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Getting Back to Basics: Part I

An Ounce of Prevention is Worth 1.2 Parts per Million of Fluoride

Tooth decay continues to be a chronic problem in the United States. Carious lesions are experienced by 78% of all children and 85% of all dentate adults in the US.1 Caries prevention, unlike the disease, has a relatively short history. It was not until 1955 that the Food and Drug Administration (FDA) approved the first fluoride toothpaste. Today, virtually all commercial toothpastes contain fluoride. In a similar manner, the US Public Heal Service first recommended community drinking water fluoridation of 0.7 to 1.2 parts per million of fluoride in 1962 to prevent dental caries.

The effects of fluoride on dental diseases are well known. Fluoride helps prevent dental caries through conversion of hydroxyapatite into a less soluble form (ie, fluorapatite). Fluoride also has a bacteriostatic effect on dental plaque and it promotes reminerilization of enamel.

The safety of fluoride in dentistry as well as community water fluoridation programs has been well documented. Despite such rigorous scientific documentation, only 58% of the US population and 66% of the municipal water users received water containing enough fluoride to protect against caries.2 Such delays in community water fluoridation cannot be attributed to economics. Community water fluoridation is cost effective, averaging approximately $0.40 per person per year for water systems serving 20,000 or more people.

Dental caries affects all people without regard to race, education, age, or socioeconomic status. Disproportionate amounts of tooth decay are found in children due to poor oral care. To address this disparity, school-linked pit-and-fissure sealant programs have been established and are effective in reducing careis among high-risk children. As worthwhile as these programs are, they are limited in scope and serve only a small percentage of the targeted population.

The population is aging and the fastest growing segment comprises those individuals aged 85 and older. Approximately 67% of the population aged 65 and older is dentate and likely to continue experiencing dental decay. Reasons are varied and include decreased functional and or cognitive capacity or a change in dietary habits (eg, eating a more refined diet secondary to existing dental problems). Other factors that may contribute to escalated caries rates among the elderly include increased use of medications that promote decreased salivary function and inability to access care due to financial, physical, or logistical reasons. As the population ages, the incidence of dental decay will also most likely increase.

To effectively address the issues associated with dental decay, many healthcare practitioners may have to alter their mindset. Dentistry continues to use the surgical model in educating its students and residents, and the vast majority of dental care is procedure driven (ie, clinicians are paid to perform and not to advise and educate). Perhaps this is why many healthcare professionals are not as passionate about caries prevention as they could be. Dental practitioners have delegated much of this educational opportunity to their qualified dental hygiene staff or to their less qualified office staff. This is not to imply that these individuals are not performing effectively. Instead, it underscores the need for the entire office to share in a common preventative philosophy with goals that are reassessed periodically. Such actions would mimic the medical practice model in which dental caries would be viewed as a preventable infections disease. Part Two of this article will discuss current recommendations in dental caries prevention for “at risk” individuals.


*Associate Professor, Director, Oral Medicine Residency Program, LSU Health Sciences Center, New Orleans, Louisiana.



  1. US Department of Health and Human Services. Oral Health in America: A report of the Surgeon General. National Institute of Dental and Craniofacial Research, National Institutes of Health. Available at: http://www.surgeongeneral.gov/library/oralhealth/. Accessed February 3, 2003.
  2. Populations receiving optimally fluoridated public drinking water—United States, 2000. MMWR [serial online] 2002;51(7):144-147. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5107a2.htm. Accessed February 3, 2003.
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