Dental Sealants in the Prevention of Tooth Decay National Institutes of Health Consensus Development Conference Statement December 5-7, 1983 This statement is more than five years old and is provided solely for historical purposes. Due to the cumulative nature of medical research, new knowledge has inevitably accumulated in this subject area in the time since the statement was initially prepared. Thus some of the material is likely to be out of date, and at worst simply wrong. For reliable, current information on this and other health topics, we recommend consulting the National Institutes of Health's MedlinePlus http://www.nlm.nih.gov/medlineplus/. For making Bibliographic reference to the consensus statement from this conference, it is suggested that the following format be used, with or without source abbreviations, but without authorship attribution: Dental Sealants in the Prevention of Tooth Decay. NIH Consens Dev Conf Consens Statement 1983 December 5-7;4(11) Introduction and Conclusions Introduction The chewing surfaces of children's teeth are the most susceptible to decay and least benefited by fluorides. In recent years scientists have developed plastic films that are applied to these chewing surfaces to seal the pits and grooves where food and bacteria can be trapped. These dental sealants offer a new approach to the prevention of dental caries. The National Institutes of Health convened a Consensus Development Conference on December 5-7, 1983, to evaluate the effectiveness, safety, and implementation of the sealant procedure. After hearing a day and a half of presentations by experts of data on dental sealants, a Consensus Panel of biomedical investigators, practicing dentists, academicians, a dental hygienist, a statistician, and representatives from public interest groups considered the evidence and agreed on answers to the following questions: With the current widespread use of fluorides and the generalized decrease in caries experience among children, is there a need for sealants? How effective are sealants? Are there risks associated with the use of sealants? What are the indications for using sealants in individual and community-based caries preventive programs? What are the clinical procedures involved in successful sealant application, and what training and education are required? What factors have influenced and should influence the adoption and utilization of sealants for caries prevention? What is the current status of sealant research and what should be the research priorities for sealants and their implementation?   Panel's Conclusions The placement of sealants is a highly effective means of preventing pit and fissure caries. It is safe. It is currently underused in both private and public dental health care delivery systems. The reasons for such underuse are complex, but intensive efforts should be undertaken to increase sealant use. Expanding the use of sealants would substantially reduce the occurrence of dental caries in the population beyond that already achieved by fluorides and other preventive measures. Because dental caries is still a disease common to most young people in the United States and in other countries of the world, such reductions would substantially improve the health of the public and reduce the expenditures for treatment of dental disease. Practitioners, dental health agency directors, and dental educators are urged to incorporate the appropriate use of sealants into their practices and programs. It must be emphasized that the substantial reductions in dental decay that have occurred in the young population in the United States are due, for the most part, to the use of systemic and topical fluorides. These programs should be continued and expanded if we are to maintain and continue the trend in caries reduction. Indeed, the control of smooth surface caries that is provided by fluorides is of critical importance to the additional effectiveness of sealants.   With the Current Widespread Use of Fluorides and the Generalized Decrease in Caries Experience Among Children, Is There a Need for Sealants? The panel believes that the answer to this question is yes. Recent studies have indicated that the prevalence of coronal caries in children and adolescents is declining, due mainly to the beneficial effect of water fluoridation and other methods of fluoride delivery. Nevertheless, by age 16, American children have an average of nearly 10 decayed, missing (extracted), or filled tooth surfaces. In other industrialized countries, caries scores have also declined but are still substantial. In a few industrialized countries and many of the developing nations, caries scores are still increasing. The vast majority of young people in the world have dental decay. Prevention of the disease is a much better objective than treatment. Worse yet is nontreatment--with the pain and impaired function that follow. Thus, the need for additional or improved preventive methods is still compelling. It is of particular interest that dental caries is today largely a disease of pits and fissures of the teeth as opposed to lesions in smooth tooth surfaces. The National Dental Caries Prevalence Survey (1979-1980) revealed that only 16 percent of the caries experience of 5- to 17-year-old children occurred in approximal (smooth) surfaces, while 84 percent involved surfaces with pits and fissures. Systemic and topical fluorides have a less profound caries preventive effect on the pit and fissure tooth surfaces than on smooth surfaces. The major remaining need in the young population is to reduce or eliminate the carious process occurring in pits and fissures. These areas include primarily the occlusal or chewing surfaces of primary and permanent molars and of premolars. Certain population groups have an especially urgent need for preventive measures, including sealants. These groups include immigrant populations, people who are institutionalized, disabled people, those with a low income, and others. How Effective Are Sealants? Sealants are highly effective in preventing pit and fissure caries. The effectiveness of dental sealants in the prevention of tooth decay has been demonstrated in a variety of research findings covering a span of 16 years. In the last several years, investigators in several countries have repeatedly demonstrated that caries protection is 100% in pits and fissures that remain completely sealed. Complete retention rates after one year are 85% or better and after five years are at least 50%. These trials have shown that a close correlation exists between retention of sealants and their effectiveness, regardless of how the latter is defined and measured. Acid-etch resin sealants are classified into three types, based on the method by which they are cured (hardened): ultraviolet light-cured, chemically or self-cured, and visible light-cured. Research studies have demonstrated that self-cured sealants are somewhat more effective than ultraviolet light-cured sealants. More research is required to establish the relative long-term effectiveness of the visible light- cured sealants, although retention rates after two years look favorable. Sealants have been demonstrated to be effective in communities both with and without fluoridated water. Effectiveness is further increased if lost or partially lost sealants are replaced or repaired at visits subsequent to initial placement. The typical recall system in a private dental practice makes such replacement and repair convenient. Although recall is more difficult in community-based programs, it would enhance effectiveness in these settings as well. The effectiveness of sealants appears to be equal whether applied by dentists, dental hygienists, or dental assistants, provided that they have received appropriate training. The use of hygienist/assistant teams has proven to be particularly effective in public health settings. While the subject of the conference was the prevention of dental caries, it is suggested that sealants may also be used to arrest the progress of incipient or small pit and fissure lesions. Further exploration of this approach through careful clinical studies is to be encouraged.   Are There Risks Associated With the Use of Sealants? The risks associated with the use of pit and fissure sealants are minimal, and sealants are safe when properly placed using state-of-the- art materials and procedures. In considering the risks associated with the use of sealants, the panel evaluated both the possible systemic and local effects of the procedure. No systemic toxicity from the clinical use of sealants has been reported. The sealants currently classified as acceptable or provisionally acceptable by the Council on Dental Materials, Instruments, and Equipment of the American Dental Association contain no known toxic materials or carcinogenic agents. Sealants have also received favorable evaluation by the Food and Drug Administration. The chemical compositions of resin formulations used for sealing developmental pits and fissures are similar to, or the same as, monomeric resins that have been used for other dental purposes for many years. Some concern has been expressed about the local tissue effects from the phosphoric acid solution used to prepare the enamel for bonding of the sealant resins. There is no evidence to indicate that this has been a significant problem when the etchant is used properly. Questions regarding the possibility of the progression of dental caries beneath properly applied sealants have been answered by clinical studies. The evidence is overwhelming that the vitality of the dental pulp is not endangered by incidental placing of sealants over small pit and fissure lesions. In fact, minor carious lesions covered by sealants seem to become inactive, and the process of tooth decay is apparently arrested by the sealant. Investigators have reported negative or reduced bacterial cultures following several years of sealing. No studies have identified significant caries progression beneath an intact sealant. Sealants apparently seal off residual bacteria from their principal nutrient supply, thus preventing the accumulation of acid in cariogenic concentrations. The fear that the enamel will become more susceptible to caries if the sealant is lost seems unfounded. Studies have shown that a tooth which has been treated and then lost its sealant is no more susceptible to caries than a tooth that has not been treated. Concern has been expressed that the placement of sealants in excessive thickness could cause occlusal disharmonies. However, there are no reports of such problems in the extensive clinical trials that have been conducted. In addition to the risk to the patient, the panel considered possible risks to dental professionals, especially those placing sealants on a regular basis. No evidence was reported for mutagenic or other systemic risks to such personnel. The Panel recommends that protective glasses be worn by operators when using either the ultraviolet or visible light-cured materials. There are social and economic risks in the widespread adoption of any new technology. For example, if a society emphasizes one technology, it runs the risk of deemphasizing others or of not having resources available to support them. These issues of social resource allocation risks or the relative importance of dental sealants and other social needs are beyond the scope of this panel.   What Are the Indications for Using Sealants in Individual and Community-Based Caries Preventive Programs? Individual Programs Patients or their guardians should be made aware of the availability of sealants and, except where sealing is clearly inappropriate, given the opportunity to have sealants placed. Those individuals who can benefit from such treatment are: Children with newly erupted teeth with pits and fissures. Children whose lifestyle, developmental or behavioral patterns, or lack of fluoride exposure put them at high risk for dental caries. Children with teeth that have pits and fissures that are anatomically susceptible to caries. Other persons who desire sealant application and for whom sealant therapy is technically feasible.   In addition, evidence has been presented that children may benefit from having small carious lesions sealed, but further studies should be conducted to define the utility of this approach. Informed dentists and guardians should have the opportunity to make such a choice. Community-Based Programs Ideally, children should have access to sealant application on the same basis whether they are in individual or in community-based programs. However, when resources do not permit this, priorities should be established. Sealant programs should be implemented in communities where the preventive effect will be optimal, with consideration for prevalence of approximal caries, fluoridation status, and unique features of the population. Within these communities, priorities may be established on the basis of eruptive patterns, control of smooth surface caries through the use of fluorides, known population groups with special needs (for example, institutionalized persons or ethnic and cultural groups with demonstrated high caries rates) and those who do not have access to restorative dental care. Sealants should be a part of state Medicaid funding programs where dental services for children are provided. Recommended priorities for sealant application among the Medicaid population are as follows: Priority #1: Permanent first molars for children ages 6 through 8 and permanent second molars for children ages 11 through 13. Priority #2: Premolars in high-risk children and primary molars. The various agencies responsible for other government-funded programs should develop priorities to ensure the most effective use of sealants for their service beneficiaries. Minority Opinion -- Robert M. Veatch, Ph.D. The establishing of priorities in community-based programs can be based on either the principle of maximizing the good in the community per unit of investment, or the principle of justice that requires treating all citizens equally, regardless of whether that will maximize efficiency. The majority has opted for the utilitarian strategy. Critics of utilitarianism have recognized that its principles can compromise the just claims and rights of some members of the community. I accept that priorities can be established ethically but do not believe it is the place of this panel to propose ways in which the needs, welfare, and rights of patients should be compromised. If priorities are established, they must be based on the just claims of individuals regardless of whether honoring their rights will maximize community welfare. I accept priorities that are based on age or eruption status. Since all members of the community pass through an age progression and experience eruption of teeth, priorities can be established on this basis in a nondiscriminatory way. Priorities based on sex, race, ethnic group, socioeconomic status, the socioeconomic status of a school, fluoridation status of the patient's community, or the community approximal caries rate should be rejected. Giving priority on the basis of any of these criteria discriminates against those children who, through no fault of their own, are in social groups that will produce less efficient investment payoffs. They will be discriminated against even if in their own cases sealant treatment predictably will produce great benefit. For example, under the utilitarian strategy of giving priority to communities with fluoridation, in a nonfluoridated community a child with low approximal caries whose parents have obtained fluoride treatment for him or her (through professional or self-application) would be excluded from a community-based sealant program. A child in a fluoridated community, who is in all morally relevant respects identical, would receive sealant treatment benefits. In my opinion, dental sealants for at least some teeth are an essential part of an adequate minimum of health care and are thus a basic right of all citizens.   What Are the Clinical Procedures Involved in Successful Sealant Application, and What Training and Education Are Required? The procedure of properly applying a sealant is conceptually uncomplicated. Under actual clinical conditions, however, it may be simple or difficult to execute correctly. Clinical procedures for successful sealant application are as follows:   The tooth must be isolated so that adequate access is established to observe the field and to reach tooth surfaces with the appropriate instruments. This isolation must also insure that saliva contamination of the surfaces to be sealed can be prevented at critical points in the procedure. The surfaces should be cleaned with a prophylaxis brush or rubber cup and a cleansing agent that contains no oil or other substance that cannot be completely and quickly washed from the surfaces with water. The cleansing agent should be carefully washed from the surfaces using a water syringe and aspiration or high-speed evacuation. When the teeth are effectively isolated from saliva contamination, the surfaces are dried and etched by application of a 30 to 50 percent phosphoric acid solution for one minute. The solution is gently agitated during the application. It should cover all of the areas to be sealed. The acid should be washed away with water and aspiration or high speed evacuation. The surfaces are carefully dried and inspected to ensure that the frosty-appearing etch covers the area intended. The absolute avoidance of contamination with saliva or air-line moisture or oil is critical from the time of acid removal and drying until the sealant is cured. If contamination is suspected, re-etching of the surface for twenty seconds is indicated. The sealant should be applied according to the manufacturers' instructions. Care should be taken to avoid entrapment of air bubbles, to extend the sealant into all the grooves and pits, and to avoid extention of the sealant onto unetched smooth surfaces or soft tissues. The sealant must remain uncontaminated and undisturbed until it is cured to hardness. The sealant should be examined to ensure that underextension, overextension, undercuring, or voids have not occurred. A reasonable attempt should be made to remove the sealant to determine if adequate bond strength has been established.   Fluoride should not be applied to the enamel surface immediately before a sealant procedure is initiated. Fluoride may be applied immediately after sealant application. The most common reason for sealant failure is contamination of the etched surface with saliva or air-line moisture or oil. Adequate isolation from saliva for the time required is usually the most difficult step. Inability to do so is the most frequent reason why sealants cannot be placed on surfaces where they would be of benefit. Only sealant products classified as acceptable or provisionally acceptable by the Council on Dental Materials, Instruments, and Equipment of the American Dental Association and thus having documented clinical effectiveness should be used. As in any clinical method, exacting execution of the method and use of proven materials is required to obtain the desired result. Research has proven that the efficacy of sealants is based on the retention of the sealant. Retention of sealants is definitely technique-related. Anyone being trained--whether dentist, hygienist, assistant, student, or experienced practitioner--should have the same understanding and competence in the technique of application. To accomplish this, the Panel recommends that all training programs consist of three components: A didactic program consisting of lectures and readings on the histologic and microbiologic implications of sealants, the rationale and indications for their use, their clinical usefulness in individual and community-based caries preventive programs, and the technique of application. A laboratory or preclinical program to familiarize the trainee with the materials and methods. A clinical program involving actual application of sealants to patients' teeth. During this time it is important to have the steps in the procedure as well as the end product monitored by experienced personnel.   Sealant technique should be taught and used as one component of a total preventive program including systemic and topical fluorides, oral hygiene instruction, dietary counseling, and periodic examinations. The amount of time to be devoted to the foregoing education program will depend on the previous knowledge and clinical experience of the trainee. Skilled practitioners with experience in patient management and related clinical techniques may require as few as one or two patients to demonstrate adequate proficiency, whereas three to five days of clinical experience should be expected for students or less experienced professionals.   What Factors Have Influenced and Should Influence the Adoption and Utilization of Sealants for Caries Prevention? Various factors have been reported as contributing to the underutilization of sealants by dental professionals. Some of the concerns which have apparently discouraged adoption and use of sealants are related to: Perceived lack of data demonstrating efficacy. Possibility of sealing in decay with subsequent progression of the lesion. Lack of retention of sealants. Unfamiliarity with technique. Difficulty in explaining the rationale and procedure to patients and parents. Lack of third-party payment. Belief that amalgam restorations are better and more economical. Insufficient instruction in curricula for dental personnel. Restrictive state dental practice acts. Lack of availability of public information about the method and its benefits, and a resulting lack of public awareness.   In reviewing information on each of the above factors, the panel noted: An extensive body of knowledge has firmly established the scientific basis for the use of sealants. With the changing pattern of caries in the direction of occlusal caries, sealants are specifically targeted to prevent most of the remaining decay in the young population. With respect to sealing in decay, there is no evidence that placing a sealant over small lesions has resulted in progression of decay. To the contrary, it appears to have prevented further progress of such lesions. Well-controlled clinical studies have demonstrated the retention of sealants for five or more years and these data clearly support the caries preventive effect. Current materials and methods are remarkably improved over first-generation sealants. The method is standardized and widely published in the scientific literature. Better printed and audiovisual material should be made readily available to the profession to assist in explaining to the public the method, rationale, effectiveness, and safety of using sealants to prevent caries. An effort should be undertaken to prepare guidelines for the use of sealants that are acceptable to third-party payers. The reimbursement situation for sealants is analogous to the situation with topical fluoride treatments 15 years ago. Recent studies have shown that a properly placed sealant will last for a period of time approximating that of a typical amalgam restoration and the cost is usually less. The noninvasive nature of sealant application is exceedingly attractive. No significant amount of tooth structure is removed and application of the sealant is usually not uncomfortable. It has been reported that recent dental graduates will use sealants in practice when they have been previously exposed to enthusiastic, comprehensive instruction by their faculty. Trends to broaden state dental practice acts allowing dental auxiliaries to place sealants are positive steps. These trends should continue so that dental auxiliaries can place sealants in all states. Personnel costs can be reduced in this manner. A vigorous effort should be undertaken to inform all sectors of the public about sealants, their effectiveness and safety, and the rationale for their use. Educational materials should be developed and disseminated by government agencies and professional organizations. The inclusion of sealants in government-funded programs would serve as an example and be influential in increasing the adoption and use of this technique in private practice and other community-based   The dental profession has been a leader in advancing research on, and advocating primary efforts in, the prevention of dental caries. A prime example is the success of fluoridation programs. The preventive, noninvasive features of sealant application are important advantages. Application is usually easy and comfortable for the patient. In an era when the public has an ever-increasing consciousness about the prevention of disease, it behooves the dental profession to explain the success of sealants to the public and thereby promote yet another advance that will further reduce one of the chronic diseases of our society.   What Is the Current Status of Sealant Research and What Should Be the Research Priorities for Sealants and Their Implementation. Basic and clinical research supports the extensive use of sealants. The details of the acid-etch technique and the subsequent bonding of sealants to the etched enamel are well understood. The basic chemistry of the sealant resins and the reactions by which they are cured are defined. Clinical investigations have shown repeatedly that sealants are a highly effective means of preventing pit and fissure caries. Studies have established the safety of the method with a high degree of confidence. Continuing research on sealants should be directed to the following objectives: Improvement of current sealant technology. a. Improvement of acid-etch methods. b. Improvement of the properties of the sealant resins, possibly including more hydrophilic resins. c. Improvement of methods of preventing saliva and other contamination of the etched surface. d. Development of high-quality fluoride-releasing resins. e. Studies on newer materials, including toxicology, tissue compatibility, and mutagenicity. More complete understanding of the effect of sealants on cariogenic bacteria in carious lesions. Obtaining more useful data on the cost-effectiveness of using sealants in community programs under a variety of circumstances and employing various strategies with respect to personnel and target populations. Development of new technologies for bonding sealants to enamel that would not require acid etching of the enamel or the strict avoidance of enamel surface contamination prior to application of the sealant. Further understanding of the reason for sealant underutilization. a. Development of low-cost screening methods to identify children at high risk of getting pit and fissure caries. Consensus Development Panel James W. Bawden, DDS, MS, PhD (Chairman) Alumni Distinguished Professor Department of Pedodontics School of Dentistry University of North Carolina Chapel Hill, North Carolina D. Walter Cohen, DDS Professor of Periodontics Dean Emeritus, School of Dental Medicine University of Pennsylvania Philadelphia, Pennsylvania Durward R. Collier, DDS, MPH Director, Division of Dental Health Services Tennessee Department of Health and Environment Nashville, Tennessee Gay-wynn Pitcher Cooper, RDH, MEd Dental Hygiene Practitioner Albuquerque, New Mexico Irving W. Eichenbaum, DDS, FACD Associate Professor of Pediatric Dentistry University of Connecticut Health Center Pedodontist, Private Practitioner New Britain, Connecticut Caswell A. Evans, Jr., DDS, MPH Director, County Health Services Division Seattle-King County Department of Public Health Seattle, Washington Marilyn C. Farray, JD, MHA Senior Health Specialist The Children's Defense Fund Washington, D.C. Joseph L. Fleiss, PhD Professor of Biostatistics Columbia University New York, New York Elverne M. Tonn, DDS, FACD Associate Professor of Pediatric Dentistry School of Dentistry University of the Pacific Pedodontist, Private Practitioner San Francisco, California Robert M. Veatch, PhD Professor of Medical Ethics Kennedy Institute of Ethics Georgetown University Washington, D.C. Speakers Harry M. Bohannan, D.M.D., M.S.D. "Indications for Use in A Community-Based Program" Dalton McMichael Fellow and Research Professor University of North Carolina School of Dentistry Chapel Hill, North Carolina Rafael L. Bowen, D.D.S. "Safety Considerations: Oral and Systemic" Director American Dental Association Health Foundation Research Unit National Bureau of Standards Washington, D.C. Brian A. Burt, B.D.S., M.P.H., Ph.D. "Clinical and Economic Considerations" Professor Director Program in Dental Public Health University of Michigan School of Public Health Ann Arbor, Michigan Judith Disney, D.M.D. "Training and Educational Needs for Personnel: Adapting Sealant Application Procedures for Use in Community-Based Programs" Clinical Director National Preventive Dentistry Demonstration Program American Fund for Dental Health Chapel Hill, North Carolina P. Jean Frazier, M.P.H. "Current Status of Use: Characteristics of Users and Nonusers, Societal and Professional Considerations" Associate Professor Department of Health Ecology University of Minnesota School of Dentistry Minneapolis, Minnesota Robert E. Going, D.D.S. "Effect of Sealing Incipient Caries: Effect on Tooth Maturation" Assistant Dean Professor of Operative Dentistry Emory University School of Dentistry Atlanta, Georgia A. John Gwinnett, Ph.D., B.D.S., L.D.S.R.C.S.(Eng) "Scientific Rationale for Sealant Use: Technical Aspects of Application" Professor of Oral Biology and Pathology State University of New York at Stony Brook School of Dental Medicine Stony Brook, New York Eva J. Mertz-Fairhurst, D.D.S. "Current Status of Retention and Caries Prevention" Associate Professor Department of Restorative Dentistry Medical College of Georgia School of Dentistry Augusta, Georgia Louis W. Ripa, D.D.S. "Training and Educational Needs for Undergraduate Dental Personnel" Professor and Chairman Department of Children's Dentistry State University of New York at Stony Brook School of Dental Medicine Stony Brook, New York William Peter Rock, D.D.S., F.D.S., D.Orth.R.C.S.(Eng) "The Effectiveness by Tooth Type and Surface" Senior Lecturer in Children's Dentistry and Orthodontics University of Birmingham, Edgbaston The Dental School Birmingham ENGLAND Linda Scheirton (Groll), R.D.H., M.A. "Training and Educational Needs for Graduate Dental Personnel: Continuing Education, Certification Courses" Associate Professor Dental Hygiene Education School of Allied Health Sciences University of Texas Health Science Center at San Antonio San Antonio, Texas Leon M. Silverstone, D.D.Sc., Ph.D., B.Ch.D. L.D.S.R.C.S.(Eng) "Overview of Sealant Research: Needs and Priorities" Associate Dean for Research University of Colorado Health Sciences Center Denver, Colorado Richard J. Simonsen, D.D.S., M.S. "Indications for Use in a Program of Patient Care" Assistant Professor Department of Restorative Dentistry University of Connecticut School of Dental Medicine Farmington, Connecticut Dennis C. Smith, D.Sc., Ph.D., F.R.S.C. "Appropriateness of Comparing Sealants with Restorations" Professor of Biomaterials Faculty of Dentistry University of Toronto Toronto, Ontario CANADA John W. Stamm, D.D.S., D.D.P.H., M.Sc.D. "Current Status of Deantal Caries: Worldwide Perspective, North American Perspective" Professor and Chairman Department of Community Dentistry McGill University Montreal, Quebec CANADA Planning Committee Alice M. Horowitz, RDH, MA (Chairperson) Coordinator, Health Education and Promotion Activities National Caries Program National Institute of Dental Research National Institutes of Health Bethesda, Maryland Pui Luen Fan, BSc, MS, PhD Assistant Secretary Council on Dental Materials, Instruments, and Equipment American Dental Association Chicago, Illinois Donald J. Galagan, DDS, MPH Former Assistant Surgeon General and Director of Dental Public Health and Dean, College of Dentistry University of Iowa Iowa City, Iowa Robert J. Musselman, DDS, MSD Professor and Head Department of Pedodontics School of Dentistry Louisiana State University New Orleans, Louisiana Louis W. Ripa, DDS, MS Chairman and Professor Department of Children's Dentistry School of Dental Medicine State University of New York at Stony Brook Stony Brook, New York Leon M. Silverstone, DDSc, PhD, BChD, LDS RCS(Eng) Associate Dean for Research School of Dentistry University of Colorado Health Sciences Center Denver, Colorado Monica Walters, MHS Office of Medical Applications of Research National Institutes of Health Bethesda, Maryland Lydia S. Burroughs Public Affairs Specialist Office of Scientific and Health Reports National Institute of Dental Research National Institutes of Health Bethesda, Maryland Michael J. Bernstein Director of Communications Office of Medical Applications of Research National Institutes of Health Bethesda, Maryland Conference Sponsors National Institute of Dental Research Harald A. Löe, DDS, Dr Odont Director Office of Medical Applications of Research J. Richard Crout, MD Director

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