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October 2009
Volume 30, Issue 8

Caries-Free Communities: Is This for Real?

Lois K. Cohen, PhD; Saskia Estupiñán-Day, DDS

When I, Lois, came to work at the National Institute of Dental Research (NIDR) in 1976, the National Caries Program (NCP) was 5 years old. It was a strong research effort to substantially reduce the caries prevalence within 10 years and was created when more than 40 million Americans lacked access to fluoridated community water. Researchers were focusing on combating caries-inducing microorganisms, increasing the resistance to tooth decay, modifying caries-promoting ingredients of the diet, and improving delivery and public acceptance of techniques that prevented caries. In 1979 the NIDR evaluated its investments and found considerable progress had been made in understanding the role of Streptoccoccus mutans, the etiology of dental caries, and metabolism, physiology, and structure of key cariogenic bacteria. Scientists also better understood the function of adherence and bacterial colonization, immunization, and secretory immunoglobulin A (IgA) system. Animal models had also been developed to test caries preventive methods, including immunizations and reductions of the cariogenic potential of foods. Investments in various fluoride delivery mechanisms proceeded as well as in sealant technology. Less progress was apparent in furthering dietary and nutritional strategies in humans or improving delivery and acceptance of caries preventive methods.

While the NCP no longer exists the research field, nonetheless, continues to flourish with support from the National Institute of Dental and Cranial Research as well as through national and global efforts, mostly enabled by the private corporate sector of dentifrice manufacturers, the food and beverage industry, and, to a certain extent, the dental materials industry. As a result, we have an array of strategies from fluoride-adjusted water supplies (associated with the birth of the NIDR in 1948) to fluoride-containing dentifrices to noncariogenic sugar substitutes to sealants to more recent advances of fluoride varnishes and methods for detection of early white-spot lesions (allowing for remineralization to occur). There are many countries with salt containing fluoride available in the marketplace and a few with fluoridated milk. An increasing number of nations are employing low-cost atraumatic restorative procedures, delivered by various levels of oral health workers, a technique developed for resource-poor environments but gaining momentum in more affluent middle income and industrialized countries where professionally trained oral health workforce is in short supply. Today, we also see a greater acceptance by the public of these products and services, although clearly pockets of populations nationally and globally lack access to both. These people are vulnerable to caries by virtue of their low oral-health literacy regarding self-care. That is, they are unaware of the tools that could be made available through schools, worksites, clinics, and marketplace These mechanisms are not currently accessible as a result of inadequate human and financial resources or because of the remoteness of these denizens’ communities.

Given that background, we recently participated in a workshop April 23 to 25, 2009 in Mexico City (during the height of the recent influenza emergency), hosted by the Ministry of Health of Mexico, Pan American Health Organization (PAHO)/World Health Organization (WHO), Mexican dental schools, and the Mexican Dental Association. The workshop focused on identifying communities in this hemisphere that are vulnerable or at high risk for dental caries, with the purpose of designing strategies to solve these problems and create caries-free communities (CFC). Perhaps this was reminiscent of the birth of the NCP as we wondered if it would be possible to accomplish the 10-year strategy that was launched in 2005 and scheduled for an evaluation by 2015. It was the PAHO/WHO that started this ambitious plan. The workshop was intended to build a coalition of partners, both public and private, that encompasses chief dental officers, deans and officers of national dental associations, and related community-based stakeholders in 39-member and associate states in the Americas. We heard a truly inspiring resolve that was articulated in the Mexico City Declaration.

The Mexico City Declaration might become mere words on paper affirming a CFC collaborative; however, we hope the agreement to form a strong and binding partnership to focus on the most vulnerable in each country will materialize. The signers agreed to use evidence-based approaches to identify the communities, solutions, and specific interventions; to ensure appropriate interventions would be based on needs assessments, disease prevention, health promotion, and health protection; to involve and inspire stakeholders in both the private and public sectors of the targeted communities; to identify human and economic resources; and to develop an evaluation mechanism to facilitate a sustainable program for communities.

Before the workshop, each country’s team (comprised of ministries of health, academia, and professional associations) collected their statistical evidence that would be the basis for the selection of the targeted communities. As a consequence of the workshop, best practices were shared among the teams for building capacity within their respective countries and expanding successful programs to reach more people in a particular community. As a public dental health administrator and a sociologist respectively, we were delighted to hear discussions of systems to organize communities for action and delivery of services and products, not just dental procedures for caries prevention, diagnosis, or treatment. Rather, all of those elements—creation of public health policies for fostering community-based prevention, screening, and care programs; community fluoride programs or marketplace availability of fluoride-containing products; educational campaigns to increase oral health literacy and to enable citizens to make wise choices about self-care and to gain access to services—created confidence in these dental leaders.

A plan has been devised for the Americas. There seems to be an informed leadership to drive the plan’s implementation; there are resources (although necessarily constrained during this recession); there is political will; and there is a commitment to galvanize social will through educational campaigns and regular use of critical monitoring mechanisms. This plan is supported by the body of evidence culled from several decades of research. With all those ingredients, we have no excuse but to try to make the CFC initiative a success.


Harris RR. Dental Science in a New Age. Rockville, MD: Montrose Press; 1999.

US Department of Health, Education and Welfare, Public Health Service, National Institutes of Health. Evaluation of the National Institute of Dental Research National Caries Program: Report of the Main Panel. 1979.

Cohen LK, Gift C, eds. Disease Prevention and Oral Health Promotion: Socio-Dental Sciences in Action. Copenhagen, Denmark: Munksgaard and FDI; 1995.

Pan American Health Organization Oral Health Web site. Accessed June 2009.

About the Authors

Lois K. Cohen, PhD
Paul G. Rogers Ambassador for Global Health Research

Saskia Estupiñán-Day, DDS
Senior Advisor and Team Leader
Special Populations and Vulnerable Population Health
Pan American Health Organization/World Health Organization

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