Japan 4 Preventive & Public Health Dentistry, Department of Public Health & Human Science, Fukuoka 4 Preventive & Public Health Dentistry, Department of Public Health & Human Science, Fukuoka Dental College, Japan Dental College, Japan 5 Department of Oral Health, National Institute of Public Health, Japan 5 Department of Oral Health, National Institute of Public Health, Japan 6 Non-profit Japanese Conference on the Promotion of the Use of Fluoride in Caries Prevention 6 Non-profit Japanese Conference on the Promotion of the Use of Fluoride in Caries Prevention (NPO-JPUF) (NPO-JPUF) The 9th World Congress on Preventive Dentistry #: 123 #: 123 September 9, 2009, at Hilton Phuket Arcadia September 9, 2009, at Hilton Phuket Arcadia Resort & Spa, Grand Ballroom 8. Theme III: Fluoride and Health (Poster)

2. Fluoride mouth rinsing (FMR) is safe, effective and easy to learn and do by preschool and school children. It is relatively inexpensive caries-preventive measure with public health. Fluoride mouth rinsing (FMR) is safe, effective and easy to learn and do by preschool and school children. It is relatively inexpensive caries-preventive measure with public health. In Japan, school-based fluoride mouth rinsing program (S-FMR) started in a single prefecture in 1970, and spread to all of 47 prefectures by 2005 (Table 1). In Japan, school-based fluoride mouth rinsing program (S-FMR) started in a single prefecture in 1970, and spread to all of 47 prefectures by 2005 (Table 1). The purposes of this study were as follows; The purposes of this study were as follows; Objective 1)to clarify the spread conditions of the school-based fluoride mouth rinsing program (S-FMR) since 1983. 2) to set up the next S-FMR goal in 2010 and promote it throughout Japan to health for all (Fig. 1).

3. Table 1 Number of prefectures adopted S-FMR during the past 38 years Table 1 Number of prefectures adopted S-FMR during the past 38 years Year Year Number of Number of prefectures prefectures Year Year Number of Number of prefectures prefectures Year Year Number of Number of prefectures prefectures 1970 1970 1 1983 1983 20 20 1998 1998 39 39 1972 1972 3 1985 1985 23 23 2000 2000 38 38 1974 1974 6 1987 1987 26 26 2002 2002 40 40 1976 1976 10 10 1990 1990 29 29 2004 2004 45 45 1978 1978 15 15 1992 1992 32 32 2005 2005 47 47 1980 1980 16 16 1994 1994 35 35 2006 2006 47 47 1982 1982 18 18 1996 1996 38 38 2008 2008 47 47

4. 1) S-FMR; Number of children will be increased to 1,000,000 in 2010 1,000,000 in 2010 2,000,000 in 2020 2,000,000 in 2020 2) Community water fluoridation; realizing in some areas (none except some natural areas in 2009) realizing in some areas (none except some natural areas in 2009) 3) Market share of fluoridated dentifrice; more than 90% (89% in 2007) more than 90% (89% in 2007) 4) Experienced person of professional topical fluoride application; more than 60% (59% in 2005) more than 60% (59% in 2005) ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ ・ * Other fluoride uses at present in Japan : ・ FMR agents as over the counter drug (OTC); none for sale at present (in 2009) ・ FMR agents as over the counter drug (OTC); none for sale at present (in 2009) ・ Number of children in FMR at home in 4-14 years old; 347,000 (estimated data in 2002) ・ Number of children in FMR at home in 4-14 years old; 347,000 (estimated data in 2002) Fig.1 The goals of S-FMR and others in Japan by NPO-JPUF * Other fluoride uses at present in Japan Fig.1 The goals of S-FMR and others in Japan by NPO-JPUF * Other fluoride uses at present in Japan

5. Subjects and Methods Data were collected by questionnaire surveys regarding the schools and children participating in S-FMR. The other contents of questionnaire for S-FMR are frequency of rinse, used agent for mouth rinsing, fluoride concentration of the rinsing solution and source of financial support for S-FMR. Questionnaires had been sent to the key persons and dentists of NPO-JPUF by mail or e-mail every two years. Data were collected by questionnaire surveys regarding the schools and children participating in S-FMR. The other contents of questionnaire for S-FMR are frequency of rinse, used agent for mouth rinsing, fluoride concentration of the rinsing solution and source of financial support for S-FMR. Questionnaires had been sent to the key persons and dentists of NPO-JPUF by mail or e-mail every two years. The latest survey, a joint with 8020 Promotion Foundation, WHO Collaborating Center for Translation of Oral Health Science and NPO-JPUF, was conducted in 2008. Questionnaires were sent to manager of oral health in all 47 prefectures. The latest survey, a joint with 8020 Promotion Foundation, WHO Collaborating Center for Translation of Oral Health Science and NPO-JPUF, was conducted in 2008. Questionnaires were sent to manager of oral health in all 47 prefectures.

6. Furthermore, the number of children participating in S- FMR program corresponds to about 5.1% of the same aged population (Table 2). Furthermore, the number of children participating in S- FMR program corresponds to about 5.1% of the same aged population (Table 2). In 2008, the total number of schools and children participating in the program were 6,433 and 674,141, respectively. (recovery rate 100%). The ratio by the total number of schools and children in Japan were 9.0 % and 5.1 %, (nursery schools and kindergartens 11.1 % and 7.0 %, primary schools 9.1 % and 6.3%, secondary schools 2.7 % and 1.5%, and schools for special needs education; physically handicapped and mentally retarded children 3.1 % and 2.7 %), respectively. In 2008, the total number of schools and children participating in the program were 6,433 and 674,141, respectively. (recovery rate 100%). The ratio by the total number of schools and children in Japan were 9.0 % and 5.1 %, (nursery schools and kindergartens 11.1 % and 7.0 %, primary schools 9.1 % and 6.3%, secondary schools 2.7 % and 1.5%, and schools for special needs education; physically handicapped and mentally retarded children 3.1 % and 2.7 %), respectively. The number of children in S-FMR by prefectures in 2006 and 2008 is drawn map, which showed in increasing among prefectures (Fig. 2; red and pink prefectures). The number of children in S-FMR by prefectures in 2006 and 2008 is drawn map, which showed in increasing among prefectures (Fig. 2; red and pink prefectures). Results (1)

7. Fig.2 The map on the number of children in S-FMR by 47 prefectures in 2006 and 2008. Fig.2 The map on the number of children in S-FMR by 47 prefectures in 2006 and 2008. 30,000 ～ 10,000 ～ 5,000 ～ 5,000 ～ 1,000 ～ 1,000 ～ less than 1,000 * Lower left side : Survey in 2006 with NPO-JPUF ** Upper right side : Survey in 2008, a joint with NPO-JPUF, 8020 Promotion Foundation and WHO Collaborating 8020 Promotion Foundation and WHO Collaborating Center for Translation of Oral Health Science Center for Translation of Oral Health Science 2008 ** 2006 *

8. Table 2 Number of schools and children participating, the rate of financial support in S-FMR by school class in 2008 Number of Number of Financial support schools children Governments etc. * / The others ** schools children Governments etc. * / The others ** Nursery school Nursery school & Kindergarten & Kindergarten Primary school Primary school Secondary school Special school, etc. ♯ Total Total Various kinds of school of school * The prefectural or municipal governments and/or educational committee ** The others (School, Parent, Dental Association, Jointed combination, etc.) *** Number of schools in S-FMR / Total schools in Japan **** Number of children in S-FMR / Total children in Japan ♯ The school for physically handicapped or mentally related children and the others 4,049 (11.1%) *** 170,177 (7.0%) **** 69.2 % / 30.8 % 2,053 (9.1%) 447,579 (6.3%) 84.2 % / 15.8 % 300 (2.7%) 54,794 (1.5%) 87.9 % / 12.1 % 300 (2.7%) 54,794 (1.5%) 87.9 % / 12.1 % 31 (3.1%) 1,591 (2.7%) 100.0 % / 0.0 % 31 (3.1%) 1,591 (2.7%) 100.0 % / 0.0 % 6,433 (9.0%) 674,141 (5.1%) 80.4 % / 19.6 %

9. Figure 3 shows the increasing number of schools and children in S-FMR by nearly every two year (1983-2008), and goal of children in 2010 ( ● ). Figure 3 shows the increasing number of schools and children in S-FMR by nearly every two year (1983-2008), and goal of children in 2010 ( ● ). In nursery schools and kindergartens, 59.2 % and 47.0 % of the participating children adopted the daily rinsing-method, respectively. In primary and secondary schools 95.7 % and 95.4% of the participating children adopted the weekly rinsing-method, respectively. In nursery schools, kindergartens and special needs education, children used more medicaments for FMR than a reagent of Sodium Fluoride and in primary and secondary schools, children used more a reagent than medicaments. In nursery schools and kindergartens, 59.2 % and 47.0 % of the participating children adopted the daily rinsing-method, respectively. In primary and secondary schools 95.7 % and 95.4% of the participating children adopted the weekly rinsing-method, respectively. In nursery schools, kindergartens and special needs education, children used more medicaments for FMR than a reagent of Sodium Fluoride and in primary and secondary schools, children used more a reagent than medicaments. Results (2)

10. * Survey in 2008, a joint with NPO-JPUF, 8020 Promotion Foundation and WHO Collaborating Center for Translation of Oral Health Science Number of children ’83 ’85 ’87 ’90 ’92 ’94 ’10’96 ’98 ’06 ’ 08 ’04’02’00 10 8 6 4 2 0 120 100 80 60 40 20 0 The turning point in Japan ● ● ● ● （ ×10 4 ） （ ×10 3 ） Fig.3 The changes on the number of schools and children in S-FMR by nearly every two year (1983 - 2008), and goal of children ( ● ). Number of schools Number of schools *

11. Table 3 Outline of the rinsing-methods in the questionnaire for S-FMR by grade level (%) Table 3 Outline of the rinsing-methods in the questionnaire for S-FMR by grade level (%) Frequency per week * Fluoride concentration * S - FMR agent for use Frequency per week * Fluoride concentration * S - FMR agent for use 5 times / once 250ppmF / 450ppmF / 900ppmF Reagents / Medicaments 5 times / once 250ppmF / 450ppmF / 900ppmF Reagents / Medicaments Nursery school Nursery school & Kindergarten & Kindergarten Primary school Primary school Secondary school Special school, etc. ♯ Total Total * These are not the approximate value, because the rinsing-methods in S-FMR are d different by regional distinction. ♯ The school for physically handicapped or mentally related children and the others 55.0 / 27.4 42.5 / 26.5 / 13.4 35.9 / 64.1 55.0 / 27.4 42.5 / 26.5 / 13.4 35.9 / 64.1 3.2 / 95.7 3.1 / 30.5 / 63.8 52.5 / 47.3 3.2 / 95.7 3.1 / 30.5 / 63.8 52.5 / 47.3 4.2 / 95.4 4.5 / 27.3 / 64.1 67.8 / 32.2 4.2 / 95.4 4.5 / 27.3 / 64.1 67.8 / 32.2 32.1 / 41.7 16.3 / 41.0 / 24.2 22.4 / 66.8 32.1 / 41.7 16.3 / 41.0 / 24.2 22.4 / 66.8 16.4 / 78.3 13.2 / 29.2 / 51.1 49.5 / 50.4 16.4 / 78.3 13.2 / 29.2 / 51.1 49.5 / 50.4 Various kinds of school of school

12. S-FMR is useful public health method. Both the increasing profiles have two phases, “first phase” was increased from 1983 to 2000. Then, “Second phase” was increasing from 2002 to 2008. It would be considered that factors of turning points were “The Synthetic opinion of fluoride application” by Japanese Association for Dental Science (1999) and announcement of guideline for FMR by Minister of Health, Labor and Welfare Japan (2003) etc..We have recognized a big regional differences even though the number of schools and children implementing FMR was increasing. S-FMR is useful public health method. Both the increasing profiles have two phases, “first phase” was increased from 1983 to 2000. Then, “Second phase” was increasing from 2002 to 2008. It would be considered that factors of turning points were “The Synthetic opinion of fluoride application” by Japanese Association for Dental Science (1999) and announcement of guideline for FMR by Minister of Health, Labor and Welfare Japan (2003) etc.. We have recognized a big regional differences even though the number of schools and children implementing FMR was increasing. We need the cooperation among dental organizations, dental schools and municipal corporations to achieve the goals and to lesson in regional differences in S-FMR. We need the cooperation among dental organizations, dental schools and municipal corporations to achieve the goals and to lesson in regional differences in S-FMR. We propose that a goal, the item with regarding to caries prevention, for S-FMR should be adopted for the final assessment of Healthy Japan 21. We propose that a goal, the item with regarding to caries prevention, for S-FMR should be adopted for the final assessment of Healthy Japan 21. Discussion

13. Okinawa Sapporo Sendai Niigata Number of Dentists: 97,198 (06 From Minister of Health, Labor and Welfare) Number of Dentists: 97,198 (06 From Minister of Health, Labor and Welfare) To one million population by 761 Dentists To one million population by 761 Dentists Number of Dental Hygienists: 86,939 (06 From Minister of Health, Labor and Welfare) Number of Dental Hygienists: 86,939 (06 From Minister of Health, Labor and Welfare) To one million population by 680 Dental Hygienists To one million population by 680 Dental Hygienists Total population: 127,773,000 Total population: 127,773,000 Children: 13,248,000 Background Kyoto 4-5 years old: 2,433,000 4-5 years old: 2,433,000 6-11 years old: 7,166,000 6-11 years old: 7,166,000 12-14 years old: 3,649,000 12-14 years old: 3,649,000 Tokyo

14. Okinawa Sapporo Sendai Niigata In Japan, medical expenses insurance is on a piece-rate basis, national dental expenses/national income is 0.5%; ¥ 25,766 billion, in 05. The dental expenses insurance was included slightly preventive care. Unfortunately, certain dentists and dental hygienists give priority professional care in clinic and self care in home over public care. * The mean DMFT at 12-year-old in 07 1.63 1.63 DT : 0.59, MT : 0.03, FT : 1.01 from Minister of Education, Culture, Sports and Technology Japan Sports and Technology Japan FT : 1.19 FT : 1.19 KyotoTokyo

15. Other fluoride uses at present in Japan : 1) Community water fluoridation; 1) Community water fluoridation; none except some natural areas (09) none except some natural areas (09) 2) Topical fluoride application in 1-14 years old; 2) Topical fluoride application in 1-14 years old; 59% (05 From Minister of Health, Labor and Welfare ) 59% (05 From Minister of Health, Labor and Welfare ) 3) Fluoridated dentifrice in market share; 3) Fluoridated dentifrice in market share; 89% (07 From Lion Foundation of Dental Health ) 89% (07 From Lion Foundation of Dental Health ) 4) Number of children in FMR at home in 4-14 years 4) Number of children in FMR at home in 4-14 years old (estimated data); 347,000 (02 From Ando, et al ) old (estimated data); 347,000 (02 From Ando, et al ) 5) FMR agents as over the counter drug (OTC); 5) FMR agents as over the counter drug (OTC); none for sale at present (20th. July. 09 ) none for sale at present (20th. July. 09 )

16. 1999: The Synthetic opinion of fluoride application 1999: The Synthetic opinion of fluoride application by Japanese Association for Dental Science by Japanese Association for Dental Science 2000: The Recommend of fluoride application in Healthy Japan 21 2000: The Recommend of fluoride application in Healthy Japan 21 by Minister of Health and Welfare, Japan by Minister of Health and Welfare, Japan The Technological support for community water fluoridation The Technological support for community water fluoridation by Minister of Health and Welfare, Japan by Minister of Health and Welfare, Japan The Strategy of regional project in Healthy Japan 21 The Strategy of regional project in Healthy Japan 21 2002: The Scientifically support for fluoride application 2002: The Scientifically support for fluoride application by Japanese Society for Dental Health by Japanese Society for Dental Health 2003: The Guideline for fluoride mouth rinse 2003: The Guideline for fluoride mouth rinse by Minister of Health, Labor and Welfare, Japan by Minister of Health, Labor and Welfare, Japan Publication of The fluoride mouth rinse practical manual for Publication of The fluoride mouth rinse practical manual for caries prevention by research meeting of fluoride application caries prevention by research meeting of fluoride application Chronological opinion around the turning point in Japan

17. In Japan, anti-fluoridationists commonly want to apply a statement in the WHO technical report. Tending to mislead by WHO statement “ FMR was not recommended for children “ FMR was not recommended for children below 6 years old, as it might contribute to below 6 years old, as it might contribute to the risk of dental fluorosis ??????????????? ” the risk of dental fluorosis ??????????????? ” (Fluoride and Oral Health, WHO, 1994) Go ahead !! Announcing by NPO-JPUF, “ Beginning of FMR is recommended for Japanese (or Asian) children “ Beginning of FMR is recommended for Japanese (or Asian) children in 4-5 years old.”

18. USA, Canada, South America, Australia, Europe and Asia (Malaysia, Singapore, Hong Kong, Korea, Thailand, China, Laos and the others), where fluoride is enough supply In Japan, fluoride use is limited to topical application, none Community Water Fluoridation S-FMR ( only 5.1% of children ) + Fluoridated toothpaste (89% of market share ) Community Water fluoridation (or Salt fluoridation, Milk fluoridation Fluoride supplement) Fluoride supplement)+ Fluoridated toothpaste

19. Let s gain everyones successful, to surely efficacy, by minimum effort. Fluoride: Community Water Fluoridation and Fluoride Mouth Rinsing Program