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Scientific Basis for the Prevention of Caries and Periodontal Disease 1

The attractiveness of the concept of prevention is enshrined in English idiom, and has been advanced with such fervour in dentistry during recent years that the rising generation may sometimes be deluded into believing that this is a modern development. Such is far from being the case, preventive dentistry having been preached and advocated in this country certainly since the beginning of this century. Among the first crusaders was James Sim Wallace, who published a book entitled 'The Cause and Prevention of Decay in Teeth' in 1900 and continued to preach the doctrine it spelled out for 50 years thereafter. Much of what is held to be innovative thinking in the field ofdental health education would not have been novel to Sim Wallace. For fifty years he reiterated instructions based on preventing dental disease by dietary measures with which no writer of today's health education leaflets would substantially disagree and yet, at the end of that time, the state of dental health of the nation was probably worse, and certainly no better, than it had been when he started. There can be few dentists who graduated in Britain during the years between the wars who were not imbued with the teachings ofSim Wallace. The value ofdetergent diets was faithfully assimilated by undergraduates of those days, and it could certainly not be said that Wallace's teachings were given less than ample exposure in the journals and textbooks of the time. The failure of this approach to prevention must be sought in causes other than inadequate communication. The most obvious reason, perhaps, is lack of receptivity on the part of the general public. From childhood to old age people prefer to eat food of their choice rather than by prescription or proscription. The knowledge that sugar is at least an important factor in the causation of tooth decay has been sufficiently widely disseminated for one to assume that in urbanized communities where the prevalence of caries is at its highest ignorance of this deleterious effect is unlikely to be an important consideration. In fact, however, it may well be that people have an exaggerated idea of the significance of sugar in the causation ofcaries. Certainly this can be said ofmany dentists, who have come to regard caries as an automatic consequence of eating sugar. Such assumptions overlook those instances that contradict preconceived ideas. An example is provided by the unusually low incidence of caries in the town of Heliconia in Colombia, where pane1a (crystallized sugarcane juice) is consumed in large quantities from infancy to old age. Bowen et al. (1977) found 20% of a group of 347 children in Heliconia to be caries-free, while in the comparable town of Don Matias only 2 out of 154 were caries-free and the caries index in the remainder was three times that observed in the children of Heliconia. Low caries incidence has been found to occur in many different parts of the world, but the noteworthy feature in this instance is that the relative resistance of children in Heliconia is associated with a water supply devoid of detectable fluoride and with an extremely high level of sucrose in the diet. This phenomenon is referred to not in order to exculpate sugar from its irrefutable role in the pathogenesis of dental caries; it merely illustrates that to regard sugar as the sole cause is an over-simplification. Diet is not the whole story and advocating the exclusion of sugar, even with evangelistic fervour, will not bring about the conquest of caries.