Prof. Shlomo Paul Zusman is the Chief Dental Officer of Israel and a specialist in dental public health, currently on sabbatical at Hebrew University Faculty of Dental Medicine. He supports the implementation of the School Dental Service oral health programme in Israel, which reaches all students enrolled in formal education settings. The service includes a yearly examination and a notice to parents with a reminder to take their child to a dental clinic for a thorough evaluation. The service also distributes a toothbrush and toothpaste to each student and provides three hours of oral health education in the classroom each year. 

Prof. Zusman obtained an MSc in Dental Public Health from the University of London and a master’s degree in Public Administration from Harvard University. He is also a member of FDI’s Public Health Committee and president of FDI’s Chief Dental Officer/Dental Public Health Section. 

FDI spoke with Prof. Zusman for his expert opinion on fluoride use as an essential measure to combat tooth decay in young children and in communities more widely. 

Fluoride is essential for the prevention of dental caries and has been used for over 70 years. However, many people today are still not receiving adequate exposure to it. What are the main barriers to achieving population-wide access to fluoride? How do you think these barriers should be addressed?

Fluoride is the only element that strengthens the tooth enamel against acid attacks. The important aspect to remember is that those who need fluoride the most – low socioeconomic status (SES) communities with high levels of caries – receive it the least. 

To overcome the barriers to access to fluoride, we need to make fluoride available and affordable to most members of the community via public health measures. This includes an ample supply of subsidized, low-priced fluoridated toothpaste, the use of fluoride varnish in community settings, and free access to preventive dental care. In addition, it is important to supply drinking water with optimal fluoride levels wherever this is feasible as a universal measure for primary prevention of dental disease. 

In your opinion, how do we improve oral health literacy and ensure people understand that twice-daily toothbrushing with a fluoride toothpaste is essential to maintaining good oral health?

Personally, I am not sure that the main problem is a lack of understanding or knowledge. For me, the main problem is a lack of compliance, a lack of persistence. Good oral health practices and habits have to be acquired at a young age. This is why oral health promotion programmes that are oriented to young children are so important, like FDI’s Brush Day & Night 21-day programme.

Fluoride has been proven to be safe and effective if used at recommended levels. What do you think is driving the demand for non-fluoridated toothpaste?

The demand for non-fluoridated toothpaste is mainly seen in affluent, high SES communities. In these communities, the caries level has significantly improved over the last decades. When health improves, people often forget the problems of the past and feel comfortable taking more risks. 

The other reason for the rising demand is the misconception that non-fluoridated toothpaste is more ‘natural’ than the fluoridated ones and, in certain communities, the ‘natural’, ‘green’ and ‘organic’ labels are more appealing.

We would very much like to hear about what have become your best practices in improving oral health as the Chief Dental Officer for Israel:

For many years, the main community-based measure for improving oral health in Israel was community water fluoridation. We reached 75% of the population until it was stopped a few years ago, a decision I did not necessarily agree with.  

Complementing community water fluoridation, we also have a School Dental Service that reaches all students enrolled in formal education settings. The dental service includes a yearly examination and a notice to parents with a reminder to take their child to a dental clinic for a thorough evaluation. If a child requires urgent dental care, the service contacts the parents by phone. 

The service also distributes a toothbrush and toothpaste to each student and provides three hours of oral health education in the classroom each year. Fluoride varnish applications in preschools were also implemented recently as an additional measure to control oral disease.

 FDI is committed to ensuring good oral health habits start early. Through the Brush Day & Night 21-day school programme, we are working together with Unilever to improve oral health globally.  We have also developed educational resources through our Mouth Heroes for Schools work. As the Chief Dental Officer for Israel, what school-based oral health programmes have you been involved in? How did you monitor and measure their success?

As described above, our School Dental Service is our flagship programme for oral health education in classrooms. Our regional dental officers monitor the service: they conduct field visits and make observations according to structured review forms. Activity reports are submitted by the service to the main office where they are reviewed. We extended the service to preschools to create a health supporting environment and to build healthy habits and skills at a young age. We also conduct satisfaction surveys among parents and teachers.

Why is brushing with fluoride toothpaste particularly important in childhood? 

The primary teeth and the new permanent teeth are more vulnerable to caries, so it is especially important to make them more resistant and help prevent decay. 

Could you share your recommendations on the appropriate levels of fluoride in toothpaste for the following age groups? (0-3 years/3-6 years/6-12 years).

FDI recommends that if a child is aged less than 3 years, then the teeth should be brushed by an adult using a very small amount (about the size of a grain of rice) of fluoridated toothpaste. For children aged between 3 and 6 years, a pea-sized amount of toothpaste with 1000 ppm fluoride can be used. From 6 years of age onward, they can use the same toothpaste as adults. 

Why is fluoride found in toothpastes? Why is it beneficial for our teeth? 

Fluoride is the only known mineral that helps to prevent tooth decay by making the teeth more resistant to the acid produced by the bacteria from sugars in the food and drinks we consume. Brushing the teeth with toothpaste that contains fluoride brings it to the surface of the teeth. Fluoride gets incorporated into the outer surface of the teeth, making the teeth more resistant to acid.

What are the benefits of using a fluoride mouthwash?  

Washing the mouth with fluoridated mouthwash can help prevent tooth decay. The best time to use mouthwash is after lunch, especially if it is not feasible to brush your teeth at that time. Don’t eat or drink for 30 minutes after using a fluoride mouthwash. However, don't use mouthwash straight after brushing your teeth.