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Caries Reduction: Indirect Factors Outweighs Clinical Treatment

Dr. Paulo Nadanovsky

Professor of the Department of Public Health in Dentistry

University College London Medical School

Email: PAULO@PUBLIC-HEALTH.UCL.AC.UK


In many industrialized countries caries level has been dramatically reduced in the last twenty years. According to Dr. Paulo Nadanovsky's doctorate paper, accepted by London University last year, the main reason for this decrease is due to the large use of fluorides, especially on toothpaste. Other possible reasons are changes in diagnostic criteria, in sugar consumption standards, in the large use of antibiotics, improvement of oral hygiene and a natural clinic variation. It seems that the reduction of caries prevalence is due more to these factors than to dental treatments.

According to this work, decreases occurred approximately at the same time in many countries, being usually related with the increase of the availability of fluoride bearing toothpaste. However, some other reasons considered important have not gathered enough evidence. For instance, many influential reviewers have considered dental services as an important cause for this reduction of caries, but they have not collected evidences to assert this conclusion. The strength of this belief may be illustrated by the recent speech of the elected president of the International Association of Dental Research, 1991, "the decline of caries in youngsters in western countries may be one of the most dramatic successful case in health care". But one may observe that many countries have had similar reduction in caries prevalence in spite of the differences in the structure and philosophy of their dental care systems.

Through four different levels of study and data accessed through articles and published reports, the work done by Dr. Paulo Nadanovsky aimed to evaluate how far changes in caries (DMF) in children since the 70's in many industrialized countries, could be conferred to clinical dental activities. As a secondary objective it was explored the association of caries decrease with wide social indicators (such as education, income level and distribution, and the market of fluoride bearing toothpaste).

In the first study, where caries changes in 12 year-old children in 18 industrialized countries were analyzed, dental services explained 3% of the ratio in DMF changes during the 70's, while social factors (including or not fluoride bearing toothpaste) explained 65%. In a second study, covering 200 health districts in England and in Whales, caries were significantly reduced in 5 year old children, opposed to the fact that these children have received very little dental care. Thus, dental services could not have contributed significantly to the reduction of caries in this age group. Among 12 year old children, in 1985 and 1988, the variation in DMF of 19% and 30%, respectively, was explained by dental services changes, and 38% and 48% respectively by wide social factors.

In health centers, the differences among municipalities in relation to changes in caries indicators in 12 year old children from 1974 to 1988, were less influenced by dental services than by macro-social factors. In the study of electoral zones in Lancaster, dental services did not explain the DMF changes of 5 year old children in 1989, while 29% of this variation was explained by wide social factors. Just like in the study of the 200 health districts in England and in Whales, little dental activity was directed to 5 year old children in Lancaster, pointing that dental service can not be considered a key factor to explain this age group low DMF in this district.

This study concludes that dental services have contributed relatively very little to the decrease of caries. Possibly, the most important contribution of dental services was the change in diagnostic and treatment criteria. "It is not a criticism to clinical dentistry to say that it has less effect on oral health than wider macro-social factors and non-personal social services. The role of dentistry in the improvement of oral health depends mainly in the performance of indirect services", concludes Paulo Nadanovsky.

Mailing address:

Department of Epidemiology and Public Health

University College London Medical School

65-72 Grower Street, London WC1E 6EA


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