PREVENTIVE

MEDICINE

5,

149-164 (1976)

Prevention in Oral Health Problems: Social Behavioral Aspects MATA Division

of

K.

NIKIAS

Sociomedical Sciences, School of Public Health, and Center for Community Health Systems, Columbia University, New York, New York 10032

The potential of prevention in oral health is perhaps greater than in any other health area. A real possibility exists that by applying the combined measures now at hand, the two main dental diseases-dental caries and periodontal disease-can be prevented. Major preventive techniques include tooth sealants, fluorides, plaque removal, and diet modification. If these measures are to fulfill their potential they must be appropriately delivered and accepted by target populations. The present paper reviews issues and data on social-behavioral aspects as they apply to potential preventive approaches. The current status of school-based experimental programs for preventive services and dental health education is discussed. Self-applied procedures, such as supervised fluoride mouth rinsings, are receiving much consideration because of effectiveness and cost/benefit advantages. School dental health education projects utilize teachers and behavior modification techniques for teaching the effective performance of oral hygiene procedures to children. Such innovative approaches have provided short-term changes in behavior and oral status, but long-range behavioral effects are uncertain. Adequate data are lacking as to the extent, nature, and effectiveness of preventive practices of dentists. The most important factor in the success of dental prevention is the population’s compliance with preventive regimens which currently require conscientiously applied home routines and changes in eating habits. Thus the importance of developing and applying knowledge on socialbehavioral aspects of preventive approaches should be recognized.

INTRODUCTION

The problems of oral health are usually grouped into the following major categories of disease entities: dental caries; periodontal disease; oral-facial malformations and malocclusions; soft tissue lesions including oral cancer; and other diseases and disorders, e.g., systemic diseases with oral manifestations. Dental caries and periodontal disease are, however, the major areas of concern because these two dental problems and their sequellae account for the major suffering, tooth loss, and commitment of dental resources in the private and public sectors. Furthermore, these two oral diseases are now the most preventable if we apply the combined measures now at hand. In fact, James Carlos, Associate Director of the National Caries Program of the National Institute of Dental Research, said that the elimination of caries as a significant public health problem, which 10 years ago was an optimistic hope, is now a realistic expectation (9). Thus, the discussion of dental disease prevention in the present paper will apply to preventing the onset and controlling the progress of dental caries and periodontal disease; the main focus will be on factors involved in the delivery and acceptance of dental preventive measures by the general public. Dental caries is a localized, progressive decay of the teeth starting with demineralization due to acids produced by bacteria that ferment dietary carbohy149 Copyright All rights

@ 1976 by Academic Press, Inc. of reproduction in any form reserved.

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drates. With the progressive loss of tooth substance, cavities form which extend if untreated, destroy the tooth, and lead to tooth loss. Research, especially during the past 10 to 15 years, has provided considerable knowledge of the causes of caries, substantiating the etiologic importance of micro-organisms, dental plaque (tenacious mats of bacteria adhering to the tooth substance), and sugars, especially sucrose. Dental caries is almost universal in the United States. It reaches its peak in late adolescence to early adulthood and is the major cause of lost teeth before age 35, when periodontal disease begins to supervene. Periodontal disease is a disease of the tissues supporting the teeth. In its incipient stage, it is an inflammatory process involving only the gingivae. If unchecked, there is detachment of the periodontal fibers, bone loss, formation of gingival pockets, and the tooth becomes loose, extruded and lost. It is an ailment of major proportions in the adult population and has a strong positive correlation with age. While several interacting factors may be involved in the initiation and progress of the disease, recent laboratory and epidemiologic research has established that the major etiologic factor and major influence in the progress and severity of disease is the bacterial plaque. The primary techniques currently available for primary prevention are: fluorides administered systemically and topically; adhesive tooth sealants; plaque removal; and diet modification. Fluorides and sealants aim at preventing caries, while plaque removal and diet modification are expected to prevent both caries and periodontal disease. Another especially important characteristic of these preventive measures for their delivery to the public is their separation into those that are self-applied and those that are applied by, or under the direct supervision, of health professionals. Examples of the former (with and without supervision) are the fluorides which, in addition to community and school water fluoridation, can be applied topically through use of fluoride-containing dentifrices, toothpastes, mouth rinses, gels, and chewing gums; removal of plaque through brushing, flossing, disclosing, and use of periodontal aids; and diet modification. The significant cost-benefit advantage of self-applied vs professionally applied procedures for effective mass prevention is, of course, obvious. Adhesive sealants, recently used to seal pits and fissures of the occlusal surfaces of teeth for caries control, must be painted on the teeth by a dentist or some other qualified person. Their application requires a meticulous technique with strict conditions of dryness and freedom from contaminants in the mouth. Additional descriptions of the characteristics of dental diseases, elements of the scientific basis for their prevention, a comprehensive picture of currently available preventive measures, and of possibilities for the development of new methods’ have recently appeared in a monograph sponsored by the Fogarty International Center of the National Institues of Health (10). An additional purpose of this publication was to call attention to the essential area of implementing dental preventive methods by both the health profession and the public. Several options are apparently now available for application in large-scale pub1 Such possibilities are: new topical fluorides and techniques; antimicrobials and enzymes; dietary substitutes and additives; trace elements; and immunization (development of caries vaccines).

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lit health programs for preventing caries and periodontal disease. Some possibilities are supervised mouth rinsing and/or plaque control programs at school and place of employment; self-applied procedures and diet modifications at home; and visiting dentists for application of sealants and of other preventive procedures. How then should decisions be made about optimum approaches for target populations, given the knowledge and resources available? We believe it can be shown that there are economic, political, administrative, and social psychological factors which are very important in the success of any mass prevention program for dental diseases. Thus economic, political, and social behavioral approaches and methodologies should be used in collecting data and for developing the kind of basic knowledge necessary for optimal delivery and acceptance of the currently available and new preventive measures. The sections that follow concentrate on social behavioral aspects and review issues and research findings relevant to some approaches and dimensions involved in preventing dental problems in the population. DENTAL

PREVENTION

IN SCHOOLS:

STATUS AND ISSUES

There is widespread professional consensus that prevention should start with children and that the school setting has the greatest potential for successful delivery of dental preventive programs. In the United States, however, the delivery of preventive services in schools is still, to a large extent, at the state of clinical trials. For over two decades, small and large samples of children, classes, and schools have been used for carefully controlled field trials to test the effectiveness of various means of preventing dental disease (32). Self-administered procedures have received the most consideration and study, the most notable examples being supervised fluoride mouth rinsing and tooth brushing. In the clinical trial model, however, the constant and close supervision of schoolchildren is a necessary prerequisite for monitoring the clinical results. These field clinical trials are also carried out with the stipulation that only children who volunteer and for whom informed parental consent has been acquired can be used as subjects. Thus there are still many unanswered questions relating to the feasibility, cost, and acceptability of these programs in real life situations. For example, there are now indications that programs using fluoride mouth rinses under supervision at schools may be the method of choice for wide-scale application in the future. Some reasons given for such preference are that they have been found effective in preventing dental caries; the procedure requires little time and few materials and supplies; and nondental personnel with minimal training can supervise the procedure, thus making it inexpensive (3 1). Yet no proposals have been advanced among those in the fields of dental research, public health, and dental care delivery about certain important issues relating to large-scale implementation. For instance, what kinds of agencies and individuals should be approached for sponsoring such preventive programs in schools on a regular basis-the Board of Education, the Parent Teachers Association, the City Council, the State Legislature, the Dental Society, the school principal, or all of these at the same time? Should supervisors be teachers, dental auxiliaries, or community workers, or should such decisions be left up to each community? How high will

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the cost be, and who will pay for it? How can dental disease prevention programs be sold to communities and their officials? The specific savings realized by the alternative means of prevention have, so far, not been documented fully. Investigations to analyze cost-effectiveness aspects of various preventive methods are at an early stage (18, 19). Even after one documents the monetary savings resulting from preventing rather than treating dental problems, cooperation in, and acceptability of, school-based programs may depend on how dental health ranks in the priorities of influentials. There are, of course, examples of schools in which clinical trials are being conducted. In most of these cases, education authorities, teachers, pupils and state directors have cooperated well. Yet the favorable experience of schools undergoing clinical trials cannot be extrapolated to the whole school system. There are doubts as to whether schools in urban centers and ghettos, with teachers overworked by teaching, paper work, and administrative duties, will cooperate in a permanent mouth rinsing program unless it is designed to be handled easily along with their other duties. School authorities may view a dental program on a regular basis as diluting the educational function of the school. Finally, acceptability of the preventive agent by the ultimate recipients themselves, their parents and the dentists in the community cannot be predicted. It is conceivable, and there have been reports that differences in taste and in vehicles such as rinses, tablets, chewing gum and gel may influence resistance or cooperation (30). At this point it is not known whether children who do not bring parental consent slips during the current trials or who drop out from a program, do so because of the taste, the inconvenience, their dentist’s objection, or simply because they lost the slip. Systematic study is needed here to determine whether or not these are real problems and to plan for their circumvention. The case of supervised mouth rinsing programs in schools was used as an illustration with some detail because it is probably the measure closest to completion and delivery. It is also significant that during the past year the National Caries Program of the National Institute of Dental Research, went beyond the clinical trial stage to include support for the establishment of a nationwide array of school-based demonstration mouth rinsing projects for the prevention of caries (44). It is hoped that these feasibility studies will provide the first needed data for developing guidelines and assessing costs for future wide-scale application of such preventive programs. If there are difficulties with implementing supervised methods at schools, classrooms can always be used merely for distributing the preventive agent and persuading the students to use it on their own at home or at school. In this case, the problem has different’and added dimensions and falls under the topic of school dental health education, which is the next substantive area that we will discuss. Some of the extensive relevant literature and recent study findings are summarized because such data and their interpretation seem to be of immediate usefulness for policy making and program planning in preventive dentistry for schoolchildren.

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EFFECTIVENESS OF SCHOOL DENTAL HEALTH EDUCATION-STATUS OFRESEARCH All schools have now or have had some teaching of dental health. A typical program usually consists of a single lecture-demonstration once a year, including identification of teeth, methods for brushing, and (recently, perhaps) flossing, with the aid of an enlarged toothbrush and model of teeth, admonition to eat proper foods, and instructions to brush after each meal and to see a dentist twice a year. However, conclusions from surveys of school dental health education programs are that while most schools were engaged in teaching dental health, the dental health practices and actual dental health status of their pupils were remarkably poor (15, 20). We probably know more about the development and the state of the art of research in school dental health education than in any other dental field because impressive reviews and assessments have been published recently (28, 54-56). Interestingly, one of these reviews notes that the 17-year period from 1953to 1970 brought forth at least 106 publications on this topic, 25 of them reports or surveys, 55 experimental studies, and 26 essays (55). The earliest research work was mainly exploratory surveys to determine the knowledge and interests of children, to motivate them better, and to design methods and materials for use in teaching dental health. At about the mid-1%0’s and after, the development of staining methods and the construction of gingival and oral hygiene indexes--e.g., the Loe & Silness Gingival Index (40) and the Greene-Vermillion Simplified Oral Hygiene Index OH1 (26), there was a great movement toward experimental studies. The focus here was to teach children to perform oral hygiene activities and evaluate the results by using objective oral status indicators rather than only self-reports. Questions asked were: Can tooth brushing be taught effectively? What is the effect of knowledge on oral hygiene and preventive practices? What kind of message should be given? To what extent should the message arouse fear? Results began to show that knowledge of dental facts or of what the children should do was not followed by actions. In the few instances where the experimental effort was to change the children’s practices through the route of behavior rather than through the route of knowledge, there was a change in behavior. Children started brushing and complying with recommendations. However, while there was some degree of improvement immediately following or concomitantly with the end of the program, either there was no follow-up evaluation to determine whether the improvement was sustained, or, when there was follow-up, in the majority of instances children had regressed after a lapse of time. This seemed especially true for children below 14 years. Such results show that the use of systematic evaluation of both planning of programs and analysis of their outcomes is one of the greater needs in developing effective school dental health education programs. Some further suggestions which emerged from recent thoughtful assessments (28, 54) relate to the need to transfer the care setting from school to home in order to maximize the likelihood that the newly changed behaviors will be

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retained. This need may require parental involvement in the conduct of school dental health education as well as educational approaches which provide followup and reinforcement over time until the newly acquired habit is firmly established. The principles and techniques of behavior modification may provide a promising approach for dealing with such problems. Following up on some of the recommendations mentioned above, some recent pilot, experimental, or research programs at schools have employed instruction and performance in modern preventive dental techniques and practices. Children are taught not only tooth brushing but also plaque disclosing and flossing, and the use of phase microscope and plaque light for understanding plaque formation and removal. Some projects in their educational approach rely on the teachers’ active participation, use behavior modification principles and techniques, set their program goals and evaluation criteria in terms of behavior change and habit formation, and measure outcome by clinical indications of changes in oral status. A selected review of such projects and of their results follows. The “Cleveland programs

System for Dental Health Education”

and the “Toothkeeper”

Two programs which have received publicity and attention recently are the “Cleveland System for Dental Health Education” developed by Clark and Fintz (12, 13) and the “Toothkeeper” programs. Both of them utilize teachers who are trained first and are then expected to transfer the information and techniques to the class. In the Cleveland program, teachers were trained by a dental consultant in a 6-hr session and then they trained their pupils for the rest of the program. During the first week for 1 hr each day, children were instructed, brushed and flossed, and their plaque was disclosed. During the second week, reinforcement of the technique was given about 1%hr each day for five consecutive days. For the remainder of the school year, self-reinforcement was encouraged for 10 min each week. The children were also encouraged to transfer the preventive information to other family members. Clark and his group have reported that after 14 months, the 122 children in the study group showed a significant reduction in plaque scores as measured by the Patient Hygiene Performance Index (PHP) (5 I), while scores for the 155 children in the control group were insignificantly lower. Furthermore, PHP scores for the study children remained low during the 6 months after instruction and reinforcement activities were terminated (14). The “Toothkeeper” is a commercially produced dental health education package containing guides and a variety of other educational materials and oral hygiene equipment and supplies to use for training teachers and pupils in supervised brushing, disclosing, and flossing in class. It takes a total of 16 weeks, with 30-min class sessions daily the first 3 weeks, gradually reduced to 15-min sessions three times a week for the remaining weeks. The program was used originally in the Alamo Heights schools in San Antonio, Texas (42), involving 36 teachers and 1,100 elementary students, and later in Texarkana, Texas, involving over 5,000 students (22). The effectiveness of the program in these two instances was assessed only by examining subsamples of participating students at the beginning and the end of the program and finding some improvement in dental status and be-

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havior. Since such assessments did not include control groups, the validity of the results was seriously questioned (52). Therefore, controlled clinical studies to evaluate the effectiveness of “‘The Toothkeeper” were undertaken recently in at least five separate sites of the country. One study was conducted by Evans and his group in Houston among elementary school students during the 1972-1973school year. The study, which had 118children in the experimental, and 95 children in the control group, concluded that children participating in the program did not improve in their gingival health or oral hygiene status. This conclusion was based on clinical measures obtained at the completion of the 16week program and again after a second 16-week period (57). A second evaluation was carried out in Vermont and used 78 test children and 77 control children 9 to 10 years of age. It was reported that the test and control children showed similar changes in dental health and that there were no beneficial carry-over effects in dental health observed from baseline to 32 weeks (58). Another evaluation of the “Toothkeeper” program was conducted in an elementary school in Flint, Michigan, among children 5 to 12 years old during the 1972-1973 school year. The evaluation was a comparison between a traditional information-oriented “show and tell” approach given to 192 children and the “Toothkeeper” program, which is a “show-and-do” approach, given to 217 children. Clinical measures obtained after 4 and 7 months indicated that meaningful plaque reductions were not demonstrated by either the traditional or the “Toothkeeper” programs (25). Two more recently reported “Toothkeeper” evaluation studies also yielded negative results. One was carried out among 75 experimental and 75 control children in the fourth and fifth grades in Roanoke, Virginia. Although the experimental group initially showed some improvement in their gingival and plaque scores, 9 months later the experimental group was not different from the control (21). Another study used control and experimental groups from the second, fourth, and sixth grades of an Army dependents’ elementary school. Results showed no significant differences between experimental and control groups for grades two and four. The grade six experimental group had significantly lower plaque scores than the corresponding control group, but this was not maintained in the 16week follow-up trial (11). Possible reasons for the ineffectiveness of the “Toothkeeper” program have been discussed, but it is rather clear that this packaged dental health education program for schools requires modification and further evaluation before it can be recommended for large-scale adoption. Behavior Change Studies in School Settings Several studies using a variety of educational approaches aimed at changing behavior have provided interesting and potentially applicable, albeit somewhat inconsistent, results. A project among second-grade schoolchildren in Minnesota tested [he utility of a behavior modification approach using token rewards and prizes as well as discovery learning through individual “contracts.” It found that the average plaque reduction of 30% among 169 children in the project group was significantly greater than the average plaque reduction of 15% for the 162 children in the control group. Furthermore, the study children continued to maintain lower

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plaque scores than the control over a 6-month period without further reinforcement or tangible incentives (41). Another study tested a “project learning” approach and a “token economy reward system” in 16 classrooms of children, ages 6-12, in Roxbury, Massachusetts. Plaque scores 6 months after the last educational intervention suggested that among first and second graders neither the “project learning” nor the “token economy reward system” was effective; the “project learning” approach was totally ineffective (33). In an ongoing study as part of the Buffalo Caries Project, seventh grade students of the Buffalo schools were assigned to four different groups of about 50 students each. Group 1 served as control, Group 2 received traditional oral hygiene instruction, and Group 3 received a variation of Rokeach’s belief congruence approach, which attempted to arouse dissatisfaction with the inconsistency between values and dental behaviors. Group 4 received a version of the behavioral-rehearsal approach of Meichenbaum. Here the desired behavior was inserted as part of a series of behaviors in the subject’s daily routine, and the individual visualized and mentally rehearsed each behavior in the list. Tooth brushing and flossing were inserted as salient activities before going to bed. Some initial results showed that only Group 3 differed significantly from the control group at the 12-week evaluation. It was also noted that Group 4 students did not like the rehearsal procedure. Unfortunately, the magnitude of changes in plaque was not clinically significant and probably clinicians looking for immediately applicable techniques for inducing changes in oral status will not be entirely satisfied with these results (17). Borrowing principles from learning theory stating that acquisition of behavior occurs through observation of suitable models, a few studies have recently explored the influence of leaders and of peers as models for teaching oral hygiene practices. One study tested the hypothesis that classroom leaders serving as behavioral models would influence adoption of brushing behavior by their classmates among 965 children in 35 third-grade classrooms in 11 schools in an eastern North Carolina county. The hypothesis was not substantiated after 10 days of trial (50). A smaller scale controlled study among 30 dental students in an Australian dental school reported that students changed oral hygiene behavior through exposure to the modeling influence of a small group of peers. The change was maintained 18 weeks after exposure to the modeling influence (45). A promising study, which is currently under way at the Department of Behavioral Sciences at the University of Connecticut, will compare group discussion methods for changing attitudes and behaviors with individual contingency management methods as a means for increasing compliance among 300 seventh graders in Hartford. The study uses a caries-preventive procedure requiring low effort (children must come to their own school three times a year for topical fluoride application) and one requiring high effort (children must use a fluoride mouth rinse at home 5 days a week for 6 months) (36). Another group of experimental studies in school dental health education used fear appeal for changing attitudes and behaviors. The findings are rather inconclusive. Haefner found that strong fear appeals were more effective than mild appeals in changing reported tooth brushing habits among school children (27). Ramirez found that all appeals were equally effective in behavioral measures of oral

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hygiene (53), and another study (6) reported that the two-sided communication (both high and low fear together) was more effective than the one-sided. It was also noteworthy that in the latter study all three persuasive appeals combined were not significantly more effective than no appeal at all. It appears that the nature of the appeals is not as important as the length of the communication, the clarity of the recommendation, the specificity of the required behaviors and interpersonal influence. In addition to the message characteristics, the characteristics of the communicator, such as his credibility, have been noted, in general, as important in effecting attitude and behavior change (5). However, in the dental health education field there are no empirical data on the differential impact of classroom teacher, dentist, hygienist, community worker, etc. on acceptance and application of preventive practices. There is no agreement, either, as to the importance of the communication source among researchers in this area (54). In summary, the state of the art of research in school dental health education aimed at effecting behavior changes and new habit formation suggests that school-based programs using innovative educational approaches have provided at least short-time changes in oral hygiene behavior and oral status. There is less certainty about their long-range behavioral effects. PREVENTION

THROUGH

DENTAL PRACTICE

There is no doubt that another major source for delivering prevention to children, as well as adults, is the dental practitioner. There is little information on what practicing dentists currently know about the new preventive methods, how much they believe in them, are using them, or recommend them for use to their patients. Some useful relevant data are being collected and will continue to be available from a nationwide survey on the “Role of the Practicing Dentist in the Delivery of Caries Prevention Methods” carried out by the American Dental Association Health Foundation, supported by the National Caries Program of the National Institute of Dental Research (7, 8, 23). According to initial reports from this mail survey of 4000 dentists, with an 87% response rate, dentists seem to have increased their use of topical fluorides over the years and they show a stability in their concerns regarding oral hygiene education and improving patient attitudes toward routine and preventive dental care (23). Dentists differ in their preventive practices from one region of the country to the other. For example, dentists in the mid-Atlantic region give plaque education least, those in the mountain region give plaque education most often, and those in the south Atlantic region give flossing instructions more than those in any other region. Also, dentists in regions with high caries incidence are weak supporters of preventive measures, and those in areas with moderate or low caries incidence are strong supporters (8). However, the whole area of dentist-patient relationship-its types and its effects on the patient’s compliance and preventive behavior-has been untouched by research in contrast to the physician-patient relationship. In her comprehensive review on health education for adults, Young notes that, “In a recent review of the literature on primary and secondary prevention in the dental health field, not a single study was found related to the effectiveness of the time spent by the dentist in educating patients in good oral hygiene practices” (63). Recently, Tryon

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surveyed 1,020 general dental practices in Connecticut to determine the amount of practice effort devoted to preventive dentistry and the scope of the services provided. He found that only 7% of the total practice effort was expended on providing preventive dental services. A small percentage of dentists never perform certain preventive services, most notably, oral hygiene measures and diet analyses and counseling (60). Some further knowledge on the topic can be obtained indirectly from reports of patients. These suggest that patients do not credit their dentist as a principal source of preventive information. For example, in a study of about 200 dental patients in North Carolina, 55% had received professional brushing instructions, but 80% never had the opportunity to practice brushing in the dentist’s office with evaluation by the dentist or assistant. Only 8% remembered receiving disclosing tablets to show plaque; 26% being told that their home care was inadequate; and 22% receiving a toothbrush. The majority of respondents (78%) said they had learned why they should brush from a nonprofessional source. Despite the paucity of data, it is probably safe to say that there is little patient dental health education conducted in most dental offices today. Some think it is understandable because dentists have been educated to think in terms of therapy, repair, and restorations with little emphasis on education and prevention. There is also some evidence indicating that a major aspect of oral hygiene education in the dentist’s office might be the ability to generate income from the time spent (24). The extent to which prophylaxis and topical fluorides are delivered may also depend, in areas and populations with dental insurance, on whether or not such services are covered by the insurance plan. Recently, however, two new elements are emerging: a) the establishment in dental schools of departments of preventive dentistry to train students in the procedures of delivering preventive dentistry; and b) the preventive dentistry movement in private practice. Much of the enthusiastic support for preventive therapy has been developed through the efforts of highly motivated clinicians and strong believers in the effectiveness of preventive programs. These practitioners have formed a professional society, advanced the preventive ideas from platforms across the country, present impressive case histories and claim universal success in their practice of prevention. Neither the means for achieving such claimed successes nor the validity of the claims have been studied systematically so far. Although there are some variations among dental offices in the preventive dentistry regimen, there are many common principles and procedures, such as the patient’s education, motivation, and instruction in the skills of plaque removal. The latter is achieved by proper tooth brushing, plaque disclosing, and use of dental floss and other aids for removing the plaque from interdental spaces. There is also diet counseling, evaluation, and reinforcement. The program is delivered in a series of visits (usually five or six) often closely spaced in the beginning, and widely spaced at later stages of the program. The spacing of the visits is governed by underlying assumptions regarding the psychology of initiating and establishing a daily habit. It is recognized that the success of the program depends on the person who instructs the preventive dentistry. This person may be a dental hygienist but is most often a specially trained dental assistant called “control

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nurse, ” “preventive therapist, ” “oral health instructor,” or “preventive care educator.” Could the movement for prevention in private practice be used for the spread of modern and new preventive programs? The answer to this question must wait for the evaluation of such private practice programs and of dentists’ effectiveness in inducing preventive behavior in their patients. Furthermore, dentists in the preventive dentistry movement are not typical practitioners, and form only a small proportion of their profession. There is also some indication that even these selective practitioners are falling short of what they should be doing for prevention. For example, members of the American Society for Preventive Dentistry who attended their 1972 annual meeting were surveyed about the type, quality, and quantity of their preventive programs. While 98% indicated that they practiced preventive dentistry, only 36% were found to have a satisfactory program according to the evaluation criteria developed by the researchers. The responding dentists showed great variation in their estimates of rates of success and attributed the cause of failure to patient apathy (1). Despite the lack of adequate data, it can be stated fairly reliably that at this moment the profession is not yet ready to deliver prevention. Further support of this belief is given by experiences of prepayment plans which offered plaquecontrol coverage as a new benefit. Administrators from at least two plans report that after considerable time the number of claims tiled by dentists for preventive services, including formal plaque-control, was negligible (49). PREVENTIVE

BEHAVIORS

OF THE POPULATION

Perhaps the most important factor of all in the success of preventive approaches, now available or to be developed in dentistry, is the response of the population. For example, in order to have preventive agents applied by dentists, people must visit the dentist for this purpose. They must also comply with the preventive dentistry regimens recommended by the dentist, his auxiliaries, or some other dental health education source. These regimens currently require conscientiously applied routines at home for the scrupulous removal of plaque or for self-application of other agents, as well as changes in eating habits. Thus, the ideas about compliance in preventive behavior and emphasis on operational indicators which have been receiving increasing attention in the general health field are also relevant in the dental field. While some research data are available for some aspects of preventive behavior, aspects of compliance and habit formation as they apply to dental health are almost totally unresearched. A recently used definition of preventive dental behavior in a symposium on dental research included a) visiting the dentist periodically on a routine basis; b) brushing at appropriate times and intervals; c) control of plaque through use of other mechanical procedures; and d) maintenance of low cariogenic diets (38). The factors relating to visiting the dentist for the usual as well as for preventive purposes have been recently reviewed comprehensively and thoroughly by Kegeles (37). Unfortunately, while this valuable review is recent, the data reviewed are not. This lack of updated knowledge regarding these potentially changeable behaviors is most likely due to lack of financial support for research in the past several years.

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In general, people visit dentists infrequently-much less often than we know-they should, given the prevalence and distribution of dental problems. At the national level, about 47% of the population visit a dentist at least once a year (43). A much smaller proportion, however, (about 25 to 30%) visits a dentist on a routine periodic basis (46). Social science researchers tried to differentiate empirically those who visit the dentist preventively from those who made dental visits only when they have symptoms. The most persistently explored variables are four perceptual factors or beliefs borrowed from social psychological theory and delined originally by Kegeles as follows: a) the individual must feel susceptible to the disease; b) he must believe that the disease would have serious consequences for him; c) he must believe that the need to take action is more important than a variety of other things he might do; and d) he must believe that the action to be carried out is effective (34). These variables have since been used in several studies for explaining preventive dental visits and tooth brushing practices (4, 29, 35,59). Findings are mixed in regard to the relation of each to observed behaviors. It seems that the more beliefs a person has, the more likely he is to visit the dentist preventively, but the data regarding the relation of these variables to tooth brushing are minimal and unclear. Sociodemographic and cultural factors have also been explored for their relationship to dental care practices. The most consistent and marked relationship is that between social class indicators and making dental visits, in general, as well as on a routine periodic basis. Preventively oriented visits to the dentist have a strong positive relationship to income, education, and occupation. Age, sex, race, cultural, and ethno-religious characteristics have also been found to be associated with routine use of dental care. Younger persons, women, members of the white majority group, and Jewish groups are more likely to seek dental care routinely than older persons, men, persons in minority groups, and religious groups other than Jewish. It should be noted that although the greater purchasing power of groups in high socio-economic levels than in low may be a factor in accounting for their greater use of dentists, this is not the only factor. For instance, under dental prepayment or in situations where the economic barrier is reduced there may be increases in use of dental care, but the patterns of variations do not change (47). Regarding home and self-care activities, there are no systematic data according to sociodemographic characteristics. It appears that tooth brushing is, in general, the single preventive activity followed by a large proportion of the general population. Data used from three nationwide interview surveys show that about 60% of the United State population reported that they brushed their teeth at least once a day (16,29). Furthermore, according to 1965data, 88% of the people interviewed had heard or seen something about toothpaste containing fluoride, but two-thirds had never heard anything about painting the teeth with a fluoride solution to cut down tooth decay. Women were invariably found to state that they brushed more than men, but the consistent social class variations found in dental utilization and dental check-ups did not obtain in brushing (48, 61). Data are not available to indicate status and pattern of other home care activities such as self-removal of plaque, use of mouth rinses, and diet modification. Some recent preliminary findings from a nationwide study show that from a na-

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tional sample of 1,613 U.S. adults questioned, only 24% have ever heard or read about dental plaque and only 20% have ever been shown at a dental office how to make sure they are cleaning their teeth completely. Similar results were reported from interviews of a sample of 78 patients coming to a dental school clinic. When asked if they knew about plaque, 63% had never heard the word at all. A question about the knowledge and use of disclosing tablets had to be dropped because there were hardly any positive responses (39). It would appear that daily mechanical plaque removal continues to be a behavioral innovation without much diffusion to the population at large. Successes reported in preventive programs of private practitioners may often reflect efforts toward selected patient groups who are already motivated to take individual action regarding their dental health. It may also be that the new behavior regarding oral hygiene routines is not maintained sufficiently long to become more generally widespread. There is total lack of knowledge about kinds of persons who enter into preventive programs and about the types of persons who continue and why. Research in the long-term compliance and effectiveness of dentists’ preventive programs is long overdue; now that patient populations of sufftcient size can be identified, such research can become a practicality. We have no information, either, about the extent to which people have reduced intake of carbohydrates or have made other changes in their diet to reduce dental disease. While it is possible that some people currently use beverages sweetened with sugar substitutes, their motive is probably weight control rather than dental disease control. There are indications that dental preventive behavior is not unidimensional (4, 61, 62). Of the several dimensions and health actions, only some may be interrelated. Visiting dentists for check-ups and habits related to tooth brushing, flossing, and eating do not necessarily go together and may not be influenced by the same set of economic, social, and psychological factors. Therefore, research should explore the different preventive behaviors separately as well as their interrelationships. The need for acquiring and disseminating research results about social and behavioral aspects of prevention is as important as that for biologic and clinical aspects, if the potential benefits of prevention are to be realized for everyone. REFERENCES 1. Akst, H., De Marco, T. .I., Meclorsky, F., and Resnick, J. A profile of clinical preventive practice. J. Amer. Dent. Assoc. 87, 857-862 (1973). 2. Allen, D. L. Oral practices of dental patients in North Carolina. J. N. C. Dent. Sot. 52, 16-23 (1969). 3. American Dental Association. Few had heard of plaque. Dent. Abst. 18, 516 (1973). 4. Antonovsky, A., and Kats, R. The model dental patient: An empirical study, of preventive health behavior. Sot. Sci. Med. 4, 367-380, (1970). 5. Aronson, E., and Golden, B. W. The effect of relevant and irrelevant aspects of communicator credibility on opinion change. J. Abn. Sot. Psycho!. 67, 31-36 (1%3). 6. Barnes, K. E. The effects of various persuasive communications on community health: A pilot study. Card. J. Pub. Health 62, 105-109 (1971). 7. Bognore, R., and Gift, H. Characteristics of Preventive Dentistry in Fluoridated Areas. Presented at the 53rd General Session of the International Dental Association, London, England, 1975. Abstract No. L 146. 8. Bognore, R., and Schaid, K. Characteristics of Preventive Dentistry in Private Practices by

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