Global Epidemiology Program: Oral Health Unit, WHO, Geneva
Marie Hélène Leclerq
Before taking any action aimed at improving oral health, whether in the field of prevention or in the form of assistance to developing countries, it is necessary to have a basic set or reference statistics on the oral health status of the population in question. This epidemiological evaluation enables the most pressing needs to be identified and appropriate strategies proposed. Furthermore, the development of the situation can be monitored over a period of years and the appropriateness of services assessed.
With this in mind, the WHO Global Oral Data Bank was set up in the early 1970s to respond to the need for information on oral health and diseases at both national and global levels. It was conceived initially as an epidemiological instrument but has now become a driving force in the generation of new information and in the development and dissemination of methodologies, based on standard criteria, readily applicable in all countries: for example, Oral Health Surveys - Basic Methods, 3rd edition, 1987.
At the outset, the Bank contained information on the two most prevalent oral problems only - dental caries and periodontal diseases - the data being obtained from surveys performed in collaboration with WHO and systematic review of the oral health literature. At the present time, the Bank contains 13,713 caries records and 3,531 on periodontal diseases (recorded using the CPITN method) for some 200 countries, representing a total of 1,337 reports.
The collection of data through the sampling and summarization of clinical care records is now being promoted and a document providing guidelines will be available in 1993. As regular health monitoring is applied in both industrialized and developing countries, data from such records are becoming increasingly important. For conditions such as oral mucosal, pre cancerous and cancerous lesions, the most rational method of collecting information on prevalence and prognosis is through clinical care records.
As it is now well-known that HIV-infected patients invariably show oral lesions which may accrue at the earliest stages of the infection, the dental profession has an important responsibility in its diagnosis. Hence, a system has been developed by WHO for recording oral lesions possibly related to HIV infection from which a data base is being established. It is proposed that data collected in this way will be supplemented by information extracted from clinical records.
Nearing completion is the development of a system for the surveillance of oral mucosal diseases. Initially it will concentrate on data extracted from publications, but will be followed by a WHO recording form.
Only with such a large collection of data as is available in the WHO Global Oral Data Bank is it possible to discern major trends in oral conditions at country level, compare them with other countries, and adopt or adapt national oral health policies and monitor global goals. In 1980, a global oral health goal of 3 or less decayed, missing or filled permanent teeth at 12 years was agreed. At that time, a booklet entitled Dental Caries Levels at 12 Years was prepared. This booklet has subsequently been updated annually and serves as an evaluation tool for the WHO Global Oral Health Program; it is also useful in informing oral health administrators of the general trends of the diseases.
By maintaining the WHO Global Oral Data Bank, devising simple but rigorous methodologies and providing health services with tried and tested epidemiological tools, the Oral Health Unit of the World Health Organization plays a major role in guiding national policy-makers in their efforts to provide improved oral health services.
WHO Collaborating Center for the Prevention of Oral Disease at the Dentistry Medical Center of Erfurt University, Germany
Dr. Roswitha Heinrich
On December 11, 1983, the Dentistry Medical Center of Erfurt University was designated as the third medical institution in the former GDR (German Democratic Republic) as a WHO Collaborating Center for the European region. Prof. Dr. Walter Kunzel, head of the Department of Preventive Dentistry and an experienced epidemiologist was appointed director of this Center.
Based on the conception of "Health for All by the Year 2000" the tasks for the Collaborating Center were towards the improvement of the oral health status with the goal of a lifelong dentition of natural teeth. Therefore the main activities of the department were concentrated on the following subjects:
· Monitoring of oral health profiles of Eastern European Countries
· Participation in the International Collaborative Study on Oral Health Outcomes (ICS-II); repetition of the ICS-I study after a period of 10 years to document and analyze the changes occurred.
· Evaluation of the usefulness of clinical indices for recording periodontal disease progression
· Elaboration of Oral Health Care recommendations for elderly in European Countries
As the problem of Oral Health Care for elderly is becoming increasingly acute, a "Gerostomatology" workshop was initiated by Prof. Kunzel in 1989 in Brno, Czechoslovakia. On this workshop first steps in specifying a gerostomatological research concept as well as the conception of a multinational gerostomatological study were taken. The WHO ORAL HEALTH ASSESSMENT FORM (1986) was modified with the entry of special gerodontological topics. For example: living situation, general health status, oral health behavior, root surface caries, teeth in occlusion, replaced teeth with bridge element or with removable denture, denture wearing, denture wearing time, enamel disorders and the need for denture by an international European group of experts in oral Epidemiology. The result of this work was a manual on methodological advice for field use with this modified assessment form.
After calibration of national coordinators a national survey of oral health status needs and behavior of an stratified sample of the elderly and old population was carried out in Germany (Eastern part), Poland, Czechoslovakia, Belarus, and Slovene in order to provide basic data for the formulation and the development of recommendations of dental care for the elderly. As a consequence of the political development in Eastern Europe, studies already initiated or partially completed were discontinued or delayed due to conceptual adaptations, e.g. Bulgaria could not take part, Hungary and Austria took part with an urban survey. Furthermore, a regional gerostomatoligical study of Italy has been included. The data of an epidemiological study carried out in 1988 in England will also be integrated in the multinational gerostomatological study coordinated by the WHO Collaborating Centre of Erfurt.
The international comparison of results, the evaluation and the discussion of recommendations and guidelines for the gerostomatological dental care in the future as well as the formulation of national goals for Oral Health for the Elderly by the Year 2010 will be accomplished in the next meeting of this gerostomatological experts group on May 29-30, 1993 in Portoroz, Slowenia.
WHO Oral Health Collaborating Center Western Pacific Region
DR. T.W. Cutress
Dr.T.W. Cutress, Director of the WHO Collaborating Center of the Western Pacific Region, sent us a letter informing the priority areas in Oral Health, according to the work performed by that Center.
Priority Areas for Research in Oral Health in the Western Pacific Region
1. Regular five-yearly national oral health surveys to: monitor changes in the pattern of oral disease; to assess the effectiveness of current and prospective oral health care systems; to define the magnitude of and reasons for edentulousness.
2. Contribute to the international collection of data on the oral manifestations of the HIV infection.
3. Analytical epidemiological studies to establish the significance of the relationship between dietary sugar and the prevalence of caries in populations.
4. (1) To check the natural levels of fluoride in water used for drinking and cooking. (2) Conduct clinical trials of the cost effectiveness of alternatives to water fluoridation such as fluoride mouth rinsing in schools, fluoride tablets, and fluoridated salt. (3) Screen for the distribution of disfiguring dental fluorosis and implement appropriate projects.
5. Promote intercountry collaborative studies to investigate the relationship of infant nutrition to the etiology of dental hypoplasia and rampant caries in children.
6. Establish controlled clinical trials on the cost effectiveness of fissure sealing by auxiliary personnel.
7. Promote health services research on the role of individuals and communities in disease prevention. For example, effectiveness of auxiliary personnel for instruction in tooth cleansing and calculus removal in control of endemic periodontal disease.
8. Plan inter-country collaborative longitudinal studies into natural histories of periodontal diseases, especially those with little or no treatment services. This would facilitate studies of diet, host factors and defense mechanisms involved in the transition from health to disease in high risk groups.
9. Establish population-based national and local registries of oral cancer to aid surveillance and international studies.
10. Evaluate the appropriateness and effectiveness of problem based, community oriented programmes for the training of oral personnel.
National Institute of Dental Research
Annual Report of International Activities -
Fiscal Year 1992
Louis K. Cohen
Director of Extramural Program and
Assistant-Director for International Health - NIDR
Nationally and internationally, dentistry is undergoing a major evolution. While great success has been achieved in understanding and preventing dental caries, dentistry has expanded its horizons to encompass all oral diseases and conditions. Advances in research have been and important contributor to this evolution. It is estimated that US$38 billion in dental expenditures have been saved in the United States from 1979 through 1989, in large measure because of the utilization of research advances in dental practice and by the public at large.
The National Institute of Dental Research (NIRD) is the major source of funds for oral health research in the United States and contributes support and expertise worldwide. Through an active and growing international program, the NIDR is encouraging collaboration between U.S. and foreign scientists and is strengthening the capability of U.S. domestic institutions to conduct research internationally.
Tremendous strides were made during Fiscal Year (FY) 1992. Twelve new extramural grants were awarded for international collaborative research, strengthening existing areas of research and expanding into new areas. Support for international conferences also increased. The NIDR intramural program hosted two internationally acclaimed scholars, one an expert in research on acquired immunodeficiency syndrome (AIDS) and gene regulation and the other a recipient of the 1975 Nobel Prize in Physiology and Medicine for studies in viral oncology. Again the NIDR selected an international expert, in immunology and vaccine research, to present the annual Seymour J. Kreshover Lecture at the National Institute of Health (NIH).
New directions were strengthened in the NIDR international programs. Through Latin American and Caribbean Initiative sponsored by the Fogarty International Center (FIC), the NIRD obtained co-funding along with its own support for research and discussions on future collaborations involving U.S. and Latin American scientists. The NIDR also contributed to the planning of initiatives with Sub-Saharan African and to a major international meeting on AIDS in Africa. Foreign scientists from Central and Eastern Europe and from Russia joined the intramural program staff to work on areas of mutual interest. And the NIDR continued to build support for international oral health research in collaborating with the G-7 nations (the seven economic summit countries), the World Health Organization (WHO), the Fédération Dentaire Internationale (FDI).
In recognition of the leadership of the NIDR, the Director of the Institute was asked to moderate and lecture at major international scientific congress and meetings in Belgium, Finland, Ireland, Sweden, and the United States. Other NIDR staff were cited for their contributions, receiving prestigious international awards and assuming leadership roles in international organizations.
WHO Collaborating Center: The NIDR serves as the WHO Collaborating Center for Epidemiology, Prevention, and Treatment of Oral Diseases and Conditions. Much of this effort relates to international AIDS activities (see above). The Director, NIDR, and the Assistant Director for International Health, NIDR, continued to serve on a special WHO Blueprint Committee that is finalizing a plan for global oral health for the first half of the 21st century. The Director, NIDR, participated in a meeting to review the blueprint, held in London, United Kingdom. He also chaired a WHO Expert Panel on Advances in Oral Health that met in Geneva, Switzerland. The panel's report has been published in WHO Technical Report Series and could be available during early FY 1993. The Director, NIDR, met with the Director-General, WHO, to discuss plans for a World Health Day, Month, and Year in 1993 that would give global visibility to oral health and to discuss U.S involvement in developing the oral health component of the Ninth WHO Programme of Work. While in Geneva, the Director, NIDR, met with the Health Attache, U.S. Mission, concerning international oral health.