Oxford Textbook of Public Health

Hardcover: 1651 pages
Publisher: Oxford University Press; 3rd edition (January 15, 1997)
ISBN: 019262553

Hardcover: 1956 pages
Publisher: Oxford University Press, USA; 4 edition (May 15, 2002)
ISBN-10: 0192630415

Paperback: 1996 pages
Publisher: Oxford University Press, USA; 4 edition (June 15, 2002)
ISBN-10: 0198509596


9.8 Dental public health
Stanley Gelbier and Peter G. Robinson


Under a variety of guises dental public health has come to the fore in developed and developing countries.
The British Association for the Study of Community Dentistry defines dental public health as: ‘the science and the art of preventing oral diseases, promoting oral health and improving the quality of life through the organized efforts of society’.
In the United Kingdom, it has become very sophisticated, there now being a recognized specialty of dental public health.
The areas which are perceived to be the business of British consultants and specialists in dental public include:

● indicators of oral health
● 口内保健に関する指標

● determinants of oral health status

● evaluation of oral health services
● 口内保健事業の評価

● prevention and control of oral disease
● 口内疾病の予防と管理

● promotion of oral health
● 口内の健康づくり

● policy and service development and prioritization
● 政策および保健機関の、整備と優先順位の決定

● evaluation of technology
● 科学技術の評価

● the effectiveness of treatment modalities
● 治療技術の評価

● promotion of clinical effectiveness
● 治療有効性の向上

● evidenced-based commissioning.
● 科学的検証をともなう仕事の委託

Although defining the United Kingdom situation, theses areas are of relevance worldwide.
They also help to provide cost and clinically effective services.

 In order to be prepared to undertake such specialized work, specialist registrars in the United Kingdom undertake a period of education and training.
Before entry to the training programme, candidates must possess a fellowship or membership in dental surgery of one of the Royal Surgical Colleges (England, Edinburgh, Glasgow, or Ireland).
この訓練課程に参加するためには、候補者は王立歯科大学 (England, Edinburgh, Glasgow, Ireland) のいずれかの歯科の特別研究員か会員でなくてはならない。
They also gain a Master of Science degree in dental public health (or its equivalent), either before or during the training period.
The training programme takes place under the direction of an established consultant in the specialty.
During training they are expected to demonstrate the acquisition of a number of distinctive competencies, which will enable them to undertake their work.
These competencies have been divided by the specialty into the eight areas listed below.
All have relevance in both developing and developed countries, although the emphasis on particular components will vary according to social factors, the burden of disease, organization of health services, geographical factors, and the economy.


1. Oral health needs and demands assessment: description of the determinants of oral disease; identification of determinants amenable to change; understanding the principles of epidemiology and biostatistics in relation to dentistry; derivation of appropriate dental indicators; survey and database design; and data analysis including interpretation of statistics and application of results.
1. 口内保健の需要と提供の評価: 口内疾病の決定要因の記述 変化に富んだ決定要因の特定。歯科に関連する疫学と生物統計学の原理の理解。適切な歯科指標の導出。調査および基本資料の設計。統計の解釈と結果への適用などの資料分析。

2. Information technology, commissioning, and evaluation of dental health services: knowledge of the availability and methods of access to various sources of information within the health service; understanding the contracting processes through which health services are purchased and monitored; contracting and service specification development to meet dental health needs; derivation and measures of oral health improvement and application of appropriate economic analysis.
2. 歯科医療の情報技術と実行と評価: 医療に関するさまざまな情報源の利用可能性と入手する方法の知識。医療に予算が投入されて定期的に監視されるまでの契約過程の理解。歯科保健のニーズに見合った契約と医療仕様の改善。口内保健の改善を導き出し評価すること、および適切な経済分析の適応。

3. Promoting oral health: ability to interpret oral health and dental practice in terms of social relationships and social context; understanding of the principles, methods, and limitations of preventive dentistry and oral health promotion.
3. 口内の保健づくり: 社会的関係と社会的背景の観点から口内保健と歯科臨床を説明できる能力。予防歯科の原理と方法と限界の理解と、口内の健康づくりの理解。

4. Research and development: identification of appropriate areas for research and development and the application to this of research methodology.
4. 研究開発: 研究開発をすべき適切な領域の識別と、研究方法の適応。

5. Teaching and training: at undergraduate and postgraduate level and in multidisciplinary/multiagency settings.
5. 教育と訓練: 卒前、卒後の水準において。総合的/複数機関の環境において。

6. Effective communication: negotiation; influencing; communication (written, oral, and non-verbal); listening; counselling.
6. 効率的意思伝達: 交渉。影響力。意思伝達 (文章、口語、非言語)。傾聴。相談。

7. Management: resource management, control, leadership, planning, conflict management, team work/co-ordination, origanization.
7. 管理: 資源管理。管理。指導力。計画。対立による摩擦の管理。共同活動/連携。組織化。

8. Political acumen: developing policy, political awareness (the art of the possible), evaluating strategy, strategic opportunism.
8. 政治的な洞察力: 政策の整備、政治意識 (可能性を模索する技術)、戦略の評価、戦略的日和見主義

In the subsequent sections we shall show how some of these areas are used in every practice.

The importance of oral health

Oral health is often a low priority for individuals, policy-makers, and publichealth specialists.
In fact, oral health is an important public health problem because oral diseases have significant impacts on individuals and the community, they are widespread, and the two most common disease—tooth decay (dental caries) and gum (periodontal) diseases—are almost entirely preventable.


 The impacts of oral disease range between frank mortality and effects on systemic health and quality of life.
Oral diseases also create a considerable burden to both individuals and the community in terms of economic productivity.

Impacts of oral disease

Mortality from oral cancer is related to the site in the mouth and the timing of the diagnosis but 5-year survival is less than 50 per cent.
In addition to mortality, oral disease affects other aspects of systemic health.
Limited dietary choice and calorific and micronutrient intake are direct consequences of conditions such as exrostomia, poorly fitting dentures, loss of teeth in nursing caries, and oral developmental disorders (Hollister and Weintraub 1993).
食事の制限、カロリーおよび微量元素の摂取の制限は、直接的に、口内乾燥症、義歯の不適合、哺乳瓶齲蝕による歯の喪失、口内発達障害といった状況をもたらす(Hollister and Weintraub 1993)。
The role of bacteraemia as a sequel of oral disease and treatment is well known in the aetiology of bacterial endocarditis but periodontal diseases may also be aetiological factors for cardiovascular disease and low birth weight.

 Oral disease also directly affect our quality of life (Slade 1997).
 口内疾病は、我々の生活の質に直接に影響を与える(Slade 1997)。
Dental pain is very common.
As many a one in eight adults in the United States experience toothache over a 6month period and still more have sore mouths and joint pains (Lipton et al. 1993).
U.S.の成人の8人に1人は、ここ6ヶ月に歯の痛みを経験しており、さらに多くの人が口内の痛みと顎関節痛を経験している(Lipton et al. 1993)。
One in six 8-year-olds in a suburb of London had experienced toothache which had caused them to cry (Shepherd et al. 1999).
London近郊の8歳児の6人に1人は、泣き叫ぶ歯の痛みを経験している(Shepherd et al. 1999)。
Oral appearance affects our self-esteem, our willingness to interact with others, and influences the judgements other people make about us (Shaw et al. 1985; Fiske and Waters 1990).
口元は、自尊心、他人と付き合う意欲に影響し、他人の私たちについての判断を左右する(Shaw et al. 1985; Fiske and Waters 1990)。
Good dental appearace is regarded as a requirement for some prestigious occupations (Jenny and Proshek 1986).
整った口元は、一流の職業につく人の要件であると考えられている(Jenny and Proshek 1986)。

 The economic coasts of dental disease are difficult to calculate.
As well as the direct costs of disease and treatment, there are indirect costs wich might include reduced employment or promotion expectations and opportunities, limitation of academic achievement, and the total societal burden through loss of economic productivity.
The direct costs are between 0.2 and 1 per cent of the gross national product in developed countries (van Amerongen et al. 1993).
直接費用は、先進国では、国民総生産の0.2-1%である(van Amerongen et al. 1993)。
The United Kingdom is at the lower end of this range.
Yet dentists’ fees for treatment within the National Health Service (NHS) in England and Wales (population 52 million) for the first 3 months of 1999 were £357 million (equivalent to £1.4 billion per annum) and the figure is rinsing each year (Dental Practice Board 1999).
しかし1999年の1-3月のEnglandとWales(人口5200万人)のNHS (National Health Service) 内における歯科医療費は714億円(年あたり2800億円)であり、この数字は年々上昇している(Dental Practice Board 1999)。
[£35700 0000, 1£=200円で計算]
This sum is all the more surprising when it is considered that only 18 million of the population are registered with an NHS dentist.
The cost of the population outside the NHS is not known.
An indication of the loss of economic productivity due to dental disease was calculated by Gift et al. (1992).
歯科疾病による経済的生産性の喪失の指標はGift et al. (1992)により算出された。
In 1989, over 20 million work days and 51 million school hours were lost in the United State due to oral disease and its treatment.
These data equate to 1.5 h for each employee annually.
Low-income families were more likely to lose time from work and school because of dental disease and so these impacts of oral disease compound the inequalities that already exist in health, income, and educational attainment.

Frequency of oral disease

Oropharyngeal cancers are amongst the 10 most common cancers in the world and their incidence is increasing.
The highest reported incidence rates are in India and Sri Lanka where the mouth is the most common site, comprising up to 40 per cent of all cancers.
発生率が最も高いと報告されているのはIndiaとSri Lankaであり、口内で最も多く癌が発症し、全ての癌の40%を占めている。
Dewpite falls in incidence of dental caries over the last three decades, 45 per cent of 5-year-olds in Great Britain have evidence of clinically significant toothy decay (Pitts and Palmer 1995).
ここ30年間の齲蝕の発症数の減少にも関わらずGreat Britainにおける5歳児の45%が臨床的に重大な齲蝕を有している(Pitts and Palmer 1995)。
Periodontal diseases are even more common.
More the 80 per cent of adults have inflamed gums (gingivitis) and most have evidence of destruction of the attachment between tooth and bone (periodontitis) (Brown et al. 1989; Todd and Lader 1991).
成人の80%以上が歯肉の炎症(歯肉炎)を有しており、ほとんどの人に、歯と骨の間の付着の破壊(歯周炎)の痕跡が見られる(Brown et al. 1989; Todd and Lader 1991)。



Finally, the two most common oral disease are almost entirely preventive.
Clinically significant dental caries occurs only in the presence of excess dietary sugar.
Estimates suggest that the incidence of disease could be kept acceptably low at levels of sugar consumption below 10 to 15 kg/person/year (Sheiham 1991).
概算によると、砂糖消費を年間1人あたり10-15kg以下とすることで、齲蝕の発症数は許容できる低さにとどめられる(Sheiham 1991)。
This dietary control of tooth decay can be supplemented by the use of fluorides which demonstrably prevent the disease whether presented in drinking water or in tooth pastes.
Likewise, the presence of dental plaque is necessary for the most common form of destructive periodontal disease.
Targets for oral cleanliness have been calculated which appear to be compatible with freedom from periodontal disease throughout life (Burt et al. 1985).
口内清掃の目的は、人生を通して歯周疾病から解放されるため、とされている(Burt et al. 1985)。
Slightly higher levels of plaque might be compatible with acceptably low levels of periodontal disease.

 Therefore oral health therefore has a public health significance.
This chapter will discuss the features, epidemiology, artiology, and management of four important oral diseases: dental caries, periodontal diseases, oral cancer, and orofacial trauma.
Approaches to oral health promotion in relation to these diseases will be outlined within a common risk factor approach.
これらの疾病に関連した口内の健康づくりの手法は、コモン・リスク・ファクター手法 から学ぶことができる。

Dental caries

Under normal circumstances, there is a chemical equilibrium between the minerals of the tooth and the adjacent oral fluids.
The equilibrium is disrupted by acidic metabolites of oral bacteria if there is an excess of dietary sugars.
Dental caries is the progressive demineralization of the tooth that results.
In the very early stages, the lesion appears as a chalky white spot on the teeth.
If the lesion progresses, the surface of the tooth breaks down and there is cavitation.
If the caries reaches the underlying dentine, it can spread more readily through the porous and less mineralized tissue toward the pulp.
Infection of the pulp may allow the passage of bacteria along the root canals to the alveolar bone.

 The direct consequences of this process are distraction of the tooth, pain, and a possible dental abscess.
Dentine is sensitive to physical, thermal, and osmotic stimuli.
When it is exposed by cavitation there may be transient pain associated with hot or cold drinks or sweet foods.
Later, as the pulp becomes inflamed, the discomfort may be spontaneous, exquisitely painful, and of longer duration.
In a dental abscess, pressure to the tooth is transmitted to the infected alveolus and the unfortunate person avoids biting or knocking the tooth.

 Four factors are necessary for the development of caries: dietary sugars, a susceptible tooth surface, the microflora of dental plaque, and adequate time.

 Despite the obvious ethical difficulties of conducting human experimental studies to investigate the role of sugars in the aetiology of dental caries, the evidence implicating them is more than compelling.
Rugg-Gunn’s (1993) encyclopaedic review classifies this evidence methodologycally into human observational studies, human interventional studies, animal experiments, enamel slab experiments, plaque pH studies, and incubation experiments.
Rugg-Gunn (1993) の百科事典的なレビューでは、この科学的検証を、ヒト観察研究、ヒト介入研究、動物実験、エナメル片実験、プラークpH研究、培養実験に分類した。
Dietary sugars are essential if the caries is to be of clinical relevance.
The bacteria of dental plaque, particularly Streptococcus mutans, metabolize them and so produce acids and use them to form extracellular polysaccharides.
プラークの微生物、とりわけStrectococcus mutansは、砂糖を代謝し、酸を産生し、また菌体外多糖を形成する。
The polysaccharides increase the bulk of the plaque, facilitate the adhesion of more bacteria, and restrict the flow of saliva to the tooth surface.
With each exposure to sugar the plaque pH falls sharply and rises slowly back to normal levels over the following hours.
It follows that caries incidence is related to the frequency of intake of sugars (Gustaffson et a. 1954) .
齲蝕の発症は、砂糖摂取の頻度に関連している(Gustaffson et al. 1954)。


 The mineral component of the tooth is predominantly calcium and phoshate in the form of hydroxyapatite.
At normal pH levels, the hydroxyapatite crystals of tooth are in dynamic equilibrium with these ions in the plaque fluid.
At high pH there is remineralization of the tooth, especially in the presence of fluoride.
Saliva plays a crucial protective role against caries by simple dilution, by buffering plaque acid, and by acting as a source of minerals and chemical and immunological plaque inhibitory factors.
For these reasons dental caries is more frequent in the sites less accessible to the saliva—the pits and fissures of posterior teeth and between these teeth.
Caries is also more common in people with restricted salivary flow.


Caries of the permanent dentition is traditionally measured using an index which records the number of decayed, missing, and filled teeth,
A more precise index records the number of surfaces affected and a similar index is used to record the status of the deciduous dentition.
Because the index aggregates both disease and treatment experience it is sensitive to the treatment decisions of dentists and so less valid with increasing age.
[DMFT indexは伝統的にDMF歯数と訳されていますが、ここではindexの性質を強調するため直訳としています]
Since each of the categories is equally weighted, it is insensitive to both the severity of the disease and outcomes of treatment.
At low levels of caries the number of people ‘caries free’ (which actually means free from clinical evidence of progressive disease and treatment) may be a more useful community-based measure of disease.

 Nevertheless the decayed, missing and filled teeth index has been used for 60 years and will continue to be used.
This does not mean that decayed, missing, and filled teeth index scores of yesteryear are directly comparable with those of today as the criteria for judging a tooth as carious have changed.
Although the threshold for diagnosis is usually whether the caries has reached dentine, many previous criteria used a sharp dental probe to determine whether there was cavitation of the tooth (WHO 1979).
診断の出発点は、一般に齲蝕が象牙質に達しているかどうか、であるが、多くの以前の基準は、歯の齲窩を検出するために、尖った歯科用探針を利用していた(WHO 1979)。
The criteria now in use in many countries avoid the use of probes to prevent damaging the tooth surface.
Consequently, the index is less sensitive and more specific (WHO 1997).
その結果として、この指標は、感度が低下し、特異度が増加した(WHO 1997)。
However, the dental status of populations is usually summarized by the mean decayed, missin, and filled teeth index of 12-year-old children.
Chronological and international comparisons are made with these data.

 Although dental caries can be identified in the teeth of skulls found in archaeology, dental caries as it is known today did not emerge until sugar became widely available (Burt 1978).
 齲蝕は、考古学において発見される頭蓋骨の歯にて認められ得るが、今日知られている齲蝕は、砂糖が広く利用できるようになるまでは、課題とはならなかった(Burt 1978)。
Levels of caries rose during the seventeeht century and reached epidemic proportions in the nineteenth and twentieth centuries.
The disease has been exceedingly common in some populations with near universal experience in some generations in many countries.
Since systematic data have been collected, the typical pattern has been one of high levels of caries in developed countries associated with exposure to sugars.
In the mid-1970s levels in many developed counries began to fall dramatically (Marthaler 1990a).
1970年代には、齲蝕の水準は多くの先進国で劇的に降下し始めた(Marthaler 1990a)。
In the United Kingdom, the mean decayed, missing, and filled teeth index decreased from 4.8 to 1.2 between 1973 and 1993 and by similar amount in Australia (4.8 to 1.1) between 1977 and 1993 (Downer 1994; Davies et al. 1997).
英国では、DMFT指標の平均値は1973年から1993年の間に4.8から1.2に減少し、オーストラリアにおいても1977年から1993年の間に同じくらい(4.8から1.1) 減少している(Downer 1994; Davies et al. 1997)。


 This fall in caries incidence in developed countries appears to have halted in the early to mid-1980s (Burt 1994; Downer 1994).
 先進国における、この齲蝕発生率の減少は、1980年代初期から中期にかけて、停滞したように見える(Burt 1994; Downer 1994)。
The mean decayed, missing, and filled teeth index of 5-year-olds in England and Wales fell from 4.0 to 1.8 between 1973 and 1983 but now apprars stable at around 1.8.
Despite the halted fall there are cohorts of children and young adults who have better oral health than precedinggenerations.
As these cohorts age there will be commensurate improvements in adult oral health.

 Data on caries levels aggregated at the national level provide useful information but can mask important trends.
The fall in caries incidence has polarized the inequalities in oral health.
[残念。階調性gradientは示していますが、二極化は見られません。From victim blaming to upstream action: tackling the social determinants of oral health inequalitiesより]
In times of high disease prevalence nearly everybody had the disease and the number of teeth affected in an individual.
With lower disease prevalence a minority of people carry the burden of most of the disease.
Half of all 12-year-olds in England and Wales have never had tooth decay of their permanent teeth (Downer 1994).
EnglandとWalesの全ての12歳児の半数は、永久歯に齲窩を有していない(Downer 1994)。
As is the case for most important disease, in developed countries dental caries and its consequences are increasingly diseases of the poor (Gratrix and Holloway 1994; Watt and Sheiham 1999) .
たいていの重要な疾病と同じように、先進国では、齲蝕とその影響は、貧困階層でますます増加している(Gratrix and Holloway 1994; Watt and Sheiham 1999)。

 There have been concerns of increasing levels of caries in developing counties although other analysts suggest that there are no major trends (Holm 1990; Manji and Fejerskov 1990; Fejerskov et al. 1994).
 大きな傾向ではないという分析もあるが、開発途上国で齲蝕水準の上昇の懸念がある(Holm 1990; Manji and Fejerskow 1990; Fejerskov et al. 1994)。
Recent surveys in Africa show that caries levels in 12-year-olds are still relatively low although there are suggestions of increases in some countries.
Aggregated national data may mask local variations, and in particular, high caries levels in urban areas.
Such trends would reflect economic and cultural trends in the region with the change from traditional starchy foods to greater consumption of refined carbohydrates (Thorpe 1993).
このような傾向は、伝統的なでんぷん食品から精製された炭水化物の大規模な消費という変化をしている地域での、経済的文化的傾向を反映している(Thorpe 1993)。
Of particular concern is the fact that 90 per cent of the caries in Africa remains untreated.

Traditional treatment

Until the nineteenth century the only useful treatment for dental caries was extraction of the affected tooth.
Since then there has been a transition to restorative care in which the infected parts of the tooth are remoced and replaced with a inert obdurating filling.
During the latter half of the twentieth century technology moved forward, dentists became keen to make use of recent innovations, and patients became willing to pay for them.
The result is that operative treatment for adults is increasingly complex and technology intensive.
Badly decayed teeth can now be restored with a range of adhesive tooth coloured materials that are either formed in the mouth or prepared in laboratories and then fitted.
Originally, missing teeth could only be replaced with removable dentures.
Now they can be replaced with bridges which adhere to the remaining teeth or with prostheses supported by osseo-integrated implants which project out through the gingivae.

 These treatments provided by dentists might reduce the social impact of dental caries on affected people but play a very minor role in preventing the disease.
Dental sercices explained 3 per cent of the reduction in caries levels in industrialized countries during the 1970s compared with the 65 per cent contribution made by broader socio-economic factors and the availability of fluoride toothpastes (Nandanovsky and Sheiham 1994,1995).
歯科医療は、1970年代の先進国における齲蝕水準の3%の減少を説明した一方で、広範な社会経済的因子とフッ化物歯磨剤の有効性は65%の貢献であった(Nadanovsky and Sheiham 1994, 1995)。


Implication of changes in caries prevalence

The low incidence of disease experienced in the developed world over the last 15 years has profound implications for the management of dental caries.
When the incidence of the disease is low, proportionatly more caries affects the accessible occlusal surfaces of the teeth and only simple restorations are needed to treat it (Stamm 1991).
疾病の発生率が低いときには、その低さに比例して、多くの齲蝕が、歯の治療が容易である咬合面に発生するため、治療に単純な修復ですむ(Stamm 1991)。
The disease also progresses more slowly which allows dentists to defer operative treatment whilst attempting to prevent the spread of of the lesion.
Many lesions are detected at an earlier stage so that new dental materials can be used in minimally invasive techniques (Elderton 1990).
多くの病変はより早期に発見されるため、低侵襲治療のための新しい歯科材料がより利用されるようになる(Elderton 1990)。

 The lower levels of disease mean that the costs of some dental services might be reducing the number of interventions and the number of dentists.
Increasing the intervbals between dental examinations is safe and effective for children and adults with low disease incidence (Riordan 1997).
歯科定期健診の間隔が延びることは、疾病の発症率が低い子供と成人にとっては、安全で効果的である(Riordan 1997)。
Since most of the restrations required by children are relatively simple, the number and costs of dentists can be reduced by using less highly trained auxiliaries.
The reduced burden of disease may allow general dental practitioners to become more involved in heaolth promotion, and to place a greater emphasis on prevention and on quality (Rear 1994).
疾病の負荷が減少することで、一般歯科臨床家はさらに健康づくりに参加することが可能になるだろうし、疾病の予防と医療の質に重点をおくことが出来るだろう(Rear 1994)。
Elderton (1994) has argued for a reduced emphasis on operative technique in dental training so that dentists can become more like physicians working with a range of auxiliaries to obtain the maximum health gain for populations.
Elderton (1994) は、歯科医師がより一層、集団全体の最大限の健康向上のための補助者として働く医師のようになるために、歯科訓練における外科技術偏重の傾向を改善をするべきだと主張した。
Conversely, there are still many older people (in this case that means more than around 35 years of age!) who have suffered the ravages of dental caries and tis treatment.
These people will continue to need and demand increasingly increasingly complex treament for the next 25 year or so (Treasure and Whyman 1995).
これらの人々は、将来25年以上にわたり、複雑な治療をますます必要とし要求し続けるであろう(Treasure and Whyman 1995)。

Periodontal diseases

Periodontal disease comprise a range of inflammantry disease of the periodontium categortized by the poison of attachment between gingiva and tooth (Caton 1989).
歯周疾病は、歯肉と歯の付着の位置により分類された、歯周組織の炎症性疾病全体からなる(Caton 1989)。
In gingivitis the attachment remains in a healthy position near the cement-enamel junction.
Periodontitis is defined by migration of the epithelium which reduces the amount of periodontal ligament and bone supporting the tooth.

 Gingivitis is an inflammatory reponse to plaque.
Along with redness and swelling, the gums may bleed on gentle prfovocation such as cleaning the teeth.
Pain is an uncommon feature.
Systemic involvement including hormonal changes, skin disease, and medication use may modify thses disease or cause other gingival changes.
The disease is exceedingly common.
Bleeding on probing is present in 79 per cent of adults in the United Kingdom and 85 per cent in the United States (Brown et al.; Todd and Lader 1991).
プロービングによる出血は、英国の成人の79%、米国の成人の85%に見られる(Brown et al. 1989; Todd and Lader 1991)。
Erythematous changes are likely to be more frequent.

 In periodontitis the loss of periodontal attachment is manifest by deepening of the pockets between the gingivae and teeth and by recession of gingivae.
In severe cases, the supporting structure are so depleted that the teeth become loose.
The disease is rarely, if ever, painful unless an acute infection complicates a periodoncal pocket (‘a lateral periodontal abscess’) or if the exposed root surfaces are temperature sentive.


 Sophisticated classificatory systems categorize periodontitis by its age of onset and systemic involvement (Caton 1989), but adult periiodontitis is by far the most common form.
 歯周炎は、洗練された体系により、その生じる年齢と全身状態をもとに分類される(Caton 1989)が、その中でも間違いなく、最も蔓延している型は、成人性歯周炎である。
Its frequency is difficult to assess.
The ‘burst theories’ suggest that there are episodes of localized destructive disease followed by quiescence (Socransky et al. 1984).
‘突発理論’は、静止期に続いて局所破壊が生じることを示唆している(Socransky et al. 1984)。
In this case lost periodontal attachment may be the legacy of previous disease and more sophisticated test are required to detect ‘active’ disease.

 Mild periodontal pocketing is common.
For example, it is seen in half or more of adults in United Kingdom and the United States (Brown et al. 1989; Todd and Lader 1991).
例えば、英国と米国の成人の半数かそれ以上に見られる(Brown et al. 1989; Todd and Lader 1991)。
Evidence of severe peridontitis is much less frequent.
Lost attachment or pockets of 6 mm or more (thought to be sufficient to threaten tooth survival) are seen in less than 8 per cent of adults in the United States nad the United Kingdom (Miller et al. 1987; Todd and Lader 1991).
歯肉付着の喪失や6mmかそれ以上のポケット (歯の生存を脅かすと考えられる) の歯周疾病患者は、米国と英国における成人の8%未満に見られる(Miller et al. 1987; Todd and Lader 1991)。
Evidence of the disease is more frequent and severe in countries where tooth cleaning practices are less sophisticated (loe et al. 1986).
歯の清掃の実践が普及していない国では、疾病の頻度は高く、また重度である(Loe et al. 1986)。

 One other periodontal disease has public health importance.
Acute necrotizing ulcerative gingivitis (Vincent’s infection or ‘trench-mouth’) causes necrosis, ulceration, soreness, and bleeding of the gingivae (Johnson and Engel 1986).
急性壊死性潰瘍性歯肉炎(Vincent感染症あるいは‘塹壕口内炎’)は、潰瘍と壊死、疼痛、歯肉出血を引き起こす(Johnson and Engel 1986)。
The ulcerated papillae may have a grey slough and there may be a characteristic fetor.
Lymphadenopathy and mild fever are variable findings.
In many developed countries, acute necrotizing ulcerative gingivitis is a disease of young adults.
There are no good incidence data, but anecdotally it has become less frequent among some developed populations in recent years.
A variant of the disease is associated with HIV infection (Robinson et al. 1998).
疾病の変異体はHIV感染症と関連がある(Robinson et al. 1998)。
Acute necrotizing ulcerative gingivitis is also seen in African children where it can be profressive in the absence of treatment (Emslie 1963).
急性壊死性潰瘍性歯肉炎は、アフリカの子供にも見られ、そこでは未処置による進行も見られる(Emslie 1963)。
In severe cases necrosis may extend over adjacent and contiguous tissues to cause gross destruction of oral and facial tissues (known as cancrum oris or noma).


The pathogenesis of perioodontittis involves the interaction of plaque pathogens with the host’s immune system (Genco and Slots 1984).
歯周炎の病因は、宿主の免疫系とプラーク病原体の相互作用からなる(Genco and Slots 1984)。
Periodontal destruction occurs directly as a result of pathogenic bacterial components and indirectly via host destructive mechanisms that are part of the immune response to infection (Genco 1990).
歯周組織の破壊は、直接的には病原微生物の構成要素で、間接的には感染への免疫応答の一部である宿主の破壊機構の結果として生じる(Genco 1990)。

 Dental plaques are consistently implicated in the aetiology of periodontal diseases.
Gingivitis is initiated by plaque and reduced by its mechanicalo and chemical suppression (Silness and Loe 1964; Loe et al. 1965; Loe and Schiott 1970).
歯肉炎は、プラークに起因し、その機械的化学的清掃により、緩和する(Silness and Loe 1964; Loe et al. 1965; Loe and Schiott 1970)。
Plaque is also implicated in periodontitis (Lovdal et al. 1958).
プラークは、歯周炎にも関連している(Lovdal et al. 1958)。
Plaque pathogens have virulence factors, including endo- and exotoxins, and initiate and enhance alveolar destruction in animal studies (Gibbons and Socransky 1966; Slots and Genco 1984; Holt et al. 1988).
プラーク病原体は、内、外毒素を含む、毒性因子を有し、動物研究において歯槽骨の破壊を生じさせ、憎悪させる(Gibbons and Socransky 1966; Slots and Genco 1984; Holt et al. 1988)。
Progression of periodontal destruction is reduced by controlled oral hygiene (Sumoi et al. 1971; Acelsson and Lindhe 1978).
歯周組織の破壊の進行は、口内衛生の管理により、減少される(Suomi et al. 1971; Axelsson and Lindhe 1978)。

 Considerable research is devoted to determining which, if any, specific pathogens are responsible for periodontal destruction (the ‘specific plaque hyphothesis’).
Dental plaque is ubiquitous but destructive disease occurs only in a minority of people.
Therefore plaque is not sufficient cause for periodontitis, and microbiological research has diverted attention away from the important determinants of periodontal disease susceptibility (Clake and Hirsch 1995).
だから、プラークは歯周炎においては重要な原因ではなく、微生物学的研究は方向を変えて、歯周疾病の感受性の重要な決定要因としては注意を向けられなくなっている(Clarke and Hirsh 1995)。

 Tobacco use is often confounded by poor oral hygiene in periodontal research, but it is now clear that tobacco exerts an independent deleterious effect (Bergstrom 1989; Ismail et al. 1990; Stoltenberg et al. 1993; Martínez-Canut et al. 1995).
 喫煙は、歯周組織の研究ではしばしば劣悪な口内衛生状態と交絡するが、現在では、煙草が単独でも有害な影響を持つことが明らかになっている(Bergstrom 1989; Ismail et al. 1990; Stoltenberg et al. 1993; Martínez-Canut et al. 1995)。
In addition, periodontal treatment is less effective in smokers (Preber and Bergstrom 1985, 1990).
さらに、歯周治療は、喫煙者には効果が低い(Preber and Bergstrom 1985, 1990)。
Stress is also a risk factor in periodontal diseases.
Greater occupational stress is associated with progressioin of periodontitis, and acute necrotizing ulcerative gingivitis has been noted among soldiers on difficult posting, students during examination terms, and people with other negative life events (Roth 1951; Giddon et al. 1963; Linden et al. 1996).
大きな職務上のストレスは歯周炎の進行と関連している。また急性壊死性潰瘍性歯肉炎は、困難な任務に就く兵士や試験期間中の学生、不幸な生活上の出来ことが生じている人々に見られることが、わかっている(Roth 1951; Giddon et al. 1963; Linden et al. 1996)。


 Periodontitis often takes decades to become detectable clinically.
Accordingly, it is more common and severe with advanced years because age confounds disease duration (Abdellatif and Burt 1987).
さらに、年齢は有病期間に交絡するため、歯周炎は高齢者においてより頻繁にみられ、また重症化している(Abdeellatif and Burt 1987)。
Periodontitis is not a consequence of age (Papapanou and Lindhe 1992), it is associated with poor oral hygiene irrespective of age (Suomi et al. 1971), and it does not progress in adults with good oral hygiene (Loe et al. 1978).
歯周炎と加齢との因果関係はなく (Papapanou and Lindhe 1992)、年齢ではなく劣悪な口内衛生と関係があり (Suomi et al. 1971)、良好な口内衛生の成人においては進行しない(Loe et al. 1978)。

 In the last years, periodontal diasease have been linked to a number of other health problems including cardiovascular disease, strokem, preterm birth, and low birth weight.
A number of authors suggest that periodontal disease may even be independent risk factors for these diseases.
Several reports have focused on the biological plausibility of these associations.
[Bradfood HillのCriteriaを参照して下さい]
Periodontal pathogens may invade endothelial cells or periodontal diseases may provide a burden of endotoxins and cytokines which initiate and exacerbate atherogenesis and thrombus formation (Beck et al. 1996; Deshpande et al. 1999).
歯周疾病原体は内皮細胞に侵入し、また内毒素やサイトカインによるアテローム発生や血栓の形成を引き起こして悪化させるという負担をもたらす(Beck et al. 1996; Deshpande et al. 1999)。

 The main epidemiological evidence supporting links between periodontal and other diseases arises from retrospective analysis of cohort data and from case-contorol studies (Beck et al. 1996; Offenbacher et al. 1996; Dasanayake 1998).
 後ろ向きコホート研究と症例対照研究による疫学的検証により、歯周疾病とその他の疾病との関連が支持されている(Beck et al. 1996; Offenbacher et al. 1996; Dasanayake 1998)。
However, there is the potential for misclassification along with other sources of bias in these types of studies.
Whilst efforts have been made to control for socio-economic and lifestyle factors, some residual confounding resulting from a failure to account fully for these variables seems inevitable.
Specific cardiovascular risk factors such as tobacco use, obesity, and lower serum high-density lipoprotein cholesterol are more common among people with whigh dental disease experience (Johansson et al. 1994).
喫煙、肥満、低血清高密度リポ蛋白コレステロールといった特異的な心血管疾病のリスク・ファクターは、歯科疾病を多く経験する人々の間によくみられる(Johansson et al. 1994)。
Some of these factors, such as tobacco smoking, are independent risk factors for both cardiovascular and periodontal diseases whereas others may be linked less directly.

 This area of research is exciting periodontal researchers.
Largescale cross-sectional, prospective, and intervention studies to evaluate these possible links are underway.
In the meantime no firm conclusions can be drawn (Davenport et al. 1998; Joshipura et al. 1998).
その間は、確固たる結論は下せないだろう(Davenport et al. 1998; Joshipura et al. 1998)。


For the majority of peole the progression of periodontal destruction is compatible with the retention of a natural dentition into old age.
Targets for oral cleanliness have been calculated which appear to be compatible with freedom form periodontal disease throughout life or compatible with acceptably low levels of periodontal disease (Burt et al. 1985).
口内清掃の目的は、人生を通して歯周疾病から自由であること、あるいは歯周疾病を許容できる低い水準とすることである(Burt et al. 1985)。

 A significant minority of people (perhaps 5–15 per cent) may loose teeth as a result of periodontal diseases, and considerable effort is spent by dentists and dental hygienists attemoting to prevent and treat them.
Both the prevention and treatment of periodontal disease focus on the mechanical remobval of plaque.
Dental professionals attempt to bring this about bu instructing patients in the use of toothbrushes and dental floss.
Adjunctive services provided by personal dental services include the moval of calcified plaque (calculus) as it may harbour micro-organisms and provide a mechanical barrier to inhibit effective layers which might be contaminated with bacterial toxins.
In some cases the architecture of the periodontium may be surgically adjusted to excise diseased tissue and allow the entry of toothbrush bristles and dental dloss into inaccessible areas.
In recent times a technique known as guided tissue regeneration has used membranes of synthetic material to prebent epithelial cells proliferating down the root surface after periodontal surgery.
This technique allows modest local gains in attachment between the tooth and the undrlying periodontium.


 A comprehensive review of professionally administered mechanical oral hygiene practices cast considerable doubts on the effectiveness of most interventions commonly emplyed to treat periodontal diseases (Frandsen 1986).
 歯科専門的により実施される機械的口内清掃に関する包括的なレビューでは、歯周疾病の処置のために行われる多くの介入の効果に関して、大きな疑問を投げかけている(Frandsen 1986)。
In general, interventions aimed at improving oral hygiene produce only short-term changes which are not sustained(Kay and Locker 1997).
一般的に、口内衛生の向上を目的とした介入は、短期間の変化を生むがそれが持続されることはない(Kay and Locker 1997)。
Other procedures to treat periodontal diseases, such as the removal of calculus by scaling and polishing, root planing, and removal of plaque at intervals greater than 4 weeks, may not be effective and are harmful in some circumstances.
スケーリングやポリッシングによる歯石の除去やルート・プレーニング 、そして4週以上の間隔を空けて行われるプラークの除去といった、これらの歯周疾病の処置方法は、効果的ではなく、状況によってはむしろ有害である。
Fourteen million of these intercentions are carried out each year in England and Wales alone.

Oral malignancy

Almost 90 per cent of oral malignancies are squamous cell carcinomas.
The site is often related to the aetiological factors.
Lesions may present as swelling, ulcers, or red or white patchesm and many are painless until they become large.
Significantly, survival is related to the stage of the disease at presentation.
Five-year survival is less than 50 per cent.

 Malignant change is often seen in a number of lesions which precede the development of the tumour.
These premalignant lesions present as leukoplakias and erythroplakias of unknown origin.
Malignant change is also seen, albeit infrequently, in oral lichen planus and hyperplastic candidasis.

 The incidence of oral cancer varies dramatically between and within countries.
In England and Wales the incidence is 4.5 per cent 100 000 which represents approximately 1 per cent of total cancer incidence (OPECS 1994).
England、Walesでは、発生率は、癌全体の発生の約1%にあたる10万人に4.5人である(OPCS 1994)。
The highest reported incidence rates are in India and SriLanka where the mouth is the most common site and comprises up to 40 per cent of all cancers (Parkin et al.1992).
最も高い発生率が報告されているのはIndia and Sri Lankaで、口内が最も癌が多発する部位であり、全癌の40%にもなる(Parkin et al. 1992)。
Men are more susceptible than women in almost all populations independent of the effects of tobacco use (Muscat et al. 1996).
喫煙の影響とは関係なく、ほとんど全ての母集団において、男性は女性よりも癌の感受性が高い(Muscat et al. 1996)。

 Variations in the incidence of oral malignancy are largely explained by varying exposure to three major risk factorts.
Cancer of teh lower lip is strongly associated with exposure to sunlight, especially in peole with fair skin (Lindquist and Teppo 1978).
下口唇の癌は日光への暴露に強く関連し、白い肌の人々においては特に顕著である(Lindquist and Teppo 1978)。
Tobacco use, whether chewed or smoked, predisposes to intra-oral cancer.
The high incidence of oral cancer among southern Asians is largely accounted for by the addition of tobacco to betel quid or pann (Johnson and Warnaaklasuriya 1993).
South Asiansにおける口内癌の高い発症率の原因は、檳榔の実の噛み煙草の喫煙で説明できる(Johnson and Warnakalasuriya 1993)。
These are dose-response relationships for the duration of use and type of tobacco inhaled.
Alcohol is also an independent aetiological factor and has a synergistic relationship with tobacco use (Rothman and Keller 1972; Bolt 1992)
アルコールは独立した原因因子で、なおかつ喫煙と相乗効果がある(Rothman and Keller 1972; Blot 1992)。


Since oral cancer is predominantly a disease of older people, it is likely that demographic changes, particularly in developing countries, will see an increased incidence of the disease (Swango 1996).
 口内癌は、主に高齢者の疾病であるので、特に開発途上国における人口構造の変化により、疾病の発症数が増加して見える(Swango 1996)。
However, age-specific incidence rates in developed countries are relatively stable.
A reduction in alcohol consumption combined with the reductions in tobacco smoking already evident in some countries has the potential to make sizeable reduction of the burden of these cancers (Macfarlanec et al. 1996).
いくつかの国々における喫煙の減少とアルコール消費量の減少は明らかに、これらの癌の負担をかなり減少させる可能性がある(Macfarlane et al. 1996)。

 Because early intervention determines survival in oral cancer, and because many cases are preceded by premalignant lesions, there is a strong argument for case finding as a method of disease control (Platz et al. 1986; Hindle and Nally 1991; Speight et al. 1993).
 口内癌においては早期治療が生命に影響し、そして多くの症例は前癌病変から進行するので、疾病抑制の方法として、早期発見が強く勧められる(Platz et al. 1986; Hindle and Nally 1991; Speight et al. 1993)。
Despite the low prevalence of the disease, screening services is greates when they are offered in workplace settings (Downer 1997).
疾病の有病割合は低いが、口内癌の検査は、十分な妥当性を有していると思われる。職域における口内癌の検査は非常に重要である。 (Downer1997)

Dentofacial trauma

Trauma to the teeth is common and frequently causes fracture of the tooth or supporting bone, and bodily movement of the tooth including complete aculsion.
In many cases the long-term survival of the tooth is threatened.
Since the anterior and most visible teeth are most often incolced the result is disfiguring.
Approximately one in four teenagers in the United Kingdom have damaged permanent teeth as a result of trauma (Todd and Dodd 1985).
英国の10代の約4人に1人は外傷により永久歯に損傷がある(Todd and Dodd 1985)。
The incidence is greatest among young children who have just learnt to walk and among school-age children who may be using bicycles nad skateboards (Gelbier 1967).
発生率が高いのは、歩くことを覚えたての幼児と、自転車やスケートボードを利用する学童である (Gelbier 1967)。
Teenagers and adults who play contact or other vigorous sports are also at risk (Federation Dentaire Internationale 1990).
接触する機会のある運動やその他の激しい運動をする10代や成人も危険である(Federation Dentaire Internationale 1990)。
A child’s risk of dental trauma is directly related to the distance that the upper teeth protrude in front of teh lower teeth (the over jet) (Todd and Dodd 1985).
子供の歯の外傷のリスクは、上顎の歯が下顎の歯の前に出ている距離 (overjet) に関連している(Todd and Dodd 1985)。
Primary prevention involves wearing a mouthguard during contact sports such as American footbaal, rugby football, hockey, and boxing.
Where possible, play areas fro young children should have cushioned surface.

 Aspects of secondary prevention are crucial for traumatized teeth.
Deciduous teeth must be monitored in case any infection occurring as a sequel to the trauma threatens the prermanent tooth developing beneath it.
In permanent teeth, adhesive fillings can be used to protect sensitive fractured teeth and calcium hydroxide dressings may be placed to allow continued root development in immature teeth.
However, the most important aspect of secondary prevention is teh first aid of teeth which have been knocked out.

 Avulsed teeth can be replaced in the socket (Andreasen and Andreasen 1994).
 脱離した歯は、窩に戻される(Andreasen and Andreasen 1994)。
Long-term survival rates of aculsed teeth are high, but are greatest if the tooth is replanted within 30 min to prevent drying, if it is stored in an isotonic medium (e.g. milk) in the interim, if the periodontal ligament is not damaged by physical or chemical cleaning, and if the tooth is held in place by a semi-rigid splint for a week.
Systemic antibiotic and antitetanus treatments is required.

 The effectiveness of this secondary preentive intervention has two pu lic health implications.
Informing athletes and their teachers and trainers of these principles can reduce the impact of dentofacial trauma.
The need for almost imediate care means that skilled emergency dental services should be available wherever possible.
Unfortunately, dentofacial trauma is not limited to office hours.


Oral health Promotion

Since oral disease are brought abot by people’s behaviours, Dentistry has traditionally adopted health education as the central thrust of prevention.
Toothbrushing and sugar reduction messages have been repeated in both chairside and public education campaigns.
However, dental educators have become disillusioned with the recognition that health education cannot readily change these behaviours which are largely determined by our social and cultural environment.
Indeed, health education carries its own dangers of disempowerment and victim-blaming and may increase inequalities in oral health (Labonte and Penfold 1981; Schou and Wight 1994).
確かに、健康教育は、無力感と犠牲者非難という特有の危険性を有しており、口内保健の格差を増加しうる(Labonte and Penfold 1981; Schou and Wight 1994)。

 Closer examination of the cause of oral disorders reveal the potential value of community-based approaches to maintain oral health by acting on the wider determinants of health.
Oral disease is brought about by the consumption of sugars, ineffective oral cleaning, tobacco and alcohol use, limited exposure to fluoride, and stress.
The common worldwide trend towards widening inequality in economic, social conditions, and health is because the most important non-communicable diseases are determined by lifestyle factors such as these.
Therefore the determinants of oral health are the determinants of health in general, and there are many opportunities for wider social and environmental action to play an invaluable role in promoting oral health.
There is an increasing recognition that a ‘common-risk factor’ approach is fundamental to the integrated approach to oral health promotion (Sheiham 1992).
‘コモン・リスク・ファクター’手法が口内の健康づくりのための統合的な方法の基礎であるという認識が広がりつつある(Sheiham 1992)。
Collective and multidisciplinary action against factors linked to many diseases reduces duplication, saves resources, and improves effectiveness (Grabauskas 1987).
多くの疾病に関連するファクターに対して、集約的な協働は、重複を減らして資源を節約し、効果を増大させる(Grabauskas 1987)。
[commong risk factor approachは、情報の矛盾を防ぐ/情報の重複を防ぐ、という2つの面から限りある資源の有効な活用につながる。The Common Risk Factor Approach: a rational basis for promoting oral health.Community Dent Oral Epidemiol 2000; 28: 399-406.に詳しい]

 An additional consideration is that preventive strategies which focus on individuals do not appear to be suitable for dental caries and periodontal diseases since as yet there are no effective ways of identifying which individuals are at high risk of developing the diseases (Rose 1985; Johnson 1991a,b).
 さらに考慮するべきことは、齲蝕と歯周疾病には、ハイ・リスクの個人を識別する効果的な方法がまだ無いために、個人に焦点を合わせた予防戦略は適切でないように考えられることである(Rose 1985; Johnson 1991a,b)。
Whilst individuals at high risk for dental disease cannot be identified with adequate sensitivity and specificity it is possible to identify at-risk populations.
In these situations it can be cost-effective to target preventive interventions at people in specific socio-economic groups, attending particular schools, or living in an area with high disease incidence (Burt 1998).
このような状況では、特定の社会経済群の人々、特定の学校、あるいは高い疾病発生率の地域に住む人々を対象にして予防介入を実施することは費用対効果が高い(Burt 1998)。
However, a strategy of targeted interventions should take place within a common risk factor approach which addresses general health conditions for the whole population.
Such an approach will reduce social inequalities and will provide a multiplicity of benefits.
It also avoids the limitations inherent in attempting to identify and treat differently those individuals at high risk for disease.
Finally, a recognition of the social context in which personal choices are made avoids the social iatrogenesis of describing oral health in individual terms (Dickson 1995).
さらに、個人の選択を形成する社会的な文脈を認識することで、口内保健を個人ごとに記述するという過ちを避けられる(Dickson 1995)。
Dentistry has been quick to adopt approaches which would now be recognized as health promoting.
For example, fluoride levels in water supplies were adjusted to prevent dental caries as early as 1945 (Dean et al. 1950).
例えば、水道水フッ化物添加は早くも1945年から齲蝕予防のために、実施された(Dean et al.1950)。

 Health promotion, the process of enabling people to take control over and to improve their health, has five broad actions: strengthening community action, developing personal skills, and reorienting health services (WHO 1984, 1986).
 人々が健康を管理し、増進させる過程である健康づくりは、5つの幅広い活動からなる: 支援環境の整備、保健政策の制定、地域活動の強化、個人的技能の開発、そして医療の再設定である(WHO 1984, 1986)。
Within this approach Sheiham (1995) suggested six policy areas relevant to oral health:
この方法の中でSheiham (1995) は、口内保健に関連する6つの政策領域を提案した。

● the use of fluoride
● フッ化物の利用

● food and health policies to reduce sugar consumption
● 砂糖消費を減らす食事と健康政策

● community approaches to improve body hygiene including oral cleaning
● 口内清掃を含む身体の衛生改善のための地域へのアプローチ

● smoking cessation
● 禁煙

● policies on reducintg accidents
● 事故減少政策

● ensuring access to appropriate preventive care.
● 適切な予防処置を受けられることの保証

This framework will be used in this cahpter.


 With the growing emphasis on evidence-based health care, oral health promotion must increasingly demonstrate its effectiveness.
Recent systematic reviews have aimed to identify oral health promotion practices which yield demonstrable health gains or modified knowledge or behavious (Brown 1994; Kay and Locker 1996、1997; Sprod et al. 1996).
近年のシステマティック・レビューは、極めて明らかな健康獲得が生じた、あるいは知識や行動が変容された健康づくりを確認することを目的としている(Brown 1994; Kay and Locker 1996, 1997; Sprod et al. 1996)。
The principle findings were of a paucity of evidence with few reports of well-designed studies in which the intended outcome was health gain.
健康獲得が設定したアウトカムとなってる良好に設計された研究報告は、ほとんどなく、[臨床疫学的] 検証はわずかであるということが、確認された。
The most robust studies tended to focus on programmes in which the intended outcome was imposed knowledge or modification of the behaviours of individuals.
Even these studies, which might be termed ‘Health education’, usually involved a relatively short follow-up.
The principle finding in meta-analysis was the effectiveness of fluoride to prevent caries (Kay and Locker 1997).
メタ分析による主な発見は、齲蝕を予防するためのフッ化物の効果であった(Kay and Locker 1997)。
A less rigorous approach adopted by Sprod et al. (1996) allowed exploration of other acenues of activity and research but still concluded that there was little evaluative literature in relation to the broader issues of health promotion.
Sprod et al. (1966) は、厳密さに欠ける方法で、他の介入方法と研究を調査したが、健康づくりの幅広い活動の関連を評価する文献はまだほとんどないと結論した。

 One problem of broad strategies to promote health is that they do not lend themselves to current concepts of outcome evaluation (Sprod et al. 1996; Health Education Board for Scotland 1996; Stillman-Lowe 1998).
 健康づくりのための多面的な戦略の1つの課題は、それらが現在のアウトカム評価の概念と一致しないということである(Sprod et al. 1996; Health Education Board for Scotland 1996; Stillman-Lowe 1998)。
The link between environment and oral health is indirect and is often mediated by individual behaviours.
It is difficult to construct formal randomized controlled trials for this type of intervention and any health gain may take some time to become measurable.
All the effectiveness reviews called for more careful evaluation and for the development of outcome measures more appropriate for oral health promotion.
One core concern is the question: ‘What is oral health?’

 Therefore oral health promotion finds itself at a cross-eoads.
Broad social and environmental approaches which act at the level of determinants of health and common risk factors for disease offer radical and exciting opportunities to promote health.
However, in an increasingly restricted financial climate and with commensurate demands for evidence of effectivenessm proponents of health promotion must act to show how these broader approaches can deliver their promise.

The use of fluoride

The presence of fluoride at the interface between plaque and dental enamel inhibits the development of caries.
To be most effective, fluoride should be present both before the teeth start to develop and then continuously throughout life.
These findings suggest its effect is derived from a combination of modes of action.
Three modes currently reveive the most attention: the effect of fluoride on plaque metabolism, the effect of its incorporation during tooth development, and its effect on the dynamics of demineralization and remineralization in exposures whitch occur after tooth development.

 Fluoride is present in dental plaque at concentrations 50 to 100 times higher than in saliva.
At these concentrations it can affect the plaque metabolism to prevent the adhesion of plaque to the teeth.
As the organisms produce acides, fluoride may be released from the plaque matrix.
At these yet higher concentrations it may kill or inhibit acidogenic organisms and so negatively reinforce acid production.
The presence of fluoride during dental enamel hydroxyapatite formation may allow its incorporation into the crystal lattice to produce the larger and more stable crystals of fluorapatite which are less soluble.
A similar phenomenon occurs during exposure to fluoride after tooth development.
The concentrations of fluoride present in plaque at low pH increases the tendency for enamel to remineralize rather than demineralize.
As the minerals precipitate back onto the enamel surface, the available fluoride is incorporated onto the mineralizing enamel as fluorapitite or calcium fluoride, both of which inhibit future demineraliation.


Water fluoridation

The beneficial effect of fluoride on dental health was discovered as a consequence of investigations of endemic developmental defects of teeth in Colorado.
McKay implicated the water supplies in the aetiology of the staining and pits and discovered that teeth with defects were less susceptible to dental caries than those without (McKay 1933).
McKayは、着色と欠損の原因に水の提供が関わっているとし、欠陥を伴う歯は、ない歯よりも齲蝕の感受性が低いことを発見した(McKay 1993)。
The staining was shown tobe due to fluoride which existed in some of McKay’s samples at levels as high as 14 ppm.

 Dean et al. (1941) went on to demonstrate hte inverse relationship between dental caries and the fluoride concentration of drinking water (and the associated fluorosis) in two cross-sectional ecological studies (now called the ‘21 Cities Studies’).
 Dean et al. (1941) は、2つの横断的エコロジカル研究(いわゆる‘21都市研究’)において齲蝕と飲料水中のフッ化物濃度(と歯のフッ素症の関係)の負の相関を示した。
The first intervention trial of fluoridation started in Grand Rapids in 1945 (Dean et al. 1950).
最初の試験介入は、1945年にGrand Rapidsにて始まった(Dean et al. 1950)。
Sinec then, similar studies have taken place in many contries including the United Kingdom, the Netherlands, and Australia (Murray et al. 1991).
それ以来、似たような研究がU.K.やNetherlands、Australiaを含む多くの国々で行われてきている(Murray et al. 1991)。

 By 1998, approximately 60 countries had reported projects to fluoride public drinking water supplies.
The entire populations o HongKong and Singapore reveive fluodated water, 67 per cent of those in Australia, 62 per cent of the United States, and approximately 10 per centof the United Kingdom.

 Where it is possible, fluoridation remains the most cost-effective methods of reducing the experience and berden of dental caries.
Indeed, it is possibly one of the most cost-effective public health and health promotion measures undertaken in industrialized countries in the last 50 years (Sprod et al. 1996).
実際に、ここ50年の先進国で企画された公衆衛生と健康づくりの方法の中で、最も費用効果的なの一つの可能性がある(Sprod et al. 1996)。
Many of the studies evaluating water fluoridation were conducted in the middle of the twentieth century and lack the scientific rigour of today’s standards.
A recent systematic review found no randomized controlled trials of water fluoridation (McDonagh et al. 2000).
近年のシステマティック・レビューにて、フロリデーションには無作為化比較試験がないことが指摘された(McDonagh et al. 2000)。
Nonetheless, the conclusion was tht fluoridation was effective, with a number needed to treat of 6.
[NNT (治療必要例数) は医学統計用語]
This figure is relatively high because the incidence of dental caries is relatively, low even in the absence of water fluoridation.
Fluoridation also prevents the impacts of oral disease by reducing the number of children with toothache and the number who require a general anaesthetic for dental extractions.

 Sequential cross-sectional studies show that the maximum benefit occurs in children who have been exposed to fluoridated water since birth (Groeneveld et al. 1990).
 連続的な横断研究は、最大の恩恵は、生誕よりフッ化物添加水に暴露されてきた子供に生じることを示している(Groeneveld et al. 1990)。
Since the permanent teeth do not begin to erupt until 6 years of age, these data demonstrate that fluoride is beneficial both before and after the teeth erupt.
For maximum effect, exposure should be continuous throughout life (Attwood and Blinkhorn 1988).
効果を最大にするために、暴露は、生涯を通じて継続的であるべきだ (Attwood and Blinkhorn 1988)。
The benefits continue through adulhood (Murray 1971).
恩恵は成人期を通じて継続する(Murray 1971)。
Long-term exposure also protects against root caries of the teeth of older adults should they become exposed (burt et al. 1986).
長期の暴露は、高齢者の根面齲蝕を防止する(Burt et al. 1986)。


 There is some evidence that water fluoridation also reduces socio-economic inequalities in caries experience (McDonagh et al. 2000).
 フロリデーションは齲蝕経験の社会経済的格差を減少させるという検証もある(McDonagh et al. 2000)。
[NHS Centre for Reviews and Dissemination 2000にあるYork大学のレビューでは、水道水フッ化物添加が社会格差を緩和するという展望を支持する科学的根拠は、わずかであった、とされています]
A series of studies conducted in northeast England show that fluoridation is effective across the spectrum of society but more teeth are saved in children from lower socio-economic status families (Carmichael et al. 1984, 1989).
Englandの北方で実施された連続した研究は、水道水フッ化物添加は、社会の多様性を越えて効果的であることを示したが、比較的低い社会経済地位の家庭の子供においては、より多くの歯が保存された(Carmichael et al. 1984, 1989)。
Several other groups have investigated the nature of this relationship between socio-economic status, fluoridation, and caries (Treasure and Dever 1994).
いくつかの他の研究班は、社会経済地位とフッ化物添加、齲蝕のこの関係の性質を調査してきた(Treasure and Dever 1994)。
Slade et al. (1996) used a range of measures of socio-economic status to show that the presence of fluoride in the drinking water had an aditive interaction with socio-economic status in reducing caries experience in 6- and 12-year-olds.
Slade et al. (1996) は、飲料水中のフッ化物の存在が、6歳と12歳の齲蝕経験の減少に、社会経済的地位に付随する相加的相互作用を有していることを示すために、社会経済的地位の評価の幅を利用した。
In deciduous teeth, fluoridation reduced the difference in caries between rich and poor by the equivalent of one affected tooth surface per child.

 The optimal concentration of fluoride in drinking water depends on other exposures to fluoride and on the amount of water drunk.
Naturaol sources of dietary fluoride include tea and the skin and bones of fish (Jenkins and Edgar 1973; Duckworth and Duckworth 1978).
自然にある食品中のフッ化物の源は、茶や魚の皮と骨にある(Jenkins and Edgar 1973; Duckworth and Duckworth 1978)。
Fluoride is also present in foods and beverages processed in areas where the water is fluoridated and there is evidence that it exerts a ‘halo effect’ which protects people who only receive fluoridated water in this form (Newbrun 1989; Slade et al. 1996).
フロリデーション実施地区で製造された食品や飲料水にも存在し、この形でのみフッ化物添加水に接する人々を守るという‘後光効果’を及ぼすという科学的検証がある(Newbrun 1989; Slade et al. 1996)。
However, in many developed countries the largest sources other than that added to the drinking water are from the fluoride added to tooth pastes, mouth rinses, and gels.

 The amount of fluid drunk is directly related to climactic temperature.
Dean et al. (1941) originally suggested that the optimal concentration for water fluoridation was 1 ppm (1 mg/l).
Dean et al. (1941) は、当初は、フッ化物添加水の至適濃度は1ppm (1 mg/l) であるとした。
Since then there has been recognition that licing in a warm climate might lead to a high daily dose of fluoride and awareness that we are exposed to fluoride in other forms.
Consequently, lower levels of fluoride are used in warmer climates (US Public Health Services 1962; WHO 1994).
その結果として、温暖な気候では、低い水準のフッ化物が利用されている(US Public Health Service 1962; WHO 1994)。
For example, the concentration in Hong Kong is 0.5 ppm.
In Australis, adjusted concentrations vary between 0.6 ppm in Darwin in the subtropical north to 1.1 pp, in Hobart in the more temperate south (Spencer et al. 1996).
オーストラリアでは亜熱帯北部のDarwinにおける0.6ppmから、温帯南部のHobartにおける1.1ppmまで、調整された濃度はさまざまである(Spencer et al. 1996)。

 In many situations fluoridation is the most cost-effective method of administering fluoride.
A modest capital investment is required to install the machinery to administer and regulate the addition of fluoride to the drinking water.
The whole population is affected and individuals need maek no additional effors (such as visiting the dentist) to obtain the benefits.
Fluoridation continues to be effective even at the low levels of caries incidence currently seen inte h developed world, and the repeatedd low-dose application acchieves the optimal pre- and posteruptive effects.
However, fluoridation is less cost-effective in areas without reticulted water supplies serving large populations.
In those areas where communities are served by a large number of smaller water supplies other methods of administering fluride are required.

Fluoride Toothpaste

Toothpastes are mixtures of abrasive cleaning agents and refershing flavourings.
They present a good vehicle for the frequent low-dose application of fluoride to increase its availability in dental plaque.
Proprietary preparations use a number of agents including sodium fluoride and sodium monofluorophosphate.
Stannous fluoride has been used in the past but stained the teeth.

 In child, fluoride toothpastes reduce the 2-year incidence of caries by up to 30 per cent(Murray and Naylor 1996) and there is a small additive effect when they are used in areas with water fluoridation (von der Fehr and Moller 1978).
 子供において、フッ化物歯磨剤は、齲蝕の2年発生率を、最大で30%減少し (Murray and Naylor 1996) 、フッ化物添加水を伴う地域において利用されたときは、小さな追加効果がある(von der Fehr and Moller 1978)。
Sorium fluoride toothpaste are also effective in preventing caries of the roots of the teeth in older people (Jensen and Kohout 1988).
フッ化ナトリウム歯磨剤は、高齢者における根面齲蝕の有病割合にも効果がある(Jensen and Kohout 1988)。


 The effectiveness is primarily related to the concentration of fluoride in the paste up to levels of 2500 ppm (2.5 g of fluoride per kilogram), although most preparations for adults contain approximately 1000 ppm.
 効果は、まず歯磨剤中のフッ化物の濃度に関連し、最大で2500ppm (2.5g of fluoride per kilogram) の水準まである。成人のためのほとんどの調合は、約1000ppmを含んでいる。
Between 1000 and 2500 ppm each additional 500 ppm provides an additional 6 per cent reduction in caries incidence (Stephen et al. 1998).
1000-2500ppmの間では、500ppm増えるごとに、齲蝕発生率は6%ずつ減少をする(Stephen et al. 1988)。
The agent used is less important as long as its is compatible with the abrasive (Holloway and Worthington 1993; Johnson 1993; Stookey et al. 1993; Volpe et al. 1993).
利用される製剤は、研磨剤と相性が良ければ、重要ではない(Holloway and Worthington 1993; Johnson 1993; Stookey et al. 1993; Volpe et al. 1993)。
Early fluoride toothpastes used chalk as teh abrasive, but this reacted with the fluoride and prevented its release.

 In some countries ther are special formulations of toothpaste available specifically for children.
These toothpastes use lower fluoride concentrations to prevent ingestion of excess fluoride and reduce the risk of dental fluorosis.
Again, the effectiveness is related to concentration but preparations containing 500 ppm appear to be similarly effective when compared with conventional preparations (Winter et al. 1989).
この場合もやはり、濃度が関連するが、500ppmを含む調合は、従来の調合と比較して、同様の効果を現す(Winter et al. 1989)。

 Therefore toothpastes offer a safe and effective vehicle for the administrations of fluoride.
The protective effects reported in trials are smaller than those in water fluoridation studies because fluoridation studies usually consider life time exposure to fluoride whereas toothpaste trials last for only 2 or 3 years.
The additions of fluoride to toothpaste is also compateble with market intersts as manufacturs compete to produce the most effective agent.
However, the use of fluoride toothpaste has a distinct disadvantage as a broad preventive strategy—it relies on people brushin their teeth.
In developed countries, poor oral hygiene and high caries incidence are associated (although not necessarily causally) and so the people who have most to benefit from the use of fluoride toothpastes are less likely to use them frequently.
先進国では、劣悪な口内衛生と高い齲蝕発生率が関連しており (必ずしも因果関係がある訳ではないが) 、フッ化物歯磨剤から利益を最も得なくてはならない人々は、頻繁に歯磨剤を使う可能性が低い。
In developing countries, there may not be a tradition of tooth cleaning with toothpastes and Western proprietary brands are likely to be expensive.

Other vehicles of administering fluoride

Other vehicles for administering fluoride can be broadly categrized by whether or not they are taken systemically.
Any fluoride taken systemically is liable to have a pre-eruptive effect if it is taken at the correct time.
Since systemic fluorides are taken by mouth they are likely to have topical posterruptive effects also.

 Fluoridized salt is used by 70 per cent of the population of Switzerland in areas where water fluoridation is not possible (Marthaler 1983).
 フッ化物添加塩は、フッ化物添加水が不可能な場所である、スイスの人口の70%に利用されている(Marthaler 1983)。
Observational studies of children in that country and in Hungary suggest that the use of salt containing 250 mg fluoride per kilogram has caries-protective effect, although perhaps not of same magnitude as that of fluoridated water (Toth 1976; de Crousaz 1985).
スイスとハンガリーにおける子供の観察研究では、250mgフッ化物/kgを含む塩の利用は、おそらくフロリデーション水と同程度ではないが、齲蝕予防効果を有する(Toth 1976; de Crousaz 1985)。
A controlled study in Colombia demonstrated 48 and 50 per cent reductions in caries incidence (depending on the formkulation used) compared with a 60 per cent reduction with water fluoridation (Mejia et al. 1976).
コロンビアにおける比較試験は、フロリデーションで60%の減少と比較して、食塩では (処方による) 48-50%の齲蝕発生率の減少を示した(Mejia et al. 1976)。
Therefore fluoridized salt is protective but its use needs to be sustained (Stephen et al. 1999).
であるから、フッ化物添加塩は予防効果があるが、継続的に利用する必要がある(Stephen et al. 1999)。

 Fluoride may also be added to milk, school drinking water supplies, and fruit juices.
Fluoride was added to the drinking water of schools in the United States for a number of years.
Several accidents resulting in acute fluoride poisoning mean that this method is no longer recommended inthtat country.
Early studies using fluoridized milk produced promising results but were flawed.
A randomized double-blind trial showed a 43 to 48 per cent reduction in caries after 5 years (Stephen et al. 1984).
無作為二重盲検試験は、5年後の齲蝕の43-48%の減少を示した(Stephen et al. 1984)。
Despite concerns that fluoride added to milk might bind with calcium or proteins to reduce its topical effect (Duff 1981), a number of schemes are being planned in nortern England.
ミルクに添加されたフッ化物は、カルシウム、タンパク質と結合して局所効果が減少してしまう(Duff 1981)にもかかわらず、イギリス北部で数多く実施されている。


 One study has tested the effect of fluoridized orange juice.
A reduction in caries incidence was observed compared with a group not revieving a placebo juice without fluoride (Gedalia et al. 1981).
齲蝕発生率の減少は、プラシーボ群と比較して観察されたが、発生率は、フッ化物無添加のプラシーボジュースを受け取った子供においても減少した(Gedalia et al. 1981)。
The use of citrus drinks as a vehicle for fluoride may no longer be recommenhded bacause of concerns about the direct erosive effet of the drinks on the teeth.

 Dietary fluoride supplements have been used in efforts to duplicate the fluoride intake of drinking water at 1 ppm.
They usually take the form of sodium fluoride tablets which are sucked or chewed and then swallowed.
Early studies of their pre-eruptive effects were flawed by problems of self-selection, lack of controls, and non-blinded examiners and so failed to distinguish between the effectieness of the supplements and the confounding effects of patient compliance and other oral-health-related behaviours.
Clinical trials of their use after the eruption of the teeth have been more robust and reveal significant preventive effects (DePaola and Lax 1968; Driscoll et al, 1978; Stephen and Campbell 1978).
臨床試験では、歯萌出後の効果が調べられ、よりしっかりした、明らかな大きな予防効果があった(DePaola and Lax 1968; Driscoll et al. 1978; Stephen and Campbell 1978)。

 One of the problems of fluoride supplementation is that programmes often rely on the compliance of individuals and their families with an additional health directed behaviour.
Many of the people most susceptible to caries find this new behaviour difficult to adopt.
Even in the most compliant individuals, fluoride supplements do not perfectly mimic the effect of water fluoridation since the fluoride is taken as a daily bolus associated with dental fluorosis (Ismail and Bandekar 1999).
もっとも服薬服従性の高い人でさえ、フッ化物補助食品はフロリデーションの効果を完全には再現しない。フッ化物が歯のフッ素症と関連した [マイナス・イメージのある] ものだからである(Ismail and Bandekar 1999)。
As a public health measure for children dietary fluoride supplementation is appropriate only for individuals at high risk for dental caries.
National bodies in the developed world recommend a number of broadly compatible dosing schedules determined by the age of the hild and the fluoride concerntration of the drinking water (Riordan 1999).
先進世界における国家機関は、子供の年齢と飲料水のフッ化物濃度により決定される多くの広く互換性のある服薬計画を、推奨した(Riordan 1999)。
Most schedules for children have been revised downwards in the last 10 years.
Dietary fluoride supplements may have some benefit for older people who are more susceptible to root caries in whom there is no risk of fluorosis.

 A number of methods of professional application of fluoride have been tried over the years.
Gels containing relatively high concentrations of fluoride were applied to the teeth in trays and were effective but only whilst they were being used.
Particular care was needed to minimize fluoride ingestion (LeCompte 1987).
この時に摂取するフッ化物を最小限にする注意が必要がある(LeCompte 1987)。
More cost-effective ways of administering fluoride are usually available.

Safty of fluoride used as a dental public health measure

Fluoride is freely available in the natural world.
It is present naturally in almost all fresh groundwaters and is also consumed in some foodstuffs such as fish (especially the skin and bones) and tea.
It is difficult to understand how any form of life has evolved and survived unless it was fully able to cope with continuous uptake of fluoride from its environment (Murray et al, 1991).
もし、さまざまな形態の生命が環境からフッ化物を継続的に摂取する状態に対応できないのであれば、どのように進化して生き延びてきたのかを理解するのは難しい(Murray et al. 1991)。
Such is the case with humans who thrive in areas where the fluoride concentration of drinking water is several times higher than the therapeutic doses used to prevent dental caries.

 In acute poisoning the certain lethal dose is 32 to 64 mg fluoride for each kilogram of body weight and the safely tolerated dose is 6 to 16 mg/kg body weight.
In chronic exposures the safely tolerated dose is lower.
Approximately 99 per cent of fluoride is stored in the hard tissues and it is there that th signs of chronic toxicity are evident.
Skeltal fluorsis manifest as osteosclerosis, calcification of tendons, and exostoses occurs at water fluoride levels over 8 ppm (Srikantia and Siddiqui 1965).
骨のフッ素症は、骨硬化症、腱の石灰化をあらわし、水のフッ化物水準が8ppmを越えると外骨腫症が生じる(Srikantia and Siddiqui 1965)。
Individual workers exposed to fluoride absorption of 14 to 68 mg/day for 20 years had skeltal fluorosis and gastric diseases.
Radiographic changes are not apparent in areas where the water contains fluoride at up to 4 ppm (Morris 1965).
水のフッ化物が4ppm以下である地域では、X線診査上の変化は生じない(Morris 1965)。
If 1 to 2 litres of water are consumed daily, the exposure to fluoride at this concerntration would be 8 to 16 mg/day.
People in the United Kingdom who drink a lot of tea may take in 8 to 10 mg of fluoride per day (Jenkins and Edgar 1973; Walters et al. 1983).
お茶をよくのむ英国の人は1日8-10mgのフッ化物を摂取している(Jenkins and Edgar 1973; Walters et al. 1983)。


 Dental fluorosis is hypomaturation or hypomineralizatino of the teeth due to chronic ingestion of fluoride.
It has a variety of presentations from small white flecks on the tooth to larger white opacities.
In the most severe cases large areas of the enamel may be absent.
The prevalence and severity of the disease are related to exposure to fluoride, particularly during the third year of life when the crowns of the upper central incisors are being developed.
Exposure to fluoride in a number of forms, including drinking water and toothpaste, is associated with dental fluorosis (Hawley et al. 1997; Clark and Berkowitz 1997).
飲料水と歯磨剤を含む、数多い形態におけるフッ化物への暴露は、歯のフッ素症と関連している(Hawley et al. 1996; Clark and Berkowitz)。
The link between dietary fluoride supplements and dental fluorosis is particularly strong, and for this reason they are not advised as a public health measure for children in any but the most caries susceptible (Wang et al. 1997; Ismail and Bandekar 1999; Riordan 1999).
食事性のフッ化物栄養補助食品と歯のフッ素症の関連は特に強いため、もっとも齲蝕感受性が高い者を除いては、子供のための公衆衛生上の対策として勧められることはない(Wang et al. 1997; Ismail and Bandekar 1999; Riordan 1999)。
Other strategies to avoid fluorosis incolve brushing children’s teeth with only a small blob of low-fluoride toothpaste.

 Whilst most studies conducted in areas of optimal or near-optimal or near-optimal water fluoridation show some fluorosis, it is infrequently severe (Clark and Vertkowitz 1997; Rock and Sabieha 1997).
 至適濃度あるいは至適濃度付近のフッ化物添加水道水の地域で実施された研究の多くでは、ある程度のフッ素症を示すが、深刻なものはまれである(Clark and Berkowitz 1997; Rock and Sabieha 1997)。
Most cases of fluorosis cannot be noticed by lay people at conversational distance and many young people regard mild fluorosis as more attractive than unaffected teeth (Riordan 1993; Hawley et al. 1996).
フッ素症の症例の多くは、対話の距離では素人には気付かれず、多くの若年者は、軽度なフッ素症を健全歯よりも魅力的であるとみなしている(Riordan 1993; Hawley et al. 1996)。

 Fluoride is frequently said to have a number of other adverse effects including cancers and diseases of most other body systems (Royal College of Physicians 1976).
 しばしばフッ化物は、数多くの副作用を有するといわれ、それには癌や体の他の大半の部位での疾病を含む(Royal College of Physicians 1976)。
Perhaps the most famous claim is that water fluoridation was associated with crude cancer death rates in the 10 largest cities of the United States (Yiamouyannis and Burk 1997).
おそらく最も有名な主張は、水道水フッ化物添加は、米国の10大都市における癌による粗死亡率に関連しているというものである(Yiamouyannis and Burk 1977)。
This association was roundly criticized and found to be spurious in two independent analyses accounting for age, sex, and racial differences between the cities (Oldham and Newell 1977; Newbrun 1989).
この関連は、徹底的に批評され、2つの独立した分析により、都市間の年齢、性別、人種の違いが原因であることが判明し、偽造であることが示された(Oldham and Newell 1977; Newbrun 1989)。

 The literature on the safety of the therapeutic use of fluorides, and in particular water fluoridation, is extensive and not always of the highest quality.
However, a number of independent reviews have been and continue to be conduncted including those by tge Royal College of Physicians in London (1976), the British Department of Health and Social Security (Knox 1985), the Australian National Health and Medical Research Council (1991), WHO (1994), and McDonagh et al. (2000).
しかし、the Royal College of Physicians in London (1976), the British Department of Health and Social Security (1985), the Australian National health and Medical Research Council (1991), WHO (1991), McDonagh et al. (2000) によるレビューを含む、数多くの独立したレビューが、実施され続けている。
These reports consistently fail to find associations between waer fluoridation and any adverse effects other than dental fluorosis.

 There are active antifluoridation lobbies in most developed countries.
Such groups tend to be small but very enthusiastic and vociferous with an impact which is oftern disproportionate to their size or the amount of support they garner.
The general arguments given against water fluoridation fall into four main categories.
Fluoridation is said to be unsafe, to be ineffective, to constitute mass medication, and to remove the freedom to drink pure water.
This very brief review attempts to convey the over whelming evidence for the effectiveness of water fluoridation in the prevention of caries.
As mentioned already, the effectiveness and safety of water fluoridation have been reviewed at a national and international level by several independent bodies and all have supported its continued use.
Water supplies are already treated with a number of chemicals to render them fit to drink and so there are precedents for mass medication if it is for the public good.
The argument in fabour of a ‘right’ to pure water is more fundamental and emotive.
Adovocates of fluoridation take a utilitarian view that the sacrifice of this right by the few supports the rights of many to have oral health.


 The debate about fluoridation is an interesting one.
Antifluoridationists tend to come from relatively healthy middle-class groups.
Because children in these groups have the lowest caries experience, they have the least to benefit from the intervention.
Unfortunately, the effect of the antifluoridationists is to maintain social inequalities in health.
Antifluoridationist arguments are often alarmist and sometimes unorthodox from the viewpoint of scientists.
Public debates between pro- and antifluoridationists often end in profluoridationists attempting to refute, in detailed scientific terms, an extensive list of claims.
With the current mistrust of science, it can be difficult to make such a position attractive in the face of very emotional arguments.
Some proponents of fluoridation avoid open debate with antifluoridationists for this reason.


Sugars are the major dietary determinant of dental caries experience and are a necessary cause of clinical significant devay.
However, evidence that practical health promotion interventions can reduce their intake and so reduce the incidence of caries is lacking (Kay and Locker 1997).
しかし、健康づくりにおける介入が砂糖の摂取、そして齲蝕の発生率を減らすという科学的検証は不足している(Kay and Locker 1997)。
Many studies of health education interventions have used self-reported sugar consumption as the primary outcome with the obvious danger of ascertainment bias (Tan et al. 1981; Schou 1985).
多くの健康教育の介入研究は、自己申告の砂糖消費量を主要なアウトカムとするため、明らかに確認バイアスの危険を伴う(Tan et al. 1981; Schou 1985)。
[ascertainment bias確認バイアスは、統計用語]
Studies which have measured clinical outcomes have combined health education approaches with the use of fluorides and thus the independent effect of the health education cannot be assessed.

 Some of the data which implicate sugars in the aetiology of caries suggest that restriction of dietary sugar is preventive.
For example, per capita sugar supplies and caries experience data correlate significantly in simple national ecological comparisons (Sreebny 1982).
例えば、単純な国内での国内環境の単純比較における、1人あたりの砂糖提供と齲蝕経験のデータには、有意な相関がある(Sreebny 1982)。
A children’ s home in Austraalia had a dietary regimen with almost no sugar and the chilsren had very low caries levels until they were allowed to make their own food choices at the age of 12 years.
Likewise, caries levels fell in parallel with the availablity of sugar during the Second World War (Toverud 1957).
同様に、第二次世界大戦の間、齲蝕水準は砂糖の利用と平行して下降していた(Toverud 1957)。

 Whether these findings can be translated into effective public health strategies remains uncertain.
A health-directed food policy seems logical.
A common risk factors approach might impact on dental diseases as well as on pbesity, diabetesm and cardiovascular diseases.
Possible strategies fall within the framework of education, substitution, regulation, pricing, or provision (Sanderson 1984).
可能な戦略としては、教育、代用品、規制、表示、提供といった枠組みの中に限られるだろう(Sanderson 1984)。
However, fer countries have suchg policies in place and the resources of health advocates are very limited cojmpared with lose of teh affluent and powerful lobby of the commercial food inductry.
Despite these difficulties, it is by operating at this level that public health might have its greatest impact.


 As well as approaches aimed at individuals, education can take the form of authoritaative dietary guidlines to inform national policies, community initiatives, and cateres.
The Committee on Medical Aspects of Food Policy works within the United Kingdom Department of Health and advises the government on food policy relevant to health.
食糧政策の医学委員会 (Committee on medical Aspects of Food Policy) は、英国の保健省 (Department of Health) 内部で活動しており、健康に関する食糧政策について政府に勧告する。
In 1989 the report Dietary Sugars and Human Disease focused on ‘non-milk extrinsic’ sugars should be reduced and replaced by fresh fruit, vegetablesm and starchty foods.
1989年の食事性砂糖とヒトの疾病の報告は、新鮮な果物や牛乳以外から摂取される、その他の全ての砂糖をさす‘牛乳ではない付加的な’砂糖に焦点を合わせた(Committee on Meical Aspects of Food Policy 1989)。
It recommended that the consumption of nin-milk extrinsic sugars should be reduced and replaced by fresh fruit, vegetables, and starchy foods.
A subsequent report, Dietary Reference Values for Food Energy and Nutrients for the United Kingdom set a target for average non-milk extrinsic sugar consumkption to constitute no more than 10 per cent of total dietary energy intake, which is approximately 60 g/person/day or 20 kg/year (Committee on Medical Aspects of Food Policy 1991).
英国における食品エネルギーと栄養のための食事性基準評価の、その後の報告 (Dietary Reference Values for Food Energy and Nutrients for the United Kingdom) は、牛乳ではない付加的な砂糖摂取の平均目標を、食事エネルギー総摂取量の10%を越えない、約60g/person/dayあるいは20kg/yearにするよう定めた(Committee on Medical Aspects of Food Policy 1991)。
One important consequence of such an authoritative body making these recoomendations has been that numerous other British organizations have followed suit with compatible guidelines.
[この重要性については、The Common Risk Factor Approach: a rational basis for promoting oral health.の冒頭にまとめられています]

 Dietary sugars can be substituted with artificial sweeteners to reduce caries increments (Frostell et al. 1974; Scheinin and Makinen 1975).
 食事性砂糖は、齲蝕の増加を止めるために、人工甘味料に代えることができる(Frostell et al. 1974; Scheinin and Makinen 1975)。
Sales of sugar-free carbonated drinks in Europe and North America demonstrate the compatibility of this tactic with commercial interests.
However, substitution of dietary sugars has only limited potential in oral health promotion.
The manufacture of many foodstuffs relies on the bulk and other specirfic properties of sugars.
In addition, some sweeteners have side-effects, and resistance to the extended use of artificial sweeteners persists.

 Regulation of advertising nad labelling of foods in tandem with the effective use substitution is illustrated by a partnership between dentists and the confectionery industry in Switzerland.
The Zahnfreundlich (tooth-friendly) logo is used to label non-acidogenic confectionery.
Zahnfreundlich (tooth-friendly) の商標が、非酸産生菓子類に貼られている(Rugg-Gunn 1997)。
The label is well recognized by children, is commonly seen on confectionery, and is thought to have been effective in reducing levels of decay (Marthaler 1990b).
商標は子供によく認知されており、菓子類に共通してみられ、齲蝕の水準を減らすのに効果があると考えられている(Marthaler 1990b)。
Fiscal policies might be used to discourage the manufacture and sale of sugar-containing products.
All of the above approaches and direct consumer pressure can be brought to bear on caterers and retail outlets to provide food in a way that makes the healthy choices the easier choices.
There are numerous other examples of approaches which may reduce sugars consumption and an exhaustive list is presented by Sheiham (1995).
砂糖消費を減らす方法の数多くの他の模範があり、網羅的な一覧表がSheilam (1995) により提示されている。

Oral cleaning

Since plaque is so strongly implicated as a necessary cause of periodontal diseases, it is logical that tooth cleaning should be the cornerstone of their management and prevention.
Interventions aimed at improving oral hygiene can be successful and achieve a commensurate reduction in gingival inflammation (Kay and Locker 1997).
口内衛生の改善を目的とした介入は、成功しうるし、歯肉炎を相応に減少させる(Kay and Locker 1997)。
Interestingly, interventions carried out in dental surgeries have been more effective than school-based interventions.
However, most studies have had short follow-up periods and the effectiveness of even the best interventions diminishes with time.
Therefore few data show that attempts to improve oral hygiene to prevent destructive disease are effective.
Earlier research showing that frequent professional cleaning reduces periodontal destruction had design flaws (Axelsson and Linde 1978).
頻繁な専門的清掃が歯周組織の破壊を減少することを示す過去の研究は、研究計画上の欠陥を有していた(Axelsson and Lindhe 1978)。
Nonetheless, there remains a consensus that the best public health approach to improve periodontal health remains with improved oral hygiene.


 The relationship between plaque removal and tooth decay is much more contentious.
In Denmark, much preventive dentistry is based on the premise that cleaning hte teeth prevents decay.
Proponents of this policy cite an uncontrolled study involving both patient education and professional cleaning with a fluoride paste (Carvalho et al. 1992).
この考え方の擁護者は、患者教育と専門的な清掃の両方を含みフッ化物歯磨剤を伴う、比較群なしの研究を引用する(Carvalho et al. 1992)。
In a carefully designed trial, a similar intervention did not demonstrate any additional preventive effect above a standard preventive programme of fissure sealants and locally applied topical fluoride received by the control groups (Arrow 1997).
注意深く設計された試験では、似たような介入は、対照群も受けた裂溝填塞 (シーラント) とフッ化物の局所応用の標準予防方法以上の、いかなる追加の予防効果も示さなかった(Arrow 1997)。
Sutcliffe’s (1996) traditional review considered the effect of research methodology on the observed relationship between oral cleaning and dental caries and concluded that there was ‘no unequivocal evidence that good oral cleanliness reduces caries experience’.
Sutcliffe (1996) の伝統的なレビューは、口内清掃と齲蝕の関係を観察する上での、研究方法の影響も考慮した上で、‘良好な口内清掃が齲蝕経験を減少するという明確な科学的検証はない’と結論した。
This area of research is fraught with difficulty.
As well as the difficulties of measuring dental disease, studies are susceptible to selection bias, leakage of intervention, and the probable confunding effects between self-reported behaciours, diet, and oral hygiene.
Studies where professional cleaning has been effective have used pastes containing fluoride (Ripa 1985; Carvalho et al. 1992).
専門的清掃が効果を有するという研究では、フッ化物含有歯磨剤を利用しているのだ (Ripa 1985; Carvalho et al. 1992)。

 What is known is that brushing with a fluoride toothpaste is effective in preventing caries.
Therefore brushing as it is currently practised in most developed countries combats both caries and periodontal diseases and is to be encouraged.

 The systematic reviews cited above demonstrated that it is difficult to achieve sustainable changes in oral hygiene to be associated with not smoking, exercise, healthy eating, managing in school, and having confidence in one’s family (Schou 1998).
 上にて引用されたシステマティック・レビューは、口内清掃行動よる持続的な変化の獲得が難しいことを示す。10代の若者を対象にした最近の研究では、良好な口内衛生は、非喫煙、運動、健康な食生活、学校での成績、家族の信頼と関連することを示した(Schou 1998)。
These types of findings invite the common risk factor approach in which oral cleanliness is promoted as both a health-related and health-directed behaviour where cleaning ones teeth makes one feel and look nice and is part of a positive and healthy lifestyle.
Toothbrushing is a habit learnt as a young child and therefore is difficult to change later in life (Blinkhorn 1978).
ブラッシングは幼児として学習される習慣であるので、年をとってから変容するのは難しい(Blinkhron 1978)。
This behaviour is often an established routine behore the child has seen a dentist, and interventions via health-care and social agencies working with young children and their mothers may be useful.

Smoking cessation

The role of smoking in the aetiology of oral cancers and periodontal diseases has already been discussed.
Johnson (1997) has listed at 20 pral conditions either directly or indirectly associated with tobacco smoking.
Johnson (1997) は、間接的・直接的に喫煙と関連する20の口内の状態を一覧表にした。
In addition to the well-known benefits to cardiovascular and respiratory health, cessation of smoking almost eliminates the increased risk of oral cancer within 5 to 10 years.

 Many of the oral conditions, such as stained teeth, receding gums, and altered taste, are readily perceptivle to the individual and may encourage or reinforce the desire to stop smoking.
The dental team are also often aware of the personal and social circumstances (fro example, pregnancy or a new job) that prompt people to give up.
Therefore smoking cessation is another area where it is particularly appropriate for dentistry to become integrated into a common risk factor approach (Grabauskas 1987).
だから禁煙は、歯科が共通のリスク・ファクター手法に参加するのにとりわけ適切な、もう一つの分野である(Grabauskas 1987)。
As clinicians the dental team canc be effective in supporting smoking cessation by providing advice (Warnakulasuriya 1984; Raw et al. 1998).
臨床家にとって、歯科医療関係者は勧告を与えることで、禁煙を支持するのに効果的でありうる(Warnakulasuriya 1984; Raw et al. 1998)。
Indeed, a group of dental practitioners achieved 11 per cent smoking cessation among their patients at 9-montgh follow-up in dental practices in the United Kingdom (Smith et al, 1998).
実際、英国の臨床の歯科医師のグループが、歯科治療時の9ヶ月の期間中に、患者の11%の禁煙を達成した(Smith et al.1998)。


Prevention of accidents

Several strategies can be used to reduce trauma to teeth.
Playground surfaces can be made of impact-absorbing materials which cushion against trauma.
Unfortunately, orthodontic treatment of large overjets is complex and prolonged, but can be justified in children of 8 or 9 years to reduce the risk of trauma (Welbury 1996).
残念なことに、大きなオーバージェット [上顎前歯部の前突] の矯正治療は、複雑で時間がかかるが、8-9歳の子供における外傷の危険を減少させ、理にかなっている(Welbury 1996)。

 The use of mouthguards is compulsory for some sports in some countries.
Mouthguards not only prevent dental injuries in sport but also prevent laceeration of the facial soft tissues against the teeth (Garon et al. 1986; McNutt et al. 1989).
マウスガードは、スポーツによる歯の外傷を予防するだけではなく、歯に対する顔面軟組織の裂傷も予防する(Garon et al. 1986; McNutt et al. 1989)。
By absorbing the force of anterior blows they reduce posterior and superior displacement of the mandible.
In so ding they reduce the risk of mandibular fracture and may protect the cranial cavity.
Moouthgurads are usually made of a copolymer of polyvinyl acetate and polyethylene.
マウスガードは、通常a copolymer of polyvinyl acetate and polyethyleneにより作られる。
The most basic type may be obtained prefabricated in a range of sizes.
A more sophisticated type may be adapted to fit the mouth, typically by softening it isn hot water first.
Custom-made devices constructed on models made from impressions of the teeth are the most comfortable and can be made to support the lower teeth and mandible during trauma (Chapman 1985; Stokes et al. 1987).
歯の印象採得より作られた模型上にて作製された特注の装置は、最も快適で、外傷中に下顎の歯と下顎を補助する(Chapman 1985; Stokes et al. 1987)。

Ensuring access to appropriate preventive care

There has been disillusionment with the prevailing biomedical model of health care.
[生物医学模型biomedical modelの欠点については、Essential Dental Public Healthに詳しい]
By focusing on the diseases of individuals, it enphasizes the hierarchy of professionals over lay people and treatemnts rather than prevention.
All of these things have taken place with busstantial economic and social costs and yet medical care has made a relatively small contribution to health (Illich 1976; McKeown 1976).
これらの全ては、相当な経済的社会的費用の発生を引き起こし、医療は健康に比較的小さな貢献しかもたらさない(Illich 1976; McKeown 1976)。
The biomedical approach distracts attenetion from the wider social, political, and economic determinants of health.
The primary health care approach is a philosophy which recognizes that these determinants are more important than medical interventions (WHO—UNICEF 1978).
しかしプライマリー・ヘルス・ケアの手法は、これらの決定要因は医療介入よりも重要であることを、ふまえている(WHO—UNICEF 1978)。

 Dental services are just as susceptible to the criticisms of the medical model of health care.
Just as we know that medical services have limited effect on health, so we are aware that dental treatment has made a relatively small contribution ot oral health (Nadanovsky and Sheiham 1994, 1995).
私たちは、医療が健康に及ぼす影響は限られていることを知っていると同時に、歯科医療は、口内の健康に比較的小さな貢献であることを知っている(Nadanovsky and Sheiham 1994, 1995)。
Dental services sometimes thave the appearance of aiming to provide dental treatment rather thant aiming to achieve oral health.
Data from the 1970s show that dental services explain 3 per cent of the cariation in oral health of 12-year-olds in developed countries compared with the 65 per cent contribution made by broader socio-economic factors.
Futhermore, the interventions used in dentistry may also be clinically inappropriate.
Dentistry has adopted a surgical approach to treatment with a cycle of placing and replacing filings.
It has long been recognized that the quality of many fillings is not high and that even the decisions to place fillings are idiosyncratic (Elderton 1976; Elderton and Nuttall 1983).
多くの充填の品質は優れてはおらず、充填の判断でさえまちまちであることが認識されて久しい(Elderton 1976; Elderton and Nuttall 1983)。
Since fillings are often replaced many times over a lifetime, the remaining tooth is increasingly damaged with each new filling.

 As well as having little positive impact on oral health, clinical dental services ignore the determinants of disease.
With its emphasis on personal behaviour and even with the search for specific periodontal pathogens, clinical dentistry and much dental research actually divert attention from the factors which determine oral health and disease.


 Dental services are also costly.
National Health Service dentistry costs £1.4 billion per year in England and Wales.
Compared with the potential costs of treatment, the resources available are few and are likely to reduce in future.
Curative services serve those who can afford them.
As well as creating dependence on professionals, the services become focused on those with least health problems.

 Since these problems of medical and dnetal care exist in parallel the same kinds of changes are applicable to both.
Twenty years after the introduction of Health for All there are still too few resources, the resources which are available are still poorly allocated, medical staff still congregate around the wealthy people, ordinary people have little control over their own health, and health professionals still do not trust people to make good decisions about their health (Mahler 1981).
Health for allの導入から20年たったが、未だ資源は乏しく、未だ利用できる資源はぞんざいに配分され、いまだ医療の人材は豊かな人々の周りに集まり、普通の人々は自分の健康をほとんど管理できず、そしていまだ健康の専門家は、人々が自分たちの健康について優れた判断をすると信じてはいない(Mahler 1981)。
[Health for allはアルマ・アタ宣言の骨子]
All of these points apply to dentisry.
Worldwide there are peole who cannot attend and/or cannot afford dnetal treatment in its current guise.
Even in countries with well-developed socialized systems of dental care, there are major inequalities in oral health (Watt and Sheiham 1999).
歯科治療に関する社会制度が良好に発展した国においてさえ、口内の健康には大きな格差がある(Watt and Sheiham 1999)。
Dental services are overdue for an evaluation and reorientation.
A more holistic practice of dentistry in line with the primary health care approach will also ensure that services are more equitable and appropriate.
Such a move will require a challenge to the professional status quo (Dickson 1993).
そのような動きには、現状を維持する専門家への挑戦が要求される(Dickson 1993)。

 Whilst realizing the limitations of clinical dentistry, it is important to recognize that it may have a role (as yet undemonstrated in clinical trials) in reducing the psychosocial impacts of oral disease.
 臨床歯科学には限界があるが、 (未だ臨床試験では示されていないが) 口内疾病の心理社会的な影響を緩和する役割もある、と認識することが重要である。
For this reason it is essential that we generate a greater understanding with in dentistry of the nature of oral health.
The movement to identify more relevant measures of oral health to assess treatment need and the outcomes of care should be encouraged (Slade 1997).
治療ニーズと処置の結果を評価するための、口内の健康のより信頼できる測定方法を開発する動きがより推奨されるべきだろう(Slade 1997)。
The evidence-based approach, the use of clinical governance, and managed care should provide both the impetus and the means to ensure that only effective and efficient interventions are used.

 Dental surgeries are natural health-related setting for health promotion.
Practice-based oral health promotion activities provide an opportunity to increase knowledge and promote self-esteem and empowerment.
診療所における口内の健康づくりは、知識の充実、自尊心の増加ならびにエンパワメント (empowerment) の機会をもたらす。
Their role could be expanded by adopting a common risk factor approach (Croucher 1993).
共通のリスク・ファクター手法を適用することで、それらの役割が広がる (Croucher 1993)。
However, practice-based health promotion is only useful for those who attend the services and mayh exclude those people with the greatest need who do not.
In addition, there needs to be a change in emphasis in health education from the elitist prescriptive medical model which ignores the needs of people it serves and so blames ‘victims’.
Patients should not feel they are being chastised or told to do things.
More effective approach would be a patient-centred model which respects patient autonomy and seeks their active participation in defining their needs (Croucher 1989).
最も効果的な手法は、患者中心型のモデルであり、それは患者の自主性を尊重し、彼らがニーズを定義する行動に参加するのをうながす(Croucher 1989)。

 One particular aspect of dentistry in many countries that may need to be revised is the system of payment of fees to dentists for each item of service provided.
Fee-per-item service payments encourage dentists to work quickly and have been associated (in the past at least) with overtreatment.
This system payment tends to encourage the curative technical approach to treatment, unless there is a specific fee for prevention.
Converselym whereas salaried dentists have both more time and incentives to emphasize health promotion hteir productivety is lower (Schou 1993).
逆に、固定給の歯科医師は、健康づくりを強調するためのより多くの時間とやる気を有しているが、彼らの生産性は低い(Schou 1993)。
The potential disadvantages of capitation systems are that they may lead to undertreatment of existing patients and may encourage dentists not to accept patients with high treatment needs (Schoen 1991).
人頭払い(治療する患者の数が固定されている)の潜在的な欠点は、診療しなくてはならない患者への過小治療の原因となり、また歯科医師が高度な治療が必要な患者を受け入れない方向に後押ししてしまうことである(Schoen 1991)。
Interestingly, there has not been evidence of widespread neglect since the introduction of capitation payments, as long as there is an additional fee for treatments provided (Daley et al. 1994).
興味深いことに、治療をしたら追加の手数料が支払われる場合であれば、人頭払いの導入による患者無視が生じると言う検証はされていない(Daley et al. 1994)。


 Other specific changes which could be made to ensure access to dental services can be categorized in the framework used by Penchansky and Thomas (1981).
 その他の特定の変化としては、歯科サービスが受けられることの保証は、Penchansky and Thomas (1981) による枠組みにおいて分類されている。
Dental services must be available, accessible, affordable, acceptable, and accommondating.
歯科サービスは、利用可能で (available) 、入手性がよく (accessible) 、良心的な価格で (affordable) 、満足が得られ (acceptable) 、協調的である(accommodating) べきである。

 Clearly people cannot use services that do not exist, and so increasing their availability has a direct effect on services use (O’Mullane and Robinson 1977; Brennan et al. 1997).
 人々が存在していない事業を利用することは出来ないことは明らかであるので、サービスが利用しやすくなることは (availability) 、サービスの利用に直接影響を及ぼす(O’Mullane and Robinson 1977; Brennan et al. 1997)。
One way of making dental services more available at limited cost is to delegate care to auxiliary staff.
限られた費用でより歯科サービスを利用しやすくする一つの方法は、歯科補助職 (auxiliary staff) に委託できる処置を任せることである。
With the decreased incidence of dental caries in developed countries, the vast majority of new cavities in children are small and relatively simple to treat.
It is therefore not cost-effective to employ highly trained and highly paid detists to undertake this les demanding and repetitive work.
A number of countries including Australia, New Zealand, Canada, and the United Kingdom employ staff with a limited repertoire of treatment options (variously called school dental nurses, dental auxiliaries, and dental therapists) who provide high-quality care at lower cost (Office of the Auditor General Western Australia 1995).
オーストラリア、ニュージーランド、カナダ、イギリスを含む多くの国では、より低い費用で高い質の処置が提供できる、限られた範囲の治療ができる職員(学校歯科看護師school dental nurses、歯科補助dental auxiliaries、歯科治療士dental therapistsとさまざまに呼ばれる)を雇う(Office of the Auditor General Western Australia 1995)。
Similar data exist for dental hygienists.
Dental auxiliary staff work under the supervision of a dentist.
By reducing the level of supervision required and expanding the role of ancillary staff the availability of care can be increased whilst limiting costs.
Dental hygienists can work independently without reducing either the quality of treatment or patients’ satisfaction with it (Perry et al. 1997; Freed et al. 1997).
歯科衛生士は、治療の品質および患者満足度を下げることなく独立して仕事ができる(Perry et al. 1997; Freed et al. 1997)。
Likewise, hygienest can be trained to conduct clinical examinations in dental surveys with no compromise to the quality of the data (Kwan et al. 1996).
同様に、歯科衛生士は訓練をすれば、歯科調査においてデータの品質を妥協することなく、臨床的診査を行える(Kwan et al. 1996)。

 Clearly the expanded use of dental auxiliaries threatens the monopoly on the provision of dental treatment held by dentists.
The dental profession is the most constant barrier to the wider use of dental auxiliaries (Riordan 1997).
歯科医師は、歯科補助職の幅広い利用を阻む、最も普遍的な障壁である(Riordan 1997)。
The American Dental Association, for example, has consistently opposed their use since 1975 (Burt and Eklund 1999).
例えば、アメリカ歯科医師会は、1975年以来それらの利用を常に妨害している(Burt and Eklund 1999)。

 Other specific changes which could be made to ensure access to dental services which limit access were explored in a qualitative investigation of people who did not go to the dentist (Finch et al. 1988).
 歯科医療の利用を制限する歯科サービスの他の特徴としては、歯科を受診しない人々への質的調査により調べられた(Finch et al. 1988)。
The costs of treatment, the need to make an appointment, and the opening hours of dentists all deterred attendance.
These obstacles can be reduced by providing subsidized care, arranging services where no appointment is necessary, and where treatment can be provided outside office hours.

Developing countries

Whilst the prevalence of dental caries in many developing countries is still low, other diseases such as oral cancer and dental fluorosis are more common than in most developed coutries.
Non-industrialized countries also suffer from a shortage of resources including human resources, appropriate technology, and universally available power supplies.
[non-industrializedという表現は、industrial revolutionの健康と社会に与える影響を念頭に使われています]
Over the last two decades, the additional burden of meeting the costs of the infection control implications of the HIV epidemic have exacerbated any deficiencies in resources (Akpabio 1993).
ここ20年以上、HIV流行と深く関係している、感染管理の費用の増加に見合うさらなる負荷は、資源の不足を悪化させている(Akpabio 1993)。

 The traditional curative approach to dental health is limited in any setting but these limitations are more extreme when they are exported to the developing world.
The surgical approach to dentistry used in industrialized countries is technology intensive and requires an infrastructure of continuous power and water supply.
It involves expensive equipment which is difficult to use and maintain.
Dentists, therefore, need to treat patients who can help them recoup theior costs.
These pressures limit the availability of services nad contribute to the inequalities in their provision.
これらの重圧は、歯科サービスの入手可能性 (availability) を制限し、サービス提供における格差を増加させる。
Hobdell (1993) has described this situation as ‘strying to implement a type of oral health care developed mainly in the last century in another part of the world using equipment and materials developed for use in an entirely different socio-economic and political setting’.
Hobdell (1993) は、この状況を‘主に前世紀に、世界の他の地域において開発された口内医療の一種を、社会経済的にそして政治的に全く異なる状況で実践しようとすること’と記述した。
Indeed, large parts of the Western model of dental care may be inappropriate in developing countries, including an overemphasis of clinical surveys in health-care planning.
Services based on normative assessment limit community participation in health care and ignore the sociodental implications of oral disease.
規範的な評価を基にした事業は、医療における地域の参加を制限し、口内疾病の社会歯科的示唆 (sociodental implications) を無視してしまう。
They may also overcomplicate health care.
In one notorious example, survey data were used to calculate the periodontal treatment needs of children in Kenya Manji and Sheiham 1986).
よく知られた例では、Kenyaにおける子供の歯周治療のニーズを計算した調査データがある(Manji and Sheiham 1986)。
Using the WHO model, the treatment proposed would have used the entire dental human resources of Kenya for up to 21 years, allowing for no other care.
Services could concentrate on the realtively few conditions which comprise the bulk of oral health problems: toothache (not tooth decay), trauma, otal infections, and neoplasms (Hodbell 1993).
医療は、口内疾病の大部分は歯痛 (齲歯ではない) 、外傷、口内感染症、腫瘍おいういくつか疾病に集中していた (Hobdell 1993)。


 The primary health care approach is still relevant to the provision of dental services in all countries but it is particularly applicable to the developing world.
It has five principles: an equitable distribution of services, communiti involvement in health, a focus on prevention, the use of appropriate technology, and a multisectoral approach.
The Berlin Declaration on Oral Health and Oral Health Services in Deprived Communities provides comprehensive guidelines for planning, implimenting, and evaluating oral health projects within this framework (Mautsch and Sheiham 1995).
貧困地区における口内保健事業についてのベルリン宣言 (The Berlin Declaration on Oral Health Services in Deprived Communities) は、この枠組みで口内健康計画を計画、実行、評価するための、包括的なガイドラインを提供した(Mautsch and Sheiham 1995)。
It was conceived by the Oral Health Alliance, an international network which provides support and information to colleagues working in this field (e-mail: wmautsch@post.klinikum.rwth-aachen.de).
それは、この分野で働く仲間に、支援と情報を提供する国際的なネットワークであり、口内健康連合 (Oral Health Alliance) により着想された(e-mail:wmautsch@post.klinikum.rwth-aachen.de)。
Specific examles of activities within this framework are presented below.

Equitable distribution

Tudor hart’s (1971) ‘inverse care law’ between the availablity of services and the need for them also occurs in dentistry.
医療の利用性 (availability) とニーズの間に生じる、Tuder Hart (1971) の‘医療反比例の法則 (inverse care low) ’は、歯科でも生じている。
It is particularly extreme in countries where there are wide disparities between rich and poor.
In Africa, 80 per cent of the trained professional personnel live nad work in affluent neighbourhoods in cities, although the same proportion of hte indigenous population libe in rural areas (Thorpe 1993).
アフリカでは、訓練された専門家の80%が都市の生活水準の高い地区に住み、働いているが、同じ割合の原住者が田舎に住んでいる(Thorpe 1993)。
The scope for dental auxiliaries in developing countries may be greater since advocates of their use may not have to compete with the well-established political lobbies of dentists which exist in industrialized nations.
Auxiliaries can be used to provide simple but essential treatments to extend the availability of services and reduce inequalities in access (Anumanrajadhon et al. 1996).
補助職は、単純だが、欠かすことの出来ない処置を提供できるので、サービスの利用性 (availability) を拡大して、入手性 (access) の不平等を減少する(Anumanrajadhon et al. 1996)。

 Models exist for indentifying the types of personnel needed for oral health care in deprived communities along with training and evaluation methods (Samarawikrama 1995).
 貧困地域において、個人に必要とされる口内医療の種類を特定するためのモデルは、訓練と評価の方法と併せて確立されている(Samarawikrama 1995)。
Such models consider the frequency of problems, the difficulties encountered in undertaking the different roles, and the identification of the difficulties themselves.

Community development

Community involvement means that people are asllowed to take control of heir own health, and it is necessary if programmes are to therive.
地域の関与 (community involvement) は、人々が自分自身の健康を管理することを許すということであり、計画の成功には不可欠である。
It is perhaps the most difficult aspect of the primary health care approach since it requires that health professionals must relinquish their traditional hierarchical role.
In addition, individuals and communities often regard health as beyound their control and may not regard oral health as a priority.
There are isolated examples of wide involvement in oral health.
In Brazil, health councils comprised of community representatives, health workers, and civil servants operate at the national, state, and municipal levels.
Only in areas where there is a well-organized community have the local health councils been able to implement policy.
One council in Porto Alegre identified oral health as a priority.
Porto Alegreの1つの委員会は、口内の健康を最優先に認識している。
Despite considerable opposition from local dentists and a scrcity of resources, it was able to create an emergency dental service and initiate preventivbe programmes in schools and health centres (Baldisserrotto 1995).
地方の歯科医師と資源の不足よるかなり大きな抵抗にもかかわらず、学校と保健所における緊急時歯科サービスと、初期予防計画がつくられた(Baldisserrotto 1995)。


Focus on prevention

Prevention is universally accepted as an essential component of health care.
However, if prevention is to avoid the existing ystem in which people are passive recipients of information and preventive therapies, it must adopt the principles of health promotion.
Examples of a more participative role include the commuinity involvement described in Porto Alegre and the use of individuals from local communities including children in preventive activities.
より地域の関与も含めて参加の役割の多い例は、Porto Alegreにおける例と、予防活動に子供を含む地域コミュニティからの個人を利用する例である。

Appropriate technology

‘Appropriate technology’ is sometimes taken to mean ‘cheap’ and ‘second rate’.
‘適切な技術 (Appropriate technology) ’は、時々‘廉価’や‘妥協’を意味すると解釈される。
It is neither of these things, but is an approach which recognizes the needs and recources of the local community.
The atraumatic restorative technique is a recent developmet which combines these requirements with new knowledge of the process of dental caries and developments in dental materials science (Frencken et al. 1996).
非外科的修復技術は、齲蝕の進行に関する新しい知見から生み出された要求と歯科材料学の発展とが結びついて、最近開発された(Frencken et al. 1996)。
It involves removal of decay with hand instruments and filling the cavities with glass ionomer cements.
These cements are hand mixed with water on a small pad or slab.
Upon insertion, the filling gradually leaks fluoride to prevent secondary disease around the cavity.
All the instruments can be carried in a small case and treatment can be provided painlessly without local anaesthesia, at low cost, and without either electricity or expensive dental equipment.
Non-dentists can be trained in the technique in a matter of weeks and manuals are available from the World Health Organization (WHO).
The technique is most suitable for exactly the types of cavities which are found in many developing countries which do not have excessively high caries levels.

Multisectoral approach

We have seen how an effective health strategy might involve a number of departments of both national and local governments, water providers, the educational system, community members, and health-care workers.
All of approaches to health promotion outlined in the second part of this chapter must be integrated.
However, integration should mean more than using the resources of other sectors to promote oral health.
Such an approach often means that dentists simply get teachers to provide dental health education which carries the risk of not truly involving the other sectors (Mautsch and Sheiham 1995).
この、単に他の部門の資源の利用するという手法はしばしば、歯科医師が単に教師に歯科健康教育を提供させることにとどまり、他の部門を真の意味で巻き込むことにならない危険性を有する。 (Mautshch and Sheiham 1995)。


Conclusions and future developments in dental public health

The last few years have seen remarkable developments in our understanding of the importance of oral health and its significance as a public health concern.
There is a greater knowledge than ever before of the nature of the oral diseases which threaten health (dental caries, periodontal diseases, oral cancer, and dentofacial trauma), the epidemiology of those diseases, and the factors which determine them.
健康を脅かす口内疾病 (齲蝕、歯周疾病、口内癌、顎顔面外傷) の性質や疫学、決定要因について、以前より多くの知識がある。
Moreover, we are starting to accumulate a body of evidence on the effectiveness of health promotion and treatment strategies.
Those strategies include the use of fluoride, food and health policies to reduce sugars consumption, commuinity approaches to improve body higiene including oral cleaning, smoking cessation, policies on reducing accidents, and ensuring access to appropriate preventive care.
Many of these strategies could work in common with apporaches to the promotion of general health.

 In keeping with the recognition that clinical services are a minor determinants of health, most of the oral health strategies discussed in this chapter do not involve clinical dental services.
There is a developing knowledge of the relative impotence of clinical dentistry to bring about oral health and a greater awareness of its potential harm.
The evidence of effectiveness should be used to identify beneficial interventions and should help reorientate dentistry from its traditional curative approach which focuses on the responsibility of clinicians and their individual patients.
In so ding we mayh be able to move toward a more shared responsibility in which all participate.

 It is importnat that all these strands of information are combined.
Perhaps most important of all, we need a more universal understanding of what is meant by ‘oral health’ and its relationship with oral disease.
The ways we measure health and the outcomes of interventions will determine not only which interventions we choose but whether we choose to intervene at all.

 Future developments in dental public health can be considered in four areas: trends in oral health, the deprofessionalization of dentistry, technological developments, and relationships between oral and general health-care delivery.

 Two trends in oral health have been observed.
Some countries, particularly develping countries, are experiencing increases in dental caries.
The increases are related to the adoption of Western dietary patterns high in sugars.
Even if these trends are currently limited to more affluent city dwellers they represent worrying concerns for the future.
The increase in treatment needs created by these trends is likely to place an unafforably high burden on developing economies.
To some extent this burden will be moderated by the low levels of perceived need in communities unused to reveiving dental treatment.
However, if the disability and handicap brought about by oral disease are to be miniomized, then appropriate methods fo treatment will be required.
しかし、もし口内疾病により生じた障害と不利 (disability and handicap) が最小になったら、その次には適切な治療方法が要求されるようになるだろう。
Numerous examples now exist of dental auxiliaries being used to provide a limited range of tretments in both the developed and developing world.
Auxiliaries can be trained quicker to provide care to similar standards to dentists, but at gretly reduced costs.
Food and health policies could also be used in countries with rising caries levels to control imports, the production and sale fo cariogenic foods and drinks, while encouraging the use of traditional foods.


 In many developed countries, the decreased cries incidence witnessed over the last two decades apperas to have stabilized in young children.
The trend may have stabilized but its effects will continue to change dentistry for decades to come.
When coupled with demographic changes, changed attitudes towards oral health and the preservation of teeth seen in developing countries over the last 50 years, this trend producces an interesting pattern.
On the one hand there is a growing and ageing group of younger people whose treatment needs will remain lower in terms of volume and complexity than preceding generations.
On the other hand, there is a large groups of older people who will live for longer and retain many heavily restored teeth for longer.
These people will require more care, some of it more complex, than the generations that preceded them.
It is difficult to predict whether there will be a net change in the need for dental care or in which direction such a change would be.
One likely change will be a greater emphasis on specialization within dentistry.
The majority of the young people’s needs will comprise simple one surface fillings which could be placed by auxiliaries.
However, this change could be offset by the more complex demands of older people seeking dental implants and treatment for root caries and tooth wear which may remain in the domain of specialist.

 A dominant political direction over recent years has been the deprofessionalization of dentistry.
This trend is manifest in several different forms.
In many developed countries, patients are demanding ‘rights’ as consumers of care.
These demands are complemented by the application of marketing theory to dentistry which places consumer satisfaction as an essential criterion in business success.
Thus, patients have been directly and indirectly implicatd in moves to regulate the way in which dentists market themselves and have ensured that patient satisfaction is an active concern of dentists.
Similar principles are conerstones of the primary health care approach and the Ottawa Charter for Health Promotion (named community participation and community actionm respectively) (WHO—UNICEF 1978; WHO 1986).
似たような原則が、プライマリー・ヘルス・ケアの手法と健康づくりのためのオタワ憲章(それぞれ地域参加、地域活動と呼ばれる)の礎である(WHO—UNICEF 1978; WHO 1986)。
These activities take public involvement in oral health well beyond clinical dentistry.
Even within clinical care, satisfaction is associated with patient compliance and is therefore regarded as ana integral part of the process of care rather than just an outcome.
Other agencies, such as governments and insurance companies, are increasingly involved in health care.
Externally applied measures to minimize teh costs of care and increase the accountability of health-care organizations whilst assuring the quality of care all serve to reduce professional power within dentistry.

 This trend of deprofessionalization is likely to continue and may help to make oral care more relevant to the needs of the people it serves.
Professions resist any tendency to undermine their power.
This reaction could present an opportunity for dental public health to facilitate and manage the deprofessionalization of dentistry.

 A number of technological developmets may also influence oral health care.
The atraumatic restrative technique shows considerable potential for providing simple, inexpensive, and effective treatment for the type of minimal caries seen in developing countries.
Because the technique requires minimal training and equipment it will allow services to be provided in relativelyh small and isolated communities.
If the technique is used by partially skilled staff it may also contribute to the deprofessionalization fo dentistry in these countries; it will certainly reduce the cost.

 In developed contries oseo-integrated implants are increasingly used to support dental prostheses.
 先進国において、骨性統合 (osseo-integrated) インプラントは、歯科補綴物を支持するために、ますます利用される。
By providing a stable and retentive base for both single and multiple tooth prostheses, implants show great potential for reducing the handicap brought about by oral disease.
One disadvantage is that, for the time being at least, implant treatment demands considerable specialist expertise and is costly.
Implants may therefore become a treatment limited to those who can afford them and thus contribute to inequalities in oral health.


 Oralth health care is becoming increasingly integrated with the delivery of other services.
In policy terms greater integration can be seen as part of the multidisciplinary approach enshrined in the Alma-Ata declaration (WHO—UNICEF 1978).
政策の上での大きな統合は、多くの専門分野にわたるアプローチとみなされ、これはアルマアタ宣言において法制化されたものである(WHO—UNICEF 1978)。
There are many examples of integration at the levelo of clinical service provision.
Dental surgeries may be linked with other clinical services in health centres.
In some cases dentists invite other types of health-care worker into their practices to provide services.
At a broader level of health promotion, integration is particularly compatible with a common risk factor approach to disease.
Health educators and health promotors recognize the value of involveing other health-care workers, teachers, and other community owrkers, either as original deliverers or reinforcers of their messages.
Oral health also becomes a consideration of local and national governments with debates about fluoridation of water supplies and whther agricultural and fiscal policy are used to promote oral health.
It is the role of specialists in dental public health to act as advocates at all these levels.

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