Prevention in practice – an initiative between BASCD and Department of Health Sue Gregory Consultant in Dental Public Health.

Prevention in practice –Prevention in practice –an initiative between BASCD and an initiative between BASCD and

Department of HealthDepartment of Health

Sue GregorySue Gregory

Consultant in Dental Consultant in Dental Public HealthPublic Health

The taskThe task• DH want to focus on prevention - How can DH want to focus on prevention - How can

prevention be built into the new contract?prevention be built into the new contract?

• What help can be given to PCTs to help What help can be given to PCTs to help them commission more effectively?them commission more effectively?

• Can we maximise the yield from the Can we maximise the yield from the preventive tools we have and the preventive tools we have and the knowledge on how they work?knowledge on how they work?

Following the publication of Choosing Better Oral Health -

3 supporting documents:• ‘Smokefree and Smiling’ - Guidance to PCTs on

smoking cessation and how it fits in with dental practice – Richard Watts, May 2007

• Guidance on improving oral health among adults and children with disabilities – Colette Bridgman, to be launched soon

• ‘Delivering Better Oral Health’ - Provision of evidence-based information to support the commissioning of preventive services – Sue Gregory, Sept 2007

September 2007

Contents

1. Reference cards - Summary guidance

2. Supporting chapters:• Principles of toothbrushing for oral healthPrinciples of toothbrushing for oral health• Increasing fluoride availabilityIncreasing fluoride availability• Healthy eating adviceHealthy eating advice• Identifying sugar-free medicinesIdentifying sugar-free medicines• Improving periodontal healthImproving periodontal health• Stop smoking guidanceStop smoking guidance• Accessing alcohol misuse supportAccessing alcohol misuse support• Prevention of erosionPrevention of erosion• Supporting referencesSupporting references

Distribution

• General practices

• Salaried services

• Consultants in Dental Public Health

• Also available online

Development of Development of ‘Delivering Better Oral ‘Delivering Better Oral

Health’Health’

The TeamThe Team

• Chair – Sue Gregory (BASCD president)• Secretary – Semina Makhani• Derek Richards (BASCD)• Gill Davies (BASCD)• Keith Milsom (National Oral Health Unit)• Rowena Pennycate (BDA)• Baldeesh Chana (FGDP)• Nigel Carter (BDHF)• Richard Watt (OHPRG)• Tom Dyer (GDP)• Tony Jenner / Jerry Read (DH)• Rosemary Khan, Jan Clarkson

The PrinciplesThe Principles

• Statements must be supported by evidence – the stronger the better

• The potential benefits of prevention have not been maximised – Not doing enough– Prevention not evidence based

• Challenges the ‘high risk’ approach in favour of a practice ‘population’ approach

TheThe PrinciplesPrinciples

• Messages would be in line with wider health messages– The common risk factor approach

• Providing information for – The whole dental team– Dental care at primary, secondary and tertiary level– Primary Care Organisations to assist with

commissioning

The outputsThe outputs

Grade Strength of evidence

I Strong evidence from at least one systematic review of multiple well-designed randomised control trials e.g Cochrane reviews.

II Strong evidence from at least one properly designed randomised control trial of appropriate size e.g. comparison of 2 toothpastes.

III Evidence from well-designed trials without randomisation, single group pre-post, cohort, time series of matched case-control studies e.g. plaque reduction studies.

IV Evidence from well-designed non-experimental studies from more than one centre or research group.

V Opinions of respected authorities, based on clinical evidence, descriptive studies or reports of expert committees.

Prevention of caries in children age 0 – Prevention of caries in children age 0 – 6 years6 years

Advice to be givenAdvice to be given EBEB Professional interventionProfessional intervention EBEB

Children Children aged up to aged up to 3 yrs3 yrs

All All children children aged 3-6 aged 3-6 yrsyrs

•Breast feeding is best for babiesBreast feeding is best for babiesFrom 6 months of age infants should be From 6 months of age infants should be introduced to drinking from a cup, and from introduced to drinking from a cup, and from age one year feeding from a bottle should be age one year feeding from a bottle should be discourageddiscouragedSugar should not be added to weaning foods Sugar should not be added to weaning foods Parents should brush / supervise Parents should brush / supervise toothbrushingtoothbrushingUse only a smear of toothpaste containing Use only a smear of toothpaste containing no less than 1000 ppm fluorideno less than 1000 ppm fluorideAs soon as teeth erupt in the mouth brush As soon as teeth erupt in the mouth brush them twice dailythem twice daily

IIIIIIII

VVVVII

IVIV

Brush last thing at night and on one other Brush last thing at night and on one other occasion, occasion, Brushing should be supervised by an adult Brushing should be supervised by an adult Use a pea size amount of toothpaste Use a pea size amount of toothpaste containing 1350-1500 ppm fluoride containing 1350-1500 ppm fluoride Spit out after brushing and do not rinse Spit out after brushing and do not rinse The frequency and amount of sugary food The frequency and amount of sugary food and drinks should be reduced and, when and drinks should be reduced and, when consumed, limited to mealtimes. Sugars consumed, limited to mealtimes. Sugars should not be consumed more than four should not be consumed more than four times per daytimes per daySugar free medicines should be Sugar free medicines should be recommendedrecommended

IIV V V, I V, I

IVIVIIIIII

Apply fluoride varnish to Apply fluoride varnish to teeth twice yearly (2.2% Fteeth twice yearly (2.2% F--))

II

Children Children giving giving concern; concern; E.g those E.g those likely to likely to develop develop caries,caries,those with those with special special needsneeds

All advice as above plus:All advice as above plus:Use a smear or pea size amount of Use a smear or pea size amount of toothpaste containing 1350-1500 ppm toothpaste containing 1350-1500 ppm fluoridefluorideEnsure medication is sugar freeEnsure medication is sugar freeAdvise that dietary supplements containing Advise that dietary supplements containing sugar and glucose polymers are given at sugar and glucose polymers are given at mealtimes when possible and not last thing mealtimes when possible and not last thing at night at night

II

VVVV

Apply fluoride varnish to Apply fluoride varnish to teeth 3-4 times yearly teeth 3-4 times yearly (2.2% F(2.2% F--) ) Prescribe fluoride Prescribe fluoride supplement and advise re supplement and advise re maximising benefitmaximising benefitReduce recall interval Reduce recall interval Investigate diet and assist Investigate diet and assist to adopt good dietary to adopt good dietary practice practice Ensure medication is Ensure medication is sugar free or given to sugar free or given to minimise cariogenic effectminimise cariogenic effect

VV

II II

VV

IIIIII

VV

Prevention of caries in children aged from 7 years Prevention of caries in children aged from 7 years

and young adultsand young adults Advice EB Professional intervention EB

All children and young adults

Brush twice daily I Apply fluoride varnish to teeth twice yearly (2.2% F-)

I

• Brush last thing at night and on one other occasion

V

• Use fluoridated toothpaste (1350 ppm F or above)

I

• Spit out after brushing and do not rinse

IV

• The frequency and amount of sugary food and drinks should be reduced and, when consumed, limited to mealtimes. Sugars should not be consumed more than four times per day

III

Those giving concern – E.g. those likely to develop caries,

those undergoing orthodontic treatment and

those with special needs

All the above, plus : Use a fluoride mouth rinse

daily (0.05% NaF) at a different time to brushing

I Fissure seal permanent molars with

resin sealant Apply fluoride varnish to teeth 3-4 times

yearly (2.2% F-) For those 8+ years with active caries

prescribe daily fluoride rinse For those 10+ years with active caries

prescribe 2800 ppm toothpaste For those 16+ years with active disease

consider prescription of 5000 ppm toothpaste

Investigation of diet and assistance to adopt good dietary practice

I

I

I

I

I

III

Prevention of caries in adultsPrevention of caries in adults Advice EB Professional intervention EB

All adult patients Brush twice daily with fluoridated toothpaste

I

Use fluoridated toothpaste with at least 1350 ppm F-

I

Brush last thing at night and on one other occasion

V

Spit out after brushing and do not rinse IV

The frequency and amount of sugary food and drinks should be reduced and, when consumed, limited to mealtimes. Sugars should not be consumed more than four times per day

III

Those giving concern – E.g. those with current active caries, exposed roots, dry mouth, other predisposing factors, those with special needs

All the above, plus : Use a fluoride mouth rinse daily (0.05%

NaF) at a different time to brushingI

Apply fluoride varnish to teeth twice yearly (2.2% F-)

For those with active caries prescribe daily fluoride rinse

For those with active disease prescription of 2800 or 5000 ppm toothpaste

Investigation of diet and assistance to adopt good dietary practice

I

I

IIII

III

Prevention of periodontal disease – to Prevention of periodontal disease – to

be used in addition to caries preventionbe used in addition to caries prevention Risk level Advice EB Professional intervention EB

All adolescents and adults

Brush teeth systematically twice daily with either a

V Demonstrate methods of improving plaque control

V

- manual brush with a small head and round end filaments, a compact angled arrangement of long and short filaments and a comfortable handle

OR - a powered toothbrush with an oscillating/

rotating head

V

I

Investigate possible improved control of predisposing systemic conditions

Take a history of tobacco use, give brief advice to users and signpost to local Stop Smoking Service

Investigate diet and assistance to adopt good dietary practice

V

V

V

Do not smoke III

Use toothpastes containing triclosan with copolymer or triclosan with zinc citrate to improve levels of plaque control

II

Clean inter-dentally using inter-dental brushes or floss

V

Eat a well balanced diet V

Prevention of oral cancerPrevention of oral cancer Risk level Advice EB Professional intervention EB

All adolescents and adults

Do not smoke Do not use smokeless tobacco E.g.

Paan, chewing tobacco, gutkha

IIIIII

Take a history of tobacco use, give brief advice to users and signpost to local Stop Smoking Service

V

Reduce alcohol consumption to moderate (recommended) levels

IVIII

Signpost to local Alcohol Misuse Support Services

Maintain good dietary practice in line

with Balance for Good Health Increase fruit and vegetable intake to

at least 5 portions per day

V

III

ErosionErosion

• Currently the evidence is based upon Currently the evidence is based upon laboratory studies or observational studies. laboratory studies or observational studies. No evidence could be found which measured No evidence could be found which measured the effectiveness of providing preventive the effectiveness of providing preventive advice in a clinical setting. advice in a clinical setting.

• Until such evidence emerges guidance will Until such evidence emerges guidance will be provided in the Appendix 8 in the be provided in the Appendix 8 in the Supporting InformationSupporting InformationWith acknowledgement of the

original work carried out by:Mrs J T DuxburyMiss M A CatleughProf R M DaviesDr G M Davies

Brand ppm fluoride

Crest Range – (Freshmint, mildmint, tartar control,) 5Complete 1450

Colgate – Sensitive – Fresh stripe, whitening 1450

ASDA range – Total care, Sensitive, whitening 1450

Boots’ Sensitive 1450

Pearl Drops – Daily whitening 1300

Aquafresh multi-action whitening 1100

Oral B Stages 1100

Tesco’s Daily care range 1090

Mentadent P 1000

Morrison’s Kids – Strawberry and milk teeth 1000

Boots’ Smile 500

Crest milk teeth 250

Sensodyne original None

Boots fluoride free None

Mu’min Halal Health and Beauty None

Commissioning Commissioning ImplicationsImplications

• Fluoride varnish costs 30 pence Fluoride varnish costs 30 pence per applicationper application

• 3 x per year, yields 3 UDAs3 x per year, yields 3 UDAs• Skill mix (hygienists & Skill mix (hygienists &

therapists)therapists)• Effective Prevention better than Effective Prevention better than

CureCure

Thank you