1

Components of a Balanced Diet; [Safe-food (EU)]

In HBSC surveys from 1997/1998 of children it was found;

Daily potato crisp eating in Ireland was the fourth highest internationally in the 11, 13 and
15 year old groups.
In the 11 year old category, Ireland was the third highest internationally for daily
consumption of sweets or chocolate, and this rose to second highest in the 13 and 15 year
olds.
In the consumption of soft drinks, Ireland scored fourth highest in all three categories.
Healthy Ireland 2013

Prospective campaign from 2013-2025 which aims to increase the proportion of people who
are healthy at all stages of life, reduce health inequalities, protect the public from the
threats to health and wellbeing, and create an environment where every individual and
sector of society can play a part in achieving a healthy Ireland.
The ethical side of this campaign aims to establish equity, fairness, proportionality, openness
and accountability, solidarity and sustainability.

Determinants of Health and Epidemiology;

By 2020, the incidence of type 2 diabetes and cardiovascular disease is expected to rise by
20-30%.
Many people living in Ireland are affected by chronic diseases and disabilities relating to
poor diet, smoking, alcohol misuse and physical inactivity.

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Employment of health is not evenly distributed in society, with prevalence of chronic

conditions and accompanying lifestyle behaviours being strongly influenced by socioeconomic status, levels of education, employment and housing.
Age
Gender
Overweight and obesity (malnutrition);
In Ireland, 61% of adults and 25% of 3-year-olds are overweight or obese, 26% of 9year-olds have a BMI outside the normal healthy range.
3 in 4 people over 50 years of age are overweight or obese.
BMI, cholesterol and blood pressure are highest among low socio-economic groups,
and poorer and lower educated individuals were among the highest.
9% of 3 year olds in low socio-economic groups are obese compared to 5% in higher
groups. 1/5 of children in all classes are overweight.
Obesity is the leading cause of cancer in non-smokers.
Smoking;
There are 1 million smokers in Ireland.
12% of children 11-17 years old smoke.
1 in 2 smokers will die of a tobacco-related death.
Alcohol and Drugs;
Alcohol consumption rate is one of the highest in Europe at 11.9L per capita in
2010.
Higher alcohol consumption also contributes to obesity.
Alcohol also contributes to half of all suicides.
Use of illegal drugs in 2013 is at 7% of adults 15-64.
Drug use was the direct and indirect cause of 534 deaths in 2008, and this included
deaths associated with heroin, benzodiazepines, methadone, and medical and
trauma deaths.
Exercise;
Younger children are more involved in vigorous activity more than 4 times a week.
These figures decrease with age to about 50% in boys and 25% in girls.
42% of adults engage in some form of physical activity, this decreasing with age.
Accidents;
Children reported more sports injuries.
In relation to car accidents, more girls than boys wear seatbelts.
The majority of accident-related injury in young adults is sports injury.
The majority in 35-54 are work-related.
55 years and older are mainly implicated in garden and home injuries.
Dental Care;
Oral hygiene was inadequate amongst children, less than 50% of boys brush their
teeth more than once a day.
Dental procedures are more common among social classes 1 and 2 and these classes
retain their own dentition more than classes 5 and 6.
Socio-economic and Environmental Factors;

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7-10% of the Irish population is living in poverty. This group encompasses the
educationally disadvantaged and those with income inadequacy.
Individuals in social class 5 (semi-skilled) and class 6 (unskilled) were more likely to
participate in activities that could adversely affect their health.
Lower socio-economic groups and long-term unemployed groups have barriers to
participation of formal and informal education systems-implications for achieving
good health.
Early school leaving correlated with long-term unemployment and ill-health lifestyle
practices.
Poor literacy skills shield opportunities in an information-based society-limiting
access to health information and services.
Housing and water includes industrial by-products and changing lifestyle which
influences air, water and food quality. Provision of water supplies, roads and
housing as well as maintenance of air quality.
Mental Health;
It is expected that depressive mental illnesses will be the leading cause of chronic
disease in high income countries by 2030.
In Ireland the mortality rate from suicide in the 15-24 group is the fourth highest in
the EU and the third highest among men 15-19.
Levels of depression and admissions to psychiatric hospital are higher among less
affluent groups.
Sexual Health;
12 births per 1000 in 2011 were of mothers 15-19 years of age.
In 2011, there was 13259 notifications of STIs, and chlamydia trachomatis
accounted for 48.3% of these.

Determinants of health (Adapted by Grant and Barton 2006);

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Current initiatives;
Healthy Ireland 2013-DOHC;
1. Focusing attention on risk factors and affective interventions of key transition periods in
peoples lives.
2. Reducing gaps between highest and lowest income groups. Targeted interventions that
address the specific needs of at-risk groups.
3. Protecting the public from threats to health and wellbeing. The 2009 H1N1 influenza
pandemic underscored the importance of communities being prepared for potential threats.
4. Creating an environment where every individual and sector of society can play their part in
achieving a healthy Ireland. Many inter-sectoral government
strategies/guidelines/programmes exist for example; age friendly County Programme, The
National Drugs Strategy, Wellbeing in Post-Primary Schools: Guidelines for Mental Health
Promotion and Suicide Prevention.
Strategy for Health Promotion in Ireland (Healthy Ireland 2013)
1.
2.
3.
4.
5.
6.

Governance and Policy

Partnerships and Cross-Sectoral Work
Empowering People and Communities
Health and Health Reform
Research and Evidence
Monitoring, Reporting and Evaluating

The Planning Cycle;

1.
2.
3.
4.

Assessment or Collection of Data

Policy Development
Programme Implementation
Evaluation of Programme
2

Health Care Structure Ireland;

The Government, the Minister for Health and Children and the Department are at the head
of health service provision in Ireland.
The Department's primary role is to support the Minister in the formulation and evaluation
of policies for the health services. It also has a role in the strategic planning of health
services in consultation with health boards, the voluntary sector, other government
departments and other interests. The Department has a leadership role in areas such as
equity, quality, accountability and value for money.
The health boards, established under the Health Act, 1970 are the statutory bodies
responsible for the delivery of health and personal social services in their functional areas.
They are also the main providers of health and personal social care at regional level.

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Health boards are composed of elected local representatives, ministerial nominees and
representatives of health professions employed by the board. Each health board has a Chief
Executive officer (CEO) who has responsibility for day-to-day administration and is
answerable to the Board. The Health (Amendment) (No. 3) Act, 1996 clarified the respective
roles of health boards and their CEOs by making boards responsible for certain reserved
functions relating to policy matters and major financial decisions and CEOs responsible for
executive matters.
In addition, many other advisory, executive agencies and voluntary organisations have a role
to play in service delivery and development in the health system.
The organisation of health provision was altered in 2004 by the Health Act 2004, in which
the HSE was established.

Medical Card Scheme;

Medical Cards allow people to access various health services free of charge.
It is issued by the HSE.
It entitles the holder to; doctor visits, prescription medicines, certain
dental/ophthalamic/aural health services, hospital care, hospital visits, medical and
midwifery care, and some personal and social care.

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A 2.50E charge is applied to prescription medicines dispensed to medical card holders.

The medical card also entitles the holder to; exemption of payment of the health portion of
PRSI, free transport for children to school who live 3miles or more away from the nearest
school, exemption from state examination fees in public second level schools, financial aid
with buying school books.
You may be eligible for a medical card by three means; means testing, on the grounds of
hardship, or by automatic entitlement (ie. you have EU entitlement or are entitled under
other government schemes).
Can also have GP-only medical cards.
These entitle the holder to free GP visits, but only for GP and not for prescribed medicines
etc.
It is tested in the same way as the full medical card, and then a decision made as to which is
more suitable.
Another category of medical card exists for the 70+ medical card. It differs from the normal
medical card as an individual is made eligible by means testing.
The following income limits apply for full medical cards for the over 70s; gross income not
exceeding 500E/week for a single person and not exceeding 900E/week for a couple.
The following income limits apply for a GP visit medical card for over 70s; gross income not
exceeding 700E/week but over 500E/week for a single person, and not exceeding
1400E/week but over 900E/week for a couple.

Health Care Provision;

HSE Dental Clinics (only up to 16yrs); To provide priority of treatment to first/second/sixth

classes, permanent dentition, medical conditions, people with disabilities, preventive
programmes, and orthodontic care for the most severe of cases.
HSE school dental screening programme; Here dentists visit primary schools and examine
second, fourth and sixth classes and grade the childs dental status according to how
quickly they require treatment.
To provide public care; fissure sealant programme, water fluoridation programme, services
for people with disabilities, services for disadvantaged groups, and evaluation of
programmes and their outcomes.
Provision of the Dental Treatment Services Scheme (DTSS) (medical card holders) by the
HSE; which covers the following for adults 16+; emergency treatment, an examination
including radiographs and two fillings per year.
Eligibility for these services is given to; preschool children, primary school children, postprimary school up to 16yrs, adult medical card holders (approx. 37% of population) and
persons in institutions funded by the HSE.
Another scheme is the Social Welfare Dental Benefit Scheme; which is available to anybody
who pays full rate PRSI (class A, E, H and P), people below the age of 21 who have
contributed for 39 weeks, people aged 21-24 who have paid contributions for 39 weeks in
current tax year and 39 weeks since started work, and people aged 25-65 who have
contributed 260 weeks contributions and 39 in current tax year. It entitles the person to one
examination per year.

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DMFT

Was established by Klein, Palmer and Knutson in 1938.

An index for tooth decay of populations.
It uses WHO diagnostic criteria. Largely visible but a CPITN probe could also be used to
accurately feel for softened dentine.
In 2002, the criteria was altered slightly. Underlying shadow in dentine (visual) and
cavitation into dentine (cavitated) were recorded differently by the ICDAS criteria to
enhance the accuracy of diagnosis (D3cvMFT).
A tooth which is recorded with more than one surface filled or decayed should only be
recorded once, otherwise the index is known as the DMFS (in which the number of surfaces
with decay are recorded as opposed to number of teeth).
The missing and filled components were only recorded if they related to decay.
In children this is called the dmft-relating to deciduous dentition.
Advantages; Caries experience and prevalence of an individual and community can be found
out and by using caries experience oral health status can be measured indirectly, the D
component indicates caries morbidity while the M component indicates caries mortality.
Disadvantages; DMFT values are not related to teeth at risk, DMFT can be invalid in older
adults as teeth may be lost due to other reasons, DMFT can be misleading in children who
have lost their teeth due to orthodontic treatment, DMFT index can overestimate filling if
preventive fillings have been placed, DMFT cannot be used for root caries, it doesnt give
account for treatment needs, rate of caries cannot be assessed in terms of how fast it has
progressed or is progressing

Significant Caries Index;

Was introduced to bring attention to the individuals with the highest caries values in each
population under investigation.
The SiC is calculated by first sorting individuals according to their DMFT values.
One third of the population with the highest caries scores is selected.
The mean DMFT for this subgroup is calculated and the value is the SiC index.
Focusing attention to the children with highest scores of DMFT with the SiC Index, will lead
to significant gains for the society and for the person concerned as more specific targeted
preventive actions can be implemented.

Health care policies/reports to improve services/care;

1. The Leyden Report (1988)
A school-based structured and systematic approach to the delivery of childrens
dental health services
Preventive approach
Priority to the permanent teeth
Water fluoridation and fluoride mouth-rinse
Fissure sealants for first and sixth class
2. Shaping a Healthier Future (1994)
Equity; reduced waiting times and increased services for disadvantaged groups
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3.
4.
5.

6.

Quality of service; including clinical audit and consumers perceptions

Accountability; Health Act 1996 provides a legal framework for accountability
A set of oral health goals were set out for 2002: twelve year old children in
optimally fluoridated areas will have an average of no more than one decayed,
missing or filled permanent teeth, and in less than optimally fluoridated areas no
more than 2 decayed, missing or filled permanent teeth.
Working for Health and Wellbeing (1998-2001)
Health strategy (2001)
Childrens Oral Health (2002) DOHC, comparison to older reports
Clinical examination for tooth decay carried out in schools, 19950 children and
adolescents were examined (junior infants, 2nd, 6th and junior cert classes).
71% of the population of ROI has fluoridated domestic water supplies. Northern
Ireland does not have domestic fluoridated water supplies.
The DMFT index was used to measure tooth decay. The modified version using both
cavitation into dentine and underlying dentine shadow was used.
Results showed that as children grow older their caries level increases as the
number of permanent teeth in the mouth increases and the teeth are exposed to
cariogenic foods over longer periods of time. This was reported in both full
fluoridated and non-fluoridated areas, but the decay rates were higher across the
board in non-fluoridated areas.
Oral health goals of 2000 were reached, and in fluoridated areas DMFT of 1.1 was
reached, while in non-fluoridated areas, a DMFT of 1.3 was reached.
In this study, ownership of a medical card was used as a surrogate for
disadvantage in ROI. The data generally supported the published literature, which
asserts that the oral health of the less well-off is worse than that of the rest of the
population.
Although little difference was seen in the proportion of untreated caries in
fluoridated and non-fluoridated groups, there is a difference in the proportion of
untreated caries according to medical card ownership. Ex. In fluoridated areas, 52%
of caries is untreated among those without a medical card and 69% among
dependents of medical card holders. In non-fluoridated areas, 70% of caries is
untreated among MCHs and 55% caries among others.
Oral Health Policy (2014-2017); The Chief Dental Officer is about to launch a process to
devise a new oral health strategy. It will include public, professional and expert group
opinion.

Reasons why dental care is not being attended/problems with health care delivery;
1.
2.
3.
4.
5.

Fear and cost are number one barrier.

Insufficient resources
Insufficient emphasis on prevention and public health
Inequality of distribution of services regionally
Inequitable access for people in certain localities and with disabilities, and for the elderly
and socially disadvantaged
6. Access problems/principles of primary health care not adhered to;
Accessibility; location-how far people have to travel to the nearest dental practise
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 Affordability; having to pay for treatment and indirect costs such as having to take
time off work, travel costs, childcare costs
Acceptability of services; Users and providers of health services have different
expectations of how health services should look and be. A dental study of homeless
people in London found that they would rather use an old shabbier dental hospital
than a new one because they felt the appearance of the older one was more
accepting of their appearance and their circumstances
Accomodation; late night opening, emergency clinics, waiting time etc.
Solutions to the barriers;

Better and equal distribution of clinics, mobile clinics.

Increase the number of dentists.
Increase the efficiency of public transport.
More conducive opening hours.

Principles of the Declaration of Alma Ata (WHO 1978)

Equitable distribution; governments must endeavour to equitably distribute those variables

which influence health.
Community Participation; individuals and communities should participate in all decisions
which affect their health.
Focus on prevention; the focus must shift from medical/dental care to healthcare
promotion and prevention.
Appropriate technology; emphasis should be on the most appropriate technology and
personnel to deal with the problem.
A multi-sectoral approach; social, economic, agriculture and education sectors must work
together to produce policies that affect health.

Principles of the Ottawa Charter (WHO 1986)

Promoting health through public policy by focusing the attention on the impact on health of
policies from all sectors, and not just the health sector.
Creating a supportive environment by assessing the impact on health of the environment
and clarifying opportunities to make changes conducive to health.
Developing personal skills by moving beyond the transmission of information, to promote
understanding and to support the development of social, personal and political skills which
enable individuals to take action to promote health.
Strengthening community action by supporting concrete and effective community action in
defining priorities, making decisions, planning strategies and then implementing them.
Reorienting health services by refocusing attention away from the responsibility to provide
curative and clinical services towards the goal of health gain.

WHO health promoting schools;

Offers an alternative approach to tackling dental trauma among adolescents

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A health-promoting school can be characterised as a school constantly strengthening its

capacity as a health setting for living, learning and working.
The following would be key principles; personal and social education, provision of
mouthguards, alcohol policy, school policy on bullying, physical environment monitoring,
school health policy, links with health services for emergency healthcare.
3/4

Special Needs;
The WHO adopted an International Classification of Impairments, Disabilities and Handicaps 1980;
1. Impairment: Is a lost or abnormality of structure or function including psychological
functioning. E.g. reduced visual acuity, diminished hearing capacity, lack of muscular
control, decreased learning ability and an inability to concentrate.
2. Disability; Is a restriction or lack of ability to perform an activity within the range considered
normal for a human being. Disabilities can be classified as physical-impairs mobility,
respiratory; mental-impairs emotional, social aspects; sensory-impairs hearing, visual;
cognitive-impairs learning, attention. Developmental disabilities are caused by impairments
that occur during development (birth to age 18) and include metabolic defects, fetal alcohol
syndrome, birth hypoxia, autism, cerebral palsy, and postnatal infections such as meningitis
or encephalitis. Acquired disabilities are caused by impairments sustained after the
developmental years, such as spinal cord damage, multiple sclerosis, arthritis and
Alzheimers disease.
3. Handicap; Is a disadvantage resulting from an impairment or disability that limits or
prevents the fulfilment of a normal role.
Oral complications of special needs individuals;

The most frequent causes are related to inadequate or infrequent removal of dental plaque
and frequent dietary consumption of refined carbohydrate. This may be due to bad general
condition due to serious illness, mental depression for a long time, poor facial motor control
due to weakness or paralysis, dysfunction in arms and hands, or dry mouth with thick ropy
mucous which complicate cleaning.
Dental Caries; People with poor cooperation or challenging behaviour tend to have more
untreated decay, more missing teeth and fewer restorations.
Tooth Wear; Many people with neurological impairment carry out habitual clenching or
grinding. Sometimes attrition is combined with erosion in people with cerebral palsy that
develop gastroeosophageal reflux disease (GORD), resulting in gagging and frank vomiting in
people who are orally fed as well as those who are fed via a percutaneous endoscopic
gastrostomy (PEG). Tooth wear in this case is linked with erosion especially on the palatal
surfaces of maxillary teeth, and the occlusal and buccal surfaces of lower molar teeth. The
intrinsic acidic sources include: Gastro-oesophageal reflux, which may be due to sphincter
incompetence, increased gastric pressure and increased gastric volume, vomiting,
rumination. The extrinsic acid sources include: Diet through the consumption of soft drinks,
alcoholic drinks and citric foods, environmental contact with acids as part of work or leisure

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activities, medications and oral hygiene products: Vitamin C and Iron preparations are acidic.
Some mouthwashes and saliva substitutes are also acidic and can erode teeth.
Gingivitis; The gingival status and periodontal health of people with impairments are
affected by poor levels of oral hygiene. Periodontal disease and early tooth loss are more
prevalent in people with Down syndrome due to a combination of poorly controlled plaque
levels and an alteration in the phagocytic activities of neutrophils.
Self-Injurious Behaviour; Self-mutilation involving oral tissues is a problem in some
individuals with severe learning disabilities. Eg: Lesch-Nyhan syndrome. A trigger such as
teething can set off a vicious circle of inadvertent biting of lips and tongue that can produce
pain and swelling. This can result in dehydration as the individuals mouth becomes too sore
to eat or drink.
Hypersalivation; Excessive drooling is seen in those with poor neuromuscular control, as
found in cerebral palsy or in those who have had a cerebro-vascular accident. There is a link
between GORD and hypersalivation. Drooling can cause chronic irritation of the facial skin;
increase in peri-oral infection, halitosis and dehydration due to fluid loss.
Xerostomia; Aging brings with it impairment and chronic conditions, like Sjogrens disease,
which is accompanied by symptoms of a dry mouth. Patients for whom radiotherapy has
removed most if not all salivary gland function, the resultant rise in rampant caries, in
previously caries-resistant teeth like lower incisors, is dramatic.
People with feeding difficulties who are tube-fed; The term tube fed will be used to include
feeding by gastrostomy, jejunostomy and naso-gastric tube. People who are tube fed have a
number of problems. The reason for tube feeding may include inadequate diet, nutritional
need, child failing to thrive and/or impaired swallowing. It has relevance to general health
because an inadequately protected airway increases the risk of gastric reflux causing
aspiration, which leads to recurrent bouts of pneumonia. Problems that can occur: Dental
erosion & Oral hypersensitivity.

Role of Carers;

An oral assessment should be recorded on a chart.

Every person with a disability should have an individualised oral care plan.
Carers should seek professional advice on how best to carry out oral hygiene care (advice
in prevention).
Individual carers should not make the decision to no longer carry out oral hygiene practises.
Trust and good working relationships should be developed.
Carers should ensure the patient is registered and attends the dentist regularly.
Carers should provide support on how best to approach the examination of the patient in
the dental practise and should liaise with the dentist on day-to-day oral care.
Carers are also responsible for the diet plan of the individual;
Sugary drinks and snacks limited to mealtimes.
Healthy snacks encouraged if possible.
Sugar-free medicines used where possible.
Consumption of fizzy drinks and citric fruits limited to mealtimes.

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Principles of treatment;

Short-term; short appointment, short sentences, spontaneous mood swings.

Long-term; intervene any dental problems as early as possible, plan appropriate preventive
measures at the start, dentures cleaned and managed regularly.

Prevention and Tx Measures; People with Disabilities (Gabre 2009)

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Practical Prevention Measures;

For a disabled person who cannot tolerate toothpaste intraorally then carers may consider
using a toothbrush dipped in fluoride mouthwash (250ppm Fl, or 1000ppmFl).
Sometimes treatment calls for cooperation with the patients physician, in some cases
antibiotics will be necessary before carrying out extractions, scaling or any other surgical
procedures.
If the patients state of health or condition permits, the most appropriate advice will be
regular mealtimes (4-5 meals per day), fresh water or mineral water to drink between meals,
and food that encourages chewing in order to increase saliva stimulation.
Instructions to carer; a soft toothbrush with a small head is recommended as well as a
systematic toothbrushing technique, and standing or sitting beside/behind the patient is the
ideal position to carry out adequate oral hygiene. For seriously ill or unconscious patients a
bite-support of plastic may be used to keep the mouth open and the patient should be
placed on their side with a towel under the chin. If the patient is unconscious then it is

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recommended that two carers carry out the task of oral hygiene. The mucous membranes
should be moistened with water-dipped swabs. Mucolytic solvent (bisolvon) should be used
to remove mucous or crust on the tongue/palate/teeth. If the patient has dentures, then
cleaning must be carried out daily with a denture brush, before the dentures are replaced
the oral cavity too must be cleaned. Angular cheilitis and denture stomatitis can form by a
colony of yeast in the layer of plaque on the fitting surface of dentures. The dentures should
be kept in fresh water during the night. Any calculus deposits on the dentures should be
removed using acetic acid.
For patients who can carry out their own oral hygiene but may find it difficult to concentrate
on keeping their mouth open as they brush, a cheek retractor may be used. Grip aids for
toothbrushing may also be used, for example a holder made of nylon fabric and wrapped
around the palm. Or a special design of toothbrush called a double toothbrush may be used
which allows all surfaces of the teeth to be brushed at a time, as well as getting the lingual
and buccal gumlines. If the patient has lost dexterity, a powered toothbrush may be
appropriate.

Journal of Clinical Periodontology, Panuti et al (2003), Efficacy of Chlorhexidine gel-mentally

handicapped;

The purpose of this investigation was to investigate the effectiveness of a 0.5% chlorhexidine
gel in reducing interdental gingival inflammation in institutionalised mentally handicapped
subjects.
The chlorhexidine gel is less effective on established plaque than on forming plaque, and is
even less effective in areas where calculus and bleeding are present.
Scaling was performed prior to beginning of administration of the gel in order to properly
identify the efficacy of the gel.
Optimal dosage is known to be 40mg/day according to Loe et al (1976).
However in this study, a total daily dosage of 120mg/day was used during the week, and the
normal 40mg/day used during the weekends.
This study, concurrent with Bassiouny and Grant (1975) demonstrated a significant
reduction in interdental bleeding after the use of the gel.
In this study, 81.8% of patients in the test group presented with dental stains after use of the
gel and this had to be removed using prophylaxis in order to properly identify the test group.
The application of chlorhexidine gel can be indicated as an adjunct to mechanical plaque
removal for special needs patients but it cannot completely replace toothbrushing and
interdental cleaning.
At institutions for the mentally handicapped, oral hygiene is the caretakers responsibility
and so caretaker motivation is imperative.

Consent and Duty for Special Needs (Bridgeman 2000);

Assent; for children and vulnerable adults. Signed by patients family. DDUH policy.
it is well established that the performance of a medical operation on a person without his
consent will be unlawful, and the charge for such is battery in the tort of trespass unless it
is in the patients best interests.

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There is no provision for proxy consent for adults within the common law. Neither proxy
consent nor opinion of a colleague will make intervention lawful in the case of an
incompetent patient.
At common law, a doctor can lawfully operate on or give other treatment to adult patients
who are incapable of consenting to his doing so, provided that the operation or treatment is
in the best interests of the patient. The operation will be in their best interests only if it is
carried out in order either to save their life or to ensure improvement or prevent
deterioration in their physical and mental health.
Doctrine of Necessity; states that one must act in the best interests of the patient even if
the patient cannot communicate due to loss of consciousness or where communication is
lost permanently.
Consultation with the next of kin has the further advantage in that it may reveal
information as to the personal circumstances of the patient and as to the choice which the
patient might have madeneither the personal circumstances of the patient nor a
speculative answer to the question what would the patient have chosen can bind the
practitioner to his choice of whether or not to treat or how to treatbut they are factors to
be taken into account by him in forming a clinical judgement as to what is in the best
interests of the patient.
The best interests in the treatment of the incompetent adult patient is thus the wellknown professionally determined test of accepted practice laid down in Bolam.

Assessment of Competence for Special Needs;

The patient who is clearly incompetent to make any decision ought to have that decision
made for them.
If the patient is capable of deciding for herself and is making a valid refusal, then any
treatment provided amounts to battery even though it may be in her best interests.
If she is incompetent then the dentist has a duty to provide the necessary care that is in her
best interests.
Roth et al found that there was no single test of competency as some individuals may
exhibit incompetence in one aspect of their life but not in others and as such a
standardised test could not be ascertained. He proposed that a combination of; evidencing
a choice, reasonable outcome of choice, choice based on rational reasons, ability to
understand and actual understanding, could only prove a persons competence in the
matter.
One way of testing the patients actual understanding was to ask them to repeat all of what
you have said in their own words.
The common law position states that a patient will lack the capacity to make a decision
when a) the patient is unable to understand and retain the information which is material
to the decision and b) the patient is unable to use the information and weigh it in the
balance as part of the process of arriving at a decision.
Where there is a high risk to health or the treatment has a low risk:benefit ratio, patients
will need to demonstrate a higher level of competence if they are refusing treatment.

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The more the dentist can learn about the patients capacity for decision-making and levels of
understanding the better the interests of both patient and dentist are protected. Family
discussion will generally lead to less dentist liability.

Use of Restraint for Special Needs;

When presented with an actively resistant patient, an assessment of the patients

competence is a legal and moral requirement.
The best interest test arises from the principle of necessity and this principle requires that
any action taken must be such as a reasonable person would in all circumstances take.
The issues surrounding the use of restraint are complex but the law is clear. The use of
reasonable restraint is lawful if to do so would be in the patients best interests.
It is generally held that restraint may be used lawfully for an examination but in the case of
treatment, this is seen as unlawful.
Restraint should not cause any physical trauma to the patient.

Incidence of oral health problems in people with disabilities;

There is evidence that people with a learning disability experience poorer general and oral
health, have unmet oral health needs and have a lower uptake of screening services.
The overall picture is one of poor periodontal health and a greater than normal unmet need
for treatment for children and adults.
People with a learning disability have an increased prevalence of physical and sensory
impairments, behavioural problems and epilepsy, which increase their health needs.
40% of people with Downs syndrome suffer from congenital heart defects and
immunosuppression.
Schizophrenia, delusional disorders, autism and behavioural disorders are similarly reported
to have an impact on their oral health and dental management.
Individuals with cognitive disabilities such as intellectual impairments and dementia have an
increased prevalence of dental caries.

Problem/barriers to treating people with disabilities;

1. User/carer barriers; some do not prioritise programmes to prevent oral disease. In the case
of the individual, he may have poor verbal skills and will not be able to communicate well a
toothache or complain of pain. Others will be unable to cooperate with treatment.
2. Professional service provider barriers; previous surveys of new dental graduates have
demonstrated low confidence scores in the management of such patients. Dentists lack of
experience of learning disabilities and the financial constraints of the system also provide
further barriers to treatment.
3. Physical barriers; a large number of people with learning disabilities also experience mobility
problems. Difficulties may arise for example ambulance transfer, availability of taxis with
wheelchair access.
4. Cultural issues; people from ethnic minorities are subjected to the same barriers to oral care
but these may be exacerbated by factors related to ethnicity including language. People

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from ethnic minorities may have different attitudes and beliefs about oral matters. Females
may prefer to be treated by female dentists.

Use of Sedation for People with Learning Disabilities:

The use of sedation in the care of people with learning disabilities is influenced by a number of
factors:
1. Age and medical condition of the patient.
2. The appropriate use of different drugs and techniques either in primary or hospital dental
service.
3. Cultural acceptance of sedation.
4. Behaviour management problems.
5. Support from carers.
6. Experience and training of the dental team in sedation techniques. Training in the use of
sedation is a General Dental council priority for undergraduates.
Sedation Indications for Pre-school Child:
Inhalation sedation, Oral sedation, or transmucosal sedation.
Sedation Indications for School Age, Transitional Stage, Adults and Older People:
Inhalation sedation, oral sedation, transmucosal sedation, or intravenous sedation (only to be used
on patients over the age of 10).
Indications for Use of General Anaesthesia for People with Learning Disabilities:
Clear inability to co-operate with contraindication of other patient management techniques
including sedation.
Pre-assessment

A full, updated medical history from the patients doctor or consultant should be obtained.
A dental history should be updated at the same time.
Past anaesthetic history should be recorded.
Provision of clear written and verbal instructions of the planned procedure to the patient,
parent or carer in order to allay anxieties.
Alleviation of anxiety by: Pre-medication (consider a pre-medication prior to or on
admission), having a familiar team and environment appropriate to individual needs,
advising that it may not be necessary to change normal clothing, and supporting carers by
considering their needs and anxieties.
Ensuring the correct consent form is completed. For those unable to give consent, this will
require a case discussion involving the multi-disciplinary team, the patients key worker and
next of kin.

Nutritional State
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The nutritional state of people with learning disabilities varies considerably. Some are under
nourished but others are likely to be overweight because of the ease of access to high
calorific food and drink.

Anatomical Considerations

Many congenital and developmental disabilities are associated with facial and oral
abnormalities. Indeed this may form part of their dental problem. It is important that the
airway of the patient is properly assessed by the anaesthetist.
A poor dentition could pose an additional problem during induction. The anaesthetist should
also be made aware of problems associated with cleft palate and enlarged tongue.

The Anaesthetic

The anaesthetist will be experienced in caring for people with learning disabilities for dental
treatment.
Discussions will take place between the anaesthetist and the dental team regarding the
patient.
The appropriate number of trained staff will be used at all times.
Arrangements must be made with ward and day surgery unit staff to make sure they
understand the needs of people with learning disabilities.
If people with learning disabilities are sharing a ward with other patients, appointments
need to be carefully arranged to minimise any disruption that might be experienced.

Social Factors in Assessment

Arrangements for effective and efficient after care should be in place. This will involve key
workers organising someone to stay with the patient on discharge.
The patient and carer should be given full instructions on postoperative care and an
emergency contact number.
The dental team may need to organise transport to and from the treatment site.
Appropriate manual handling procedures should be followed.

Irish Dental Council Guidelines;

GENERAL ANAESTHESIA:
A controlled state of unconsciousness accompanied by a partial or complete loss of protective
reflexes, which may include inability to maintain an airway independently and to respond
purposefully to physical stimulation or verbal control.
1. The Council considers that general anaesthesia, a procedure which is never without risk,
should be avoided in the practice of dentistry if at all possible. Patients seeking general
anaesthesia, where it is not clinically appropriate, should be advised of and encouraged to
accept alternative methods of anxiety control.
2. If it is decided to provide dental treatment under general anaesthesia, ideally the
anaesthetic should be administered in an appropriate hospital setting but it may be
administered in a dental surgery or clinic that have adopted and implemented contemporary
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3.

4.

5.
6.
7.

8.

9.
10.

monitoring protocols. The Standards of Monitoring during Anaesthesia and Recovery issued
by the Association of Anaesthetists of Great Britain and Ireland are appropriate.
General anaesthesia must be regarded as a postgraduate subject and general anaesthetics
must only be administered by dental/medical personnel with recognised specialist training
and relevant experience in the discipline. The anaesthetist must remain with the patient
throughout the procedure and until the patients protective reflexes have returned and the
patient has recovered control of his/her own airway.
When administering a general anaesthetic the anaesthetist should be supported by another
person sufficiently trained and experienced in the skills necessary to assist in the
monitoring of the patients condition and be competent to provide effective assistance in
case of an emergency.
Under no circumstances must a general anaesthetic be administered by a dentist who is
treating the patient.
The acceptance of patients for a general anaesthetic should be subject to a thorough
medical assessment, a detailed medical and dental history and a full dental examination.
Prior to the administration of a general anaesthetic the procedure, including potential risks,
should be fully explained to the patient and/or parent/guardian and written consent
obtained.
Good contemporaneous records of all treatments and procedures must be kept and should
contain all details of treatments, drugs used and procedures undertaken including any
complications or difficulties encountered.
Patients and/or parents/guardians must be provided with comprehensive pre and post
treatment instructions and advice in writing.
Any dentist who carries out treatment under general anaesthesia without fulfilling the above
conditions will almost certainly face a charge of professional misconduct.

SEDATION:
Simple dental sedation is a carefully controlled technique in which a single intravenous drug or a
combination of oxygen and nitrous oxide, midazolam or propofol are used to reinforce hypnotic
suggestion and reassurance in a way, which allows dental treatment to be performed with
minimal psychological stress. Verbal communication with the patient should be maintained at all
times throughout the procedure and it is essential that the protective pharyngeal and laryngeal
reflexes remain intact at all times, and that the patient breathes spontaneously without respiratory
obstruction. The technique must carry a margin of safety wide enough to render unintended loss of
consciousness unlikely. Any technique of sedation other than as defined above requires the
implementation of all the previously stated requirements for the administration of general
anaesthesia. Midazolam or Propofol can be used. Propofol is typically advantageous for short
procedures of less than 10 minutes but can also be used for longer procedures. Midazolam
provides excellent anxiolysis and has a greater margin of safety.
Intravenous Sedation:
1. The definition of dental sedation requires intravenous sedation to be limited to the use of
one sedative drug with a single titrated dose and an end point remote from anaesthesia. The
use of more than one sedative drug must not be considered simple sedation and would
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2.

3.
4.

5.
6.
7.
8.
9.

10.

11.
12.

require the same precautions as for the administration of a general anaesthetic.

Appropriate local anaesthesia should routinely be used with sedation.
Where intravenous sedation is employed a dentist may assume the responsibility of
sedating the patient as well as operating, provided that the dentist has successfully
completed a Dental Council recognised postgraduate training programme in the
administration of intravenous sedation. A second appropriate person should be in
attendance. Such person might be a suitably trained dental nurse whose experience and
training enables her to be an efficient member of the dental team capable of monitoring the
clinical condition of the patient and, should the occasion arise, be competent in providing
effective assistance in case of emergency.
Dentists who administer intravenous sedation should attend refresher training at regular
intervals.
Intravenous sedation must not be used unless proper equipment and adequate facilities,
including appropriate drugs, for the resuscitation of the patient are readily available with
both dentist and staff trained in resuscitation techniques. Resuscitation is very much a
matter of skill and timing and dentists must ensure that all those assisting them know
precisely what is required of them, should an emergency arise. They should regularly
practise their resuscitation routine in a simulated emergency against a clock. The Council
considers it essential that the equipment necessary for basic life support must already be set
up and be immediately to hand, ready for use.
A pulse oximeter is essential for monitoring the sedated patient and dentists must be
aware of the significance of pulse oximetry readings.
An indwelling cannula should always be used and should not be removed until the patient
is fully recovered.
Practitioners should have available immediately an emergency kit of drugs and equipment,
including oxygen, to deal with any emergency that might arise.
The benzodiazepine antagonist drug, flumazenil, should be solely reserved for emergency
use.
The dentist should be familiar with drug manufacturers data sheets and should adhere to
the recommendations contained therein. Dentists should be aware that dreams/vivid
hallucinations, including sexual fantasies, hysterical reaction or becoming sexually aroused
have been frequently reported and associated with the benzodiazepine group of drugs.
Before undertaking sedation, practitioners must ensure that a dental nurse or other
appropriate person acts as a chaperon for the patient and is present from the time of
administration of the sedation until the patient leaves the practice. This persons name
should be recorded in the patients notes.
Where sedation is to be administered, a detailed medical and dental history of the patient
must be taken and a full dental examination carried out. Only patients falling into the
fitness groups of ASA I or II should be accepted for sedation in general practice. If there is
any doubt as to the patients fitness, sedation should be avoided.
Intravenous sedation is not recommended for children, particularly under the age of 10
years.
Prior to the administration of intravenous sedation the procedure including potential risks
should be fully explained to the patient and/or parent/guardian and written consent to the
sedation, local anaesthesia and proposed treatment obtained.

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13. Good contemporaneous records of all treatments and procedures must be kept and should
contain details of treatments, drug used and patients vital signs, including any complications
or difficulties encountered.
14. Clear and comprehensive pre and post treatment instructions and advice in writing should
be provided in advance to patients and/or their parents/guardians or accompanying
persons.
15. Following treatment, recovery facilities must be available with appropriate monitoring and
continuous individual observation undertaken on a one-to-one basis until the patient is
sufficiently recovered to leave the premises, accompanied by a responsible person.
16. Any dentist who carries out treatment under intravenous sedation without fulfilling the
above conditions will almost certainly face a charge of professional misconduct.
Inhalation Sedation:
1. Where inhalation sedation techniques are used, a suitably experienced practitioner may
assume the responsibility of sedating the patient as well as operating provided the
practitioner has successfully completed a Dental Council recognised postgraduate training
programme in the administration of inhalation sedation.
2. It is important that the practitioner realises that the planes of sedation and anaesthesia
overlap considerably and that there is a gradual transition between one plane and the next
with no clear demarcation between the planes. It is important to recognise that in a small
number of patients as little as 50% nitrous oxide may bring about loss of consciousness
and considerable care must be exercised if the concentration of nitrous oxide rises above
35%. Accordingly, to ensure an end point remote from anaesthesia, practitioners should
not exceed a fixed upper limit of 50% nitrous oxide.
3. A pulse oximeter is essential for monitoring the patient.
4. Scavenging equipment should be used to reduce the effects of nitrous oxide contamination
of the surgery environment.
5. Practitioners should have available immediately an emergency kit of drugs and equipment,
including oxygen, to deal with any emergency that might arise.
6. It is essential that the clinician monitors both the patient and the equipment and as a
minimum requirement a second person must be present throughout. Such a person might
be a suitably trained dental nurse whose experience and training enables her to be an
efficient member of the dental team and who is also capable of assisting in the monitoring
the clinical condition of the patient. Should the occasion arise she should be competent in
providing efficient assistance in case of an emergency.
7. Prior to the administration of inhalation sedation the procedure, including potential risks,
should be fully explained to the patient and/or parent/guardian and written consent to the
sedation, local anaesthesia and proposed treatment obtained.
8. Clear and comprehensive pre and post treatment instructions and advice in writing should
be provided in advance to patients and/or their parents/ guardians or accompanying
persons.
Oral Sedation:

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1. When oral sedation is administered an appropriate drug which undergoes rapid

absorption and has a relatively short duration of action should be chosen.
2. The relevant drug should be administered under supervision in the dental surgery and
adequate time, in accordance with the manufacturers recommendations, allowed for
maximum absorption before treatment is started.
3. The prescription for oral sedation should only be used with a full understanding of the
pharmacology, indications, contraindications and drug interactions of the compounds used.
4. A pulse oximeter is essential for monitoring the patient.
5. It is essential that the dentist monitors the patient and a second person who is capable of
assisting in this monitoring should be present. Clinical assessment of respiratory rate, depth
and colour allows for airway management. Pre and post-operative records of vital signs
should be maintained.
6. Patients who have had oral sedation administered must be escorted home and be asked to
follow the same post treatment instructions as for intravenous sedation. Specifically,
patients must agree in advance to avoid operating machinery, driving, or drinking alcohol.
5
Mode of Action of Fluoride;
Enhanced remineralization; This allows the early carious attack on enamel to be reversed and new
mineral crystals with better structure and greater acid resistance to be deposited. Fluorapatite can
only be dissolved if the pH goes below 4.5. It also increases the uptake of minerals (by attracting
calcium and phosphate ions when adsorbed to the crystal surface).
Reduced acid production; It inhibits bacterial metabolism after diffusing into the bacteria as the
hydrogen fluoride molecule when the plaque is acidified which interferes with bacterial enzymatic
activity (for ex. fluoride inhibits enolase-an enzyme necessary for the bacteria to metabolize
carbohydrates).
Fluoride substitution; fluoride entering the developing teeth from the diet via the bloodstream is
incorporated into the new mineral crystals. This partly fluoridated hydroxyapatite is thought to be
more resistant to acid attack than that formed without fluoride. However, use of fluoride toothpaste
renders this mechanism less significant.
Reduced pit and fissure depth; Fluoride entering developing teeth at an early stage appears to result
in reduced pit and fissure depth but this mechanisms effect is made insignificant by fluoride
toothpaste.
Bactericidal at high concentrations
Fluorosis;

Dental fluorosis is a hypoplasia or hypomaturation of tooth enamel or dentine produced by

the chronic ingestion of excessive amounts of fluoride during the period when the teeth are
developing.
The major cause of fluorosis is the consumption of water containing high concentrations of
fluoride during the first six years of life.

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Fluorosis presents as opaque or white areas, lines or flecks in the enamel surface and are
most noticeable when they occur on front teeth. These opacities usually occur due to
ingestion of excessive fluoride during the period of enamel formation.
For incisor teeth, the greatest period of risk is between 15 and 30 months of age.
To reduce the risk of fluorosis, parents should supervise children while brushing under the
age of 7. When fluoride tablets or drops are used they should be given at a different time
to brushing. However, fluoride supplementation is not recommended in countries like
Ireland where water fluoridation is being implemented nationally.
Acute toxicity is about 5mg/Kg, Lethal dose probably in the region of 32-64mg/Kg.
Chronic toxicity; skeletal fluorosis at 10mg/Kg over at least 10 yrs.
Risk factors; inappropriate fluoride supplements, age of child when toothbrushing started,
frequency of brushing/swallowing toothpaste and residence in an optimum fluoride area.
High levels of fluorosis are associated with high concentrations of fluoride in the water
supply, but also in temperate climates with optimal or low fluoridated water supplies where
fluoride uptake from other sources, in particular fluoride supplements and fluoride
toothpaste, in early infancy, have resulted in an increase in the prevalence of enamel
mottling.
People with kidney disease will have a low excretion rate of fluoride.

Methods of delivery of fluoride;

Fluoride Toothpaste

This is the most effective topical fluoride agent for personal use and is thought to be the
main reason for the decline in caries prevalence in Europe during the last 30 years.
There is no clear evidence that pastes containing less than 1000ppm are effective but they
are available.
Toothpastes containing 1000-1500ppm are highly effective and should be used by all
children from the age of seven years.
There is evidence that rinsing after brushing with fluoride toothpaste reduces the benefit
both in relation to the development of new cavities and the prevention of recurrent caries
around fillings.
Toothpastes containing 1000-1500ppm reduces caries prevalence by 30%
Five clinical studies into the effectiveness of pastes with low fluoride concentrations have
been reported and from these it has been concluded that caries inhibition increased with
increasing fluoride content of the toothpaste.
Fluoride toothpastes in the range of 100-250ppm should be confined to children under 6
years to prevent opacities of the anterior teeth but their affectivity is unknown.
Recently, Baysen et al (2001) concluded that dentifrice containing 5000ppm Fl was
significantly better at remineralizing primary root surface caries than one containing
1100ppm Fl (duraphat toothpaste).

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Fluoride Tablets and Drops

Supplementing the diet of children during the period of tooth development with fluoride in
the form of tablets and drops is no longer considered to be an effective public health
measure.
Fluoride dietary supplements may be considered for those for whom the consequences of
decay pose a hazard to general health or for whom dental treatment would be difficult
because of their medical or physical condition. These groups include children with heart
disease or cardiac defects who need pre-operative antibiotic cover for any dental
procedure, as well as children prone to infection due to systemic illness and special needs
children.
A stop-start pattern of use of these supplements is not likely to provide any significant
benefit.
Daily dosage schedule: 0.25 mg Fl (6mths-3yrs), 0.5 mg Fl (3-6yrs) and 1 mg Fl (6yrs+).
It is generally advised that for maximum benefit their use be continued until the
appearance of the second molar teeth, usually at about 11-12yrs. However, some experts
believe that allowing the tablets to dissolve slowly in the mouth a more beneficial topical
post-eruptive effect may be achieved, both for older children and adults who may be at risk
of caries.
For areas with 0.3ppm or more Fl in the water supply a lower dosage should be considered.
No supplements should be given in areas where the water supply contains more than
0.7ppm Fl.
78% of cases of fluorosis occur due to these supplements.

Topical Fluorides (Applied by Dentist)

Topical fluorides have been used in dental practise for the last fifty years.
There are four main preparations; neutral sodium fluoride solutions, stannous fluoride
solutions, acidulated phosphate agents and fluoride varnishes.
The need to keep the fluoride agent in close proximity to the tooth surface for as long as
possible gave rise to the development of fluoride varnishes, in particular Duraphat, which
yields 2.26% Fl (22600ppm) from a suspension of sodium fluoride in an alcoholic solution of
natural varnish substances. It is claimed that this product tolerates moisture well and it
covers even moist teeth with a film of varnish.

Fluoridated Milk

School-based fluoridated milk programmes are now operating in over 15 countries from
Russia to Chile.
An additional benefit that fluoridated milk may present is that it may help displace
sweetened soft drinks from the refrigerated vending machines found in many schools.
Results from early clinical trials indicate a reduction in caries levels comparable to those
achieved by water fluoridation.
2.65ppm in milk.
Ericsson (1958) showed that fluoride as absorbed in the gut just as readily from milk as from
water, refuting the suggestion that high calcium content of milk would render the fluoride

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unavailable. However the binding of added fluoride to calcium or protein might reduce the
topical fluoride effect in the mouth compared with fluoride in water.
Fluoridated Salt

As a dietary vehicle for ensuring adequate ingestion of fluoride-domestic salt comes

second to drinking water.
It was a medical practitioner concerned with prevention of goitre in Switzerland over 40
years ago who pioneered the addition of fluoride to salt as a caries-preventive measure.
De Crousaz et al (1985) detailed that caries experience was consistently lower in children
who consumed salt fluoridated to 250 mg Fl/Kg compared with children in control
communities.
Fluoridated salt, when well accepted by the public, has some parallels to water fluoridation
in terms of wide coverage, little conscious action by the individual and low expense. It too
required systems of monitoring quality at the processing plant.
The introduction of fluoridated salt would need to be accompanied by public education and
promotion given the consumers choice in whether or not to buy fluoridated or nonfluoridated salt.
The Swiss canton of Vaud removes that choice by fluoridating all salt on supermarket
shelves as well as the salt delivered in bulk to restaurants, bakeries, hospitals and other
institutions.
Salt fluoridation is not recommended in countries where there is extensive water
fluoridation already.

Water Fluoridation;

The first reference to a prophylactic role of fluoride was made by Erhadt in 1874.
However, the man who had the greatest impact on the early history of water fluoridation
was Dr McKay who arrived in Colorado Springs in 1901. He first noticed that many patients
there had a permanent stain on their teeth which was named Colorado stain.
McKay called the stain mottled enamel and characterised it by; minute white flecks, or
yellow or brown spots or areas, scattered irregularly or streaked over the surface of a tooth,
or it may be a condition where the entire tooth surface is of a dead paper-white like the
colour of a china dish.
Following McKay was the work of Dean. Taking a selected sample of 9-year-old children he
found that 114 children who had continuously used a domestic water supply comparatively
low in fluoride (0.6-1.5ppm) only 5 (4%) were caries-free. On the other hand, of the 122
children who had continuously used domestic water containing 1.7-2.5ppm fluoride, 27
(22%) were caries-free. The results clearly show the association between increasing
fluoride concentration in the drinking water and decreasing caries experience in the
population. Furthermore, this study showed that near maximal reduction in caries
experience occurred with a concentration of 1ppm Fl in the drinking water.
Countries in tropical areas should reduce the Fl concentration in their water. For example,
Hong Kong fluoridated their water at 0.7ppm Fl and have since reduced this to 0.6ppm Fl.
Grand Rapids-Muskegon Study; Both city councils agreed to carry out a study with Grand
Rapids becoming the experimental town and Muskegon, the control town (baseline studies

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of both were similar). In addition, children continuously resident in the natural fluoride area
of Aurora Illinois (1.4ppm) were examined to provide further baseline information. Sodium
fluoride was added to the Grand-Rapids water supply. The effects of six and a half years
were clear, caries experience of 6-year olds in Grand Rapids children was almost half that
of the Muskegon children. Furthermore, caries experience in the fluoridated community of
Grand Rapids was very similar to that occurring in the natural fluoride area of Aurora.
Newburgh-Kingston Study; Sodium fluoride was added to the drinking water of Newburgh
and the town of Kingston was chosen as the control town. After 10 years, they reported that
caries experience in the 10-12 year olds had changed little in Kingston in comparison to the
similarly aged children of Newburgh who saw the DMFT rate fall from 23.5% to 13.9%

Forum on fluoridation (2002)

Responses were sought to 3 questions; 1) Has water fluoridation improved the oral health of
the Irish population, 2) is there scientific evidence that water fluoridation at a level of 1ppm
endangers human health, and 3) what recommendations are needed in the area of water
fluoridation.
Conclusions; Water fluoridation has been very effective in improving the oral health of the
Irish population, especially of children, but also of adults and the elderly. The best available
and most reliable scientific evidence indicates that at the maximum permitted level of
fluoride in drinking water at 1ppm, human health is not adversely affected. Dental fluorosis
(a form of discolouration of the tooth enamel) is a well-recognised condition and an
indicator of overall fluoride absorption, whether from natural sources, fluoridated water or
the inappropriate use of fluoride toothpaste at a young age. There is evidence that the
prevalence of dental fluorosis is increasing in Ireland.
R1; Policy aspects of water fluoridation
1. Fluoridation of public water supplies should continue.
2. Redefine the optimal level of fluoride in drinking water from present (0.8-1ppm) to
between 0.6 and 0.8ppm, a target of 0.7ppm.
3. Adhere to most recent international specifications on the process of fluoridation.
4. Appoint an expert body to implement such recommendations.
R2; Technical aspects of water fluoridation
1. Guidelines and codes of practise should be provided to ensure that all technical
aspects of water fluoridation are being carried out appropriately.
2. Audit procedures should be carried out to assure quality control.
R3; Toothpaste
1. The use of fluoride toothpaste should continue everywhere.
2. No toothpaste should be given to children under two years of age.
3. Children aged 2-7 yrs should be supervised whilst brushing and a pea-sized amount
of toothpaste will suffice.
R4; fluoride products
1. Labelling of fluoride products should be understood by all, even those with
impairments and as such, lay-man terms should be used.
2. Clear instructions for use should be placed on the labels of such products.
3. Child-resistant containers should be used for mouthrinses and fluoride supplements.

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R5; infant formula

Infant formula should be reconstituted with boiled tap water.

R6; fluoride research

1. Future research in accordance with the health research strategy should be carried
out.
2. Ongoing research is necessary in the case of fluoride.
3. Research should include fluoride and its effects relating to general health.
4. The current 10 yr cycle of adult/child dental health surveys should continue.
R7; dissemination of the information
1. Widespread dissemination of the forum findings via the media.
2. Availability of the information of this document to schools and local libraries.
3. Surveys and other methods to measure public response should be undertaken.

A Systematic Review of Public Water Fluoridation (2000);

Objective 1; Assessment of the effect of water fluoridation on the development of caries.

The review, through a simple qualitative method of analysis, suggests that water
fluoridation does appear to reduce caries. When water fluoridation was stopped, in 12 out
of 16 studies, the direction of the association is that the caries burden increases more in the
previously-fluoridated groups than in the never fluoridated groups.
Objective 2; If water fluoridation is shown to have beneficial effects, what is the effect over
and above that offered by the use of alternative interventions and strategies. In examining
the post-1974 studies, the evidence suggests that water fluoridation has an effect over and
above that of fluoridated toothpaste and other sources of fluoride.
Objective 3; determination of whether fluoridation results in a reduction of caries across
social groups and between geographical locations, bringing equity. Two studies found similar
effects on dmft/DMFT scores among 5 and 12 year olds using measures of social deprivation,
and these studies show a greater effect in deprived areas.
Objective 4; Does water fluoridation have negative effects. In the case of fluorosis, a doseresponse relationship was ascertained from the studies reviewed. The prevalence of
fluorosis at 1ppm drinking water was estimated to be 48% for any fluorosis and 12.5% for
aesthetic fluorosis. In the case of bone fracture and bone development problems, no clear
associations have been made. There is also no clear picture of associations between water
fluoridation and overall cancer incidence and mortality.
Objective 5; Assessment of natural versus artificial fluoridation effects. The review
concluded that there were no differences.
6

The European average of dentists per million of population is 740, compared with the 606
registered to the Dental Council of Ireland (2010).
Areas which are not fluoridated or are poorly fluoridated are on school fluoride mouthrinsing programmes.
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 Geographical mapping of number of dentists to ascertain the distribution of dentists in the

population.
Rota system, incentives to set up practises in rural areas (grant system, more holidays, free
healthcare for family), mobile clinics, visiting schools.
Ratio of dentists:hygienists, OConner (2002) proves that it is cheaper to allow hygienists to
fissure seal rather than dentists. Perhaps incentivise hygienists rather than dentists.
Increase awareness by posters, oral hygiene day, competitions, mighty mouth programme.
Index ages and age groups;

5 years; detects levels of caries in the primary dentition, which my exhibit changes over a
shorter time span than the permanent dentition at other index ages.
12 years; this is the global monitoring age for caries for international comparisons and
monitoring of disease trends. This is also the age at which children leave primary school and
in many countries is the last age at which reliable sample may be obtained easily through
the school system. All permanent teeth except for third molars and maxillary canines will
have erupted.
15 years; Permanent teeth have been exposed to the oral environment for 3-9 years
therefore assessment of caries prevalence is more meaningful than at 12 years. It is also an
important age for the assessment of periodontal disease indicators in adolescents.
35-44 years; Standard monitoring group for health conditions of adults. The full effect of
dental caries, the level of severe periodontal involvement, and general effects of care
provided can be monitored suing data from this age group.
65-74 years; This age group has become more important with the changes in age
distribution and increases in life-span that are now occurring in all countries.

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Eruption sequences;

Irish Expert Body on Fluorides and Health (HSE);

As of july 1st 2007, the levels of fluoride in the water supplies have been set at between 0.6
and 0.8ppm.
73% of population receiving fluoridated water and the remainder is receiving private
supply.
The HSE is ultimately responsible for fluoridating water supplies in Ireland. However on a
smaller scale, it is the sanitary authorities who are responsible for sourcing, treatment and
distribution.
The expert body has set out a code of practise relating to how the water is fluoridated.
The expert body concludes that water fluoridation is an effective measure of reducing the
dmft/DMFT in Ireland and if it were to cease, then the dental health of the population would
decline rapidly.

Fluoride Revisited: A Review on Water Fluoridation (2012) Dobrinski et al;

The effects of fluoridating the water can extend to communities without a fluoridated water
supply through a phenomenon known as the halo effect. The effect occurs when food and
beverages prepared with fluoridated water are consumed in non-fluoridated communities
sharing the benefits of fluoridated water.
Deborah OReilly

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