Do life‐ or school‐satisfaction and self‐esteem indicators explain the oral hygiene habits of schoolchildren?

OBJECTIVES: The aim of this study was to ascertain how frequently toothbrushing and flossing are practiced among schoolchildren in Kuwait and whether life- and school-satisfaction and self-esteem indicators are associated with oral hygiene habits. METHODS: A sample of 2312 schoolchildren between 11 and 13 years old filled out a structured questionnaire anonymously in school classrooms during 2002 and 2003. For this study, nationally representative samples of children were drawn from all six governorates of Kuwait. Only government schools were included. The questionnaire of the Health Behaviour in School-Aged Children Study was used in this study after it was modified to suit Kuwait. A chi-squared test and logistic regression model were used for analyzing the data. RESULTS: Over half of the pupils reported brushing their teeth more than once a day; girls reported brushing more frequently than boys did. One-fifth of the pupils did not brush their teeth even on a daily basis. The life- and school-satisfaction and self-esteem indicators were associated with more-than-once-a-day toothbrushing frequency. The strongest predictors for recommended brushing were: feeling very happy (OR 2.0, 95% CI 1.38-2.77), feeling that other pupils always accept him/her (1.5; 1.16-2.02), never/sometimes feeling lonely and feeling that it is very easy to make friends (1.4; 1.06-1.94). The summary variables of life-satisfaction, school-satisfaction and self-esteem seemed to be strongly associated with brushing. Dental floss was never used by 45% of the children, weekly by 18% and daily by 17%; 20% did not even know what dental floss was. CONCLUSIONS: Among intermediate schoolchildren in Kuwait, oral hygiene practices were far behind the international recommendations. Special emphasis should be placed on children who have personal problems with their life, school and self-esteem.     

Daily consumption of sugary drinks and foods as a behavioural risk for health of adolescents in kuwait

Purpose: To determine the levels of daily consumption of soft drinks, sweets and cakes/pastries by schoolchildren in Kuwait and the possible background factors associated with these habits. In addition, the association between daily consumption of these sugar-rich products and other health-related habits was studied. Materials and Methods: A nationally representative sample of children from public schools was drawn for this study. Altogether, 1292 schoolchildren of an average age of 13 years (SD ± 1.04) participated by anonymously filling out a structured questionnaire in school classrooms. The questionnaire of the WHO Collaborative study (Health Behaviour in School-aged Children) was used after modifications for the Kuwaiti situation. Results: Daily consumption of soft drinks, sweets and cakes was very high, especially among the Kuwaiti schoolchildren. Very strong correlations were found between daily consumption of sweets and cakes/pastries (r = 0.60; P < 0.01), soft drinks and sweets (r = 0.50; P < 0.01) and between soft drinks and cakes/pastries (r = 0.42; P < 0.01). Among other unfavourable habits, late bedtime, watching TV often and smoking were strongly correlated with the daily use of sugary drinks and foods. Sociodemographic or socioeconomic factors were only weakly associated with the consumption of sugar-rich products. Conclusions: Daily consumption of sugar-rich products seems to be alarmingly high in Kuwait, higher than in any other of the 34 countries in the HBSC study. Other unhealthy habits were associated with the daily consumption of these sugar-rich products.     

Dental health habits in Austria, England, Finland and Norway

Individually, people can prevent dental caries by sugar restriction and periodontal disease by toothbrushing. The aim of this study was to determine the toothbrushing frequency and consumption of sweets and soft drinks in some European countries. The data were obtained during the winter of 1983-84 from schoolchildren aged 11.5, 13.5 and 15.5 in Austria, England, Finland and Norway. Except for England, the samples were nationally representative. The questionnaires were completed at school. Dental health habits apparently were best in Norway, as the toothbrushing frequency was highest and the consumption of sweets and soft drinks was lowest. The toothbrushing frequency of boys was lowest in Finland. The consumption of sweets and soft drinks was very high in Austria and England. Such international comparisons should be used when evaluating and directing national programmes of preventive dentistry.     

Frequent use of sugar products by schoolchildren in 20 European countries, Israel and Canada in 1993/1994

The aim of this study was to describe the daily use of certain between-meal sugar products (soft drinks and sweets) of schoolchildren in 20 European countries, Israel and Canada as a part of the Cross-National Survey on Health Behaviour in School-Aged Children--a WHO Collaborative Study. The data were collected using standardised anonymous questionnaires in school classrooms during the 1993/1994 school year. In each country nationally or regionally representative samples of about 1,300 schoolchildren (450 in Greenland) were targeted. Use of sugar products was analysed according to sex, age, country, self-reported school performance and self-reported family economy. One third to one half of the children (30-48 per cent) drank coke or other soft drinks more than once a day in Israel, Northern Ireland, Scotland, the Slovak Republic and Flemish-speaking Belgium. Use of soft drinks was very uncommon in Finland, Sweden, Norway, Denmark, Latvia and Estonia. The strongest association (odds ratios) was between the use of soft drinks and good family economy; in Russia (20.3), in Lithuania (11.3), in Latvia (10.0), in Poland (8.5) and in Estonia (8.0). In Israel, Scotland, Northern Ireland, Russia and French-speaking Belgium 41-29 per cent of the children ate sweets more than once a day. Boys drank soft drinks and ate sweets slightly more often than girls did. In conclusion, large differences were found between the different countries in the frequency of use of soft drinks and sweets. This should be considered when developing the content of oral health promotion programmes.     

Sugar consumption and caries experience in 12- and 13-year-old Icelandic children

Dietary habits with regard to sugar consumption and caries experience were studied in a group of 275 Icelandic children aged 12 and 13 years. The pattern of meals and sugar-containing food intake frequency were assessed by means of a dietary questionnaire. All dental examinations were performed by one examiner, using standardized methods and diagnostic criteria. Only 75% of the children had three regular meals daily. Breakfast and lunch were the most frequently omitted meals. Sweet buns were consumed by 32% of the children with meals and by 58% between meals, whereas soft drinks were consumed by 42% and 46%, respectively. Eighty-three per cent of the children reported eating sweets daily. The most popular products included confectionery, buns, cakes, and soft drinks, which constituted 53% of the intake with meals and 68% of that between meals. A higher caries incidence was associated with frequent intake of buns and cakes with meals and confectionery.     

Sugar snack consumption in Ugandan schoolchildren: Validity and reliability of a food frequency questionnaire

OBJECTIVES: This study assessed the reproducibility and relative validity of an eight-item self-administered food frequency questionnaire (FFQ) on intake of sugared snacks in Ugandan schoolchildren. A 5-day precoded food behaviour checklist (FBC) was used as validation criteria. Sociodemographic correlates of a sum frequency sugar score were explored. METHODS: The study was conducted in Kampala, Uganda, in 2004. Six hundred and fourteen schoolchildren (mean age 12.4 years) completed the FFQ on cakes/biscuits, chocolate, ice sticks, soft drinks, coffee, tea, sugared desserts and sweets/candies at school. They were examined clinically for dental caries. Forty students completed the FFQ twice, 1 week apart and 325 students completed the 5 day FBC at school. RESULTS: The mean decayed, missing and filled tooth index score was 0.98 (SD 1.6, range 0-15). Reproducibility scores (Cohen's kappa) for the sugar items ranged from 0.17 (ice sticks) to 0.55 (biscuits). No differences were seen between the average intakes at test and retest. Higher intake was reported in FFQ than in FBC across all sugar items. Crude agreement between students reporting intake at least 3-5 times a week/less than three times a week ranged from 50% to 55% (e.g. biscuits, chocolate) to 87% (tea). Spearman's correlation coefficients ranged from 0.14 (desserts) to 0.27 (sweets). anova revealed significant increase (P = 0.001) in the mean FBC sum scores by increasing quartiles of the FFQ sum scores. The average sum FFQ sugar scores were higher in girls than in boys and higher in older than in younger students. CONCLUSION: Fair reproducibility was established for the FFQ sugar items. The FFQ was acceptable in classifying individuals into broad categories of low and high sugar consumption.     

A comparative study of oral health as related to general health, food habits and socioeconomic conditions of 4-year-old Swedish children

ABSTRACT An epidemiologic study of oral health, food habits and socioeconomic conditions of 187 randomly selected 4-year-old children was carried out in the city of Umeå in the north of Sweden. The findings were compared with those in an investigation performed 4 years previously in the same area. The investigation showed a decrease in caries frequency from 1967 to 1971, which might be explained by the advice which had been given at Child Health Centers. The food habits had altered, in that there was less between-meal consumption, particularly of sweets, buns, cakes and soft drinks. Also, increased consumption of fluoride tablets was noted. Multiple regression analyses confirmed the findings of the 1967 study, namely that a high frequency of sweets consumption was positively correlated with caries indexes and that children of parents with a higher educational level had lower caries indexes. It was also found that the Gingival Index was affected by the frequency of consumption of buns, cakes and soft drinks and by a high number of contacts between the teeth.     

Oral health habits of schoolchildren in 11 European countries

This study is part of the Cross-National Survey on Health Behaviour in Schoolchildren--A WHO Collaborative Study, which started in 1982. The aim of the study was to describe the oral health habits (oral hygiene habits, use of sugar snacks and use of fluorides) in schoolchildren in 11 countries. The data were gathered during the 1985-86 school year, and the age groups studied were 11-, 13- and 15-year olds from Austria, Belgium, Finland, Hungary, Israel, Norway, Scotland, Spain, Sweden, Switzerland and Wales. The data are nationally representative for the age groups concerned. Exact results are presented for toothbrushing frequency and use of dental floss, toothpicks, sweets, soft drinks, fluoride toothpaste, fluoride rinses and fluoride tablets. Toothbrushing was consistently less frequent among boys than among girls. Use of dental floss is still very rare. Efforts must be continued to reduce the consumption of sweets and soft drinks. These findings should be taken into consideration when attempts are made to improve oral health education.     

Food and drink consumption,sociodemographic factors and dental caries in 4-5-year-old children in Amman,Jordan

OBJECTIVE: To investigate the association between type of food and drink consumption, sociodemographic factors and prevalence and severity of caries in 4-5-year-old Jordanian children. METHOD: Two-stage random sampling procedure was used to select children enrolled in kindergartens in Amman. Clinical examinations were carried out by one examiner. Mothers completed a questionnaire relating to sociodemographic factors and food and drink consumption. RESULTS: Snack foods were consumed by a high percentage of children. Amongst the most popular 'high in NME sugar snacks', confectionery was reported to be regularly consumed by 76% and biscuits and cakes by 71% of them. More than 50% had carbonated drinks. Children from a lower social class, attending a kindergarten with lower tuition fees had more dessert, squashes and more teas with sugar. When all variables were considered, consumption of confectionery was independently associated with caries prevalence and consumption of teas with sugar was independently associated with caries severity. CONCLUSION: The types of foods and drinks consumed as snacks by young Jordanian children were similar to those of Western countries. In the absence of more widespread oral health promotion measures and in the presence of high prevalence and severity of caries,the oral health of Jordanian children is a matter of concern.     

Consumption of sweet foods among adolescents in Finland

Abstract The importance of sugar in the etiology of dental caries is well known but only few representative studies at population level have been carried out to analyze nutritional factors related to dentistry. As the main exposure to caries the frequency of the use of sugar-products should be known more exactly than we do. The purpose of this study was to analyze the frequency of consumption of sugar-containing products among Finnish adolescents. A representative sample of 3209 Finnish adolescents between the ages of 13 and 19 was drawn. The data were obtained by mail questionnaire in February and September 1977, and in February and September 1979. The separate sample was drawn in February 1978 to analyze the changes with time during 1977–79. The response rate to all the mailed questionnaires was close to 90%. The sugar-containing foods included in the study were sugar in codec or tea, hot chocolate, pastries and cookies, soft drinks, chewing gums, sweets and pastilles. In addition, the data on the consumption of artificial sweeteners were collected. According to current health behavior dogma, girls behaved better than boys. A clear relationship was observed between a householder's educational and occupational status and the children's sugar consumption. Children from homes of low social status consumed more sugar than the others. The percentage of children frequently consuming sugary products decreased with improved school success. It can be concluded that the use of sugar-containing products is especially frequent among young age groups, particularly among boys from low social background and children with poor school success. Health education should be especially directed towards them.     

Profile of the customers and the pattern of purchasing in sweet shops, Kuwait

PURPOSE: This study aimed to describe the profile and the purchasing pattern of the customers of two sweet shops in Kuwait. MATERIALS AND METHODS: The data were collected by observing 500 customers in two sweet shops between 11 a.m. and 2 p.m. and between 5 p.m. and 10 p.m. during a two-week period. One shop was in the city (Capital Governorate; n = 330) and the other was in the suburban area (Ahmadi Governorate; n = 170). Every tenth adult customer was also interviewed, when they had completed their purchasing. RESULTS: There were 58.2% females and 41.8% males among the customers. The mean estimated age of the customers was 29.6 (SD = 13.8) years. The mean payment for the purchase was $5.32 USD (SD 2.350). Females commonly purchased larger amount of sweets (42.6%) compared with males (30.1%; p<0.001). Chocolate was the most common choice of purchase (71%), and only 10% of the products were sugar-free products. The mean age of the customers interviewed was 35.6 years (SD = 9.4). The favourite sugar product of the interviewed customers was also chocolate (36%). The proportion of the customers considering sugar-free products as their favourite decreased consistently with increasing age. More than half of the customers used soft drinks every day (58%). CONCLUSION: Knowledge of the caries risk from sweets needs to be increased with a health education programme. Increasing the availability of sugar-free or tooth-friendly products should be one of the aims of the Kuwait Ministry of Health.     

Dental health related behaviour of Scottish and English secondary schoolchildren

The purpose of this investigation was to compare the dental health related behaviour of groups of 13-14-year-old English and Scottish schoolchildren, in order to explain the differences in caries experience demonstrated by the 1983 national children's dental health survey. The data-bank of health-reported behaviour of schoolchildren in the United Kingdom held by the Schools Health Education Unit (SHEU), Exeter University was used. Seventy-four secondary schools in England and 8 secondary schools in Scotland participated in the study. The information obtained from the questionnaires of 2283 children in England and 259 children in Scotland was examined. The daily intake of sweets, sugary fizzy drinks and a 'sugary' carbohydrate index were analysed from a 24-hour recall dietary record. There was a general consistency between the findings from the SHEU data and the 1983 United Kingdom children dental health survey (Todd & Dodd 1985) with regard to toothbrushing behaviour and dental attendance. Therefore, as dietary information was not gathered in the 1983 survey, exploration of the SHEU data bank allowed a comparison of the dietary habits between Scottish and English schoolchildren. Scottish schoolchildren consumed more sugar-containing items than English schoolchildren. Children from lower social groups in both countries consumed more sugar; however, the major dietary difference between the two countries was not in the mean number of sweets consumed or the daily sugary carbohydrate index, but in the mean number of sugary fizzy drinks consumed.     

Occurrence of risk factors for dental erosion in the population of young adults in Norway

OBJECTIVES?: The aim of this study was to describe the occurrence of risk factors for dental erosion for a group of young adults who are particularly susceptible to erosion. Another aim was to describe the awareness of erosion and distribution of risk factors according to the educational background of the parents. METHODS?: The sample (n?=?2004 individuals) was randomly drawn from the population of 19-20-year-old Norwegians. The data were collected using telephone interviews. We measured awareness about erosion using the following question: 'Have you ever heard about dental erosion?' We obtained information about the frequency of intake of the following risk factors: soft drinks with and without sugar, and juice. Soft drinks with sugar included lemonade (Coca-Cola, Solo, Pepsi, Mozell and ice tea) and sport drinks (XL1, Maxim). Soft drinks without sugar included Cola light, Zero, PepsiMax, Solo light and ice tea light. Juice included orange, grapefruit, apple and kiwi juice. The parents' level of education was based on the Norwegian school system, which has three levels: compulsory schooling (10?years), upper secondary school education (up to 13?years) and university/college education. The data were analysed using logistic regressions analyses. RESULTS?: Awareness of erosion was high - 93.5% of respondents were aware of the problem. The majority of respondents believed that erosion can be prevented - altogether 84.9%. They also believed that soft drinks with and without sugar are equally important for the development of erosion. 17.5% of respondents drank soft drinks with sugar daily or several times a day. The corresponding figures for soft drinks without sugar and juice were 4.9% and 34.1%, respectively. Young adults with mothers with high education drank soft drinks both with and without sugar less frequently than those who had mothers with low education. This pattern was the opposite for juice. CONCLUSION?: Consumption of soft drinks and juice is high, even though awareness and knowledge about the causes of erosion are widespread. This indicates the need for effective intervention strategies to reduce the level of consumption. These strategies should take into account the fact that the distribution of risk factors is skewed with respect to parents' level of education.     

Dietary pattern of Finnish children with low and high caries experience

The correlations between dietary patterns and caries were studied in a series consisting of 534, 5-, 9- and 13-year-old Finnish rural children from low-fluoride areas (0.10-0.46 parts/10(6)). The food consumption of the children was assessed by the 24-hour recall method. The consumption of sweets was estimated by the dietary history method. Caries was diagnosed by clinical inspection. Children with a low and children with a high caries experience were compared with regard to food and nutrient intakes per 1000 kcal. The intakes of most foods and nutrients were similar in the low-caries and in the high-caries groups. However, the diet of the high-caries groups of 5- and 13-year-olds contained less iron, thiamine and ascorbic acid than the diet of the low-caries groups. The intake of sugar and sugar-containing products per unit of energy was higher in the high-caries groups. This was true for soft drinks in particular. Among the 9-year-olds the proportion of sugar consumed as such was greater in the high-caries than in the low-caries children. With regard to the total monthly consumption of sweets no significant differences were observed between the high- and low-caries groups. Analysis of the energy-standardized consumption of food and nutrients thus showed that the relative proportion of sugar and sugar-containing products was somewhat greater in the diet of the high-caries children than in the diet of the low-caries children, but not as high as could be expected. These products replaced foods with a higher nutritive value with the result that the diet of the high-caries groups was on the whole more refined than the diet of the low-caries groups.     

Diet and dental erosion in young people in south-east Brazil

Background. The regular consumption of acidic foods and drinks may be associated with dental erosion, and soft drink consumption appears to be increasing both in developed and developing countries. Dentists are aware that an acidic diet can contribute to the development of erosion; however, there may be confusion within the profession concerning the general health message of eating five portions of fruits and vegetables each day. Objective. The aim of this study was to investigate associations between dental erosion and the consumption of acidic foods and beverages in schoolchildren in south-east Brazil. The objective was to gather information, by means of a dietary questionnaire, on frequency of intake and patterns of consumption of acidic foods and drinks in a group of schoolchildren. The hypothesis was that the experience of dental erosion among the study sample was associated with the frequency and pattern of consumption of soft drinks, fruit juices, fruits, and yogurt. Methods. A cross-sectional study was conducted in Três Corações, south-east Brazil. A sample of 458 schoolchildren, mean age 13.8 (SD 0.39) years, completed the study. Information about potential dietary risk factors for dental erosion was collected through a questionnaire survey completed by the schoolchildren. For the dental examinations, the subjects were examined for dental erosion in a school room. Associations between dental erosion and the variables under study were investigated through processes of bivariate and multivariate analyses. The statistical significance level was set at 5%. Results. Analysis of the questionnaire surveys showed that the frequency of consumption of sugared carbonated drinks was the only variable independently associated with the erosive process, with subjects who had a daily consumption of such drinks having a greater likelihood of having erosion (P = 0.015, odds ratio 1.752, 95% confidence interval 1.116–2.750). Conclusions. Of all tested factors in this sample of schoolchildren the consumption of sugared carbonated drinks is most associated with dental erosion.     

Dental health behaviours in a Norwegian population

The purpose of the present paper was to explain brushing behaviour, interdental cleaning behaviour and sugar behaviour using a selected set of independent variables among 13-14, 23-24, 35-44 and 45-54 year old Norwegians. The empirical data were derived from the Tr?ndelag survey in 1983 (n = 3339), and the data collection was carried out by means of a self-administered questionnaire. Multiple regression analysis was applied. The model was able to explain from 15-19 per cent of the variance in brushing behaviour, from 6-10 per cent in interdental cleaning behaviour, and from 1-5 per cent in sugar behaviour in the four age groups. It provided a good fit for brushing behaviour and interdental cleaning behaviour among adults. Brushing was found to be a habitualized behaviour supported by social norms, and the habit of toothbrushing seems to persist into later life. Among schoolchildren interdental cleaning behaviour and sugar behaviour seemed to be influenced by the same forces. The model did not fit sugar behaviour of adults, which means that other personal and social processes govern their sugar consumption, and the present model is not able to capture these processes. This might indicate that the motives behind the consumption of sweets are different between adolescent subjects and adults.     

Variation of posterior approximal caries incidence with consumption of sweets with regard to other caries-related factors in15–18-year-olds

The aim of this study was to analyze the relationships between caries incidence and a number of caries-related factors in 15-18-yr-olds, in order to estimate the explanatory value of consumption of sweets under different conditions. Sixty-nine 18-yr-olds were interviewed about consumption of sweets and other sugar-containing products during the past 3 yr. Data on oral hygiene, salivary counts of mutans streptococci and lactobacilli, salivary flow rate and oral sugar clearance time were collected when the individuals were 15 and 18 yr old. Caries incidence for the 3-yr period was expressed as a percentage of the number of caries-free approximal surfaces of premolars and molars at the age of 15. Simple linear correlations between caries incidence and the different variables showed that lactobacilli count ranked first (r = 0.26), sweets second (r = 0.25), and mutans streptococci count third (r = 0.24). The r value for caries incidence and consumption of sweets increased in subgroups with combinations of poor oral hygiene, a high intake of other sugary products and a low salivary flow rate (r = 0.67-0.70). In conclusion, consumption of sweets should still be considered an important caries-related factor and particularly harmful when oral hygiene is poor and consumption of other sugary products is high.     

Background factors of enamel focal demineralization in groups of Finnish and Russian children

The aim of this study was to analyze the occurrence of EFD lesions in relation to some background factors in Finnish and Soviet children. Children aged 7, 9 and 12 years (n = 1187) were examined clinically in Helsinki, Kuopio (Finland), Moscow and Leningrad (USSR). A questionnaire sent to the parents was used to collect data on toothbrushing frequency, use of sweets, cakes, soft drinks, sugar-sweetened tea/coffee and mother's education. In addition to bivariate analysis, log-linear regression models were used for comparing the simultaneous association in two ethnic groups. In general, the Finnish children had more EFD lesions than the Soviet children did. Among the Finns no consistent associations were found between the number of EFD lesions and the use of different sugar products or differences in toothbrushing habits. The number of EFD lesions decreased consistently according to mother's education with the Finnish children, but not with the Soviet children. The final multivariate model for Finnish children included age, toothbrushing frequency, place of residence (Kuopio) and use of soft drinks. The respective model for the Soviet children included age and place of residence (Leningrad). Evidently, the demineralization process or tooth resistance differs in these two ethnic groups.     

Patterns in consumption of potentially erosive beverages among adolescent school children in the Netherlands

Aim: To determine the frequency of intake and patterns in consumption of potentially erosive beverages in school children in the Netherlands. Methods: A cross‐sectional, single centre study was performed among 502 school children in Rotterdam, in age varying between 12 and 19 years. Data on consumption of soft drinks, energy drinks, sports drinks and alcopops were obtained through a self‐reported questionnaire. Gender‐ and age‐related differences in consumption were analysed with Chi‐square, Kruskal–Wallis and Mann–Whitney tests. Associations between variables were investigated with Chi‐square tests and Spearman’s rank order correlation analysis. Results: Boys consumed soft drinks, energy drinks and sports drinks more frequently than girls, and on average also consumed higher amounts of these drinks. No gender‐related differences were observed in alcopop consumption. Consumption of all drinks was most frequent at 14‐ or 15‐year of age, with the exception of alcopops which was most frequent by 16‐year‐old school children. Significant positive associations were observed between the consumption of soft drinks, energy drinks and/or sports drinks. Alcopop consumption was only associated with consumption of energy drinks. Conclusion: Consumption of soft drinks, energy drinks, sports drinks and alcopops by school children is related to age and gender. The significant positive associations between the consumption of these drinks suggest that a subgroup of school children exists with a high cumulative intake of these potentially erosive drinks.     

Restoring oral health

During the last decade, a continuous decrease in dental caries has been observed among schoolchildren in Iceland. In this paper, various epidemiological studies have been reviewed and summarized to illustrate caries prevalence, and how it has changed during the last decades. Furthermore, an attempt has been made to describe some of the factors involved and their possible effects on caries disease. During this period, sugar consumption increased, especially in the form of sweets and soft drinks. At the same time, the import of toothpaste increased, and preventive measures such as fissure sealants and fluoride rinsing programs were intensified. Other factors likely to have had an impact were changes in treatment philosophy and increased personnel resources. There does not seem to be any single factor responsible for the onset of the caries decline. It rather looks as if this was a multifactorial effect due to a number of different preventive measures. During recent years, a change in treatment philosophy, the evident increase in fluoride toothpaste consumption, and possible changes in the oral microbial flora, together with the use of fluoride varnishes, sealants, and increased manpower, may explain the decline.