Prevention in practice –
an initiative between BASCD and
Department of Health
Sue Gregory
Consultant in Dental
Public Health
The task
• DH want to focus on prevention - How can
prevention be built into the new contract?
• What help can be given to PCTs to help
them commission more effectively?
• Can we maximise the yield from the
preventive tools we have and the
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.
2.
Reference cards - Summary guidance
Supporting chapters:
•
•
•
•
•
•
•
•
•
Principles of toothbrushing for oral health
Increasing fluoride availability
Healthy eating advice
Identifying sugar-free medicines
Improving periodontal health
Stop smoking guidance
Accessing alcohol misuse support
Prevention of erosion
Supporting references
Distribution
•
•
•
•
General practices
Salaried services
Consultants in Dental Public Health
Also available online
Development of
‘Delivering Better Oral
Health’
The 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 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
The Principles
• 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 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 – 6 years
Advice to be given
Children aged
up to 3 yrs
All children
aged 3-6 yrs
Children
giving
concern; E.g
those likely to
develop caries,
those with
special needs
EB
•Breast feeding is best for babies
From 6 months of age infants should be introduced to
drinking from a cup, and from age one year feeding from a
bottle should be discouraged
Sugar should not be added to weaning foods
Parents should brush / supervise toothbrushing
Use only a smear of toothpaste containing no less than
1000 ppm fluoride
As soon as teeth erupt in the mouth brush them twice daily
I
III
Brush last thing at night and on one other occasion,
Brushing should be supervised by an adult
Use a pea size amount of toothpaste containing 1350-1500
ppm fluoride
Spit out after brushing and do not rinse
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
Sugar free medicines should be recommended
I
V
V, I
All advice as above plus:
Use a smear or pea size amount of toothpaste containing
1350-1500 ppm fluoride
Ensure medication is sugar free
Advise that dietary supplements containing sugar and
glucose polymers are given at mealtimes when possible and
not last thing at night
Professional intervention
EB
Apply fluoride varnish to teeth
twice yearly (2.2% F-)
I
Apply fluoride varnish to teeth 3-4
times yearly (2.2% F-)
Prescribe fluoride supplement and
advise re maximising benefit
Reduce recall interval
Investigate diet and assist to adopt
good dietary practice
Ensure medication is sugar free or
given to minimise cariogenic effect
V
V
V
I
IV
IV
III
I
V
V
II
V
III
V
Prevention of caries in children aged from 7 years and young adults
All children and
young
adults
Those giving
concern –
E.g. those
likely to
develop
caries,
those undergoing
orthodontic
treatment
and
those with
special
needs
Advice
EB
Professional intervention

Brush twice daily
I

•
Brush last thing at night and
on one other occasion
V
Apply fluoride varnish to teeth twice
yearly (2.2% F-)
•
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

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
All the above, plus :

Use a fluoride mouth rinse
daily (0.05% NaF) at a different
time to brushing
I





EB
I
I
I
I
I
I
III
Prevention of caries in adults
All adult patients
Those giving
concern – E.g.
those with
current active
caries,
exposed roots,
dry mouth,
other
predisposing
factors, those
with special
needs
Advice
EB

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
All the above, plus :

Use a fluoride mouth rinse daily (0.05%
NaF) at a different time to brushing
I
Professional intervention
EB

I



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
II
II
III
Prevention of periodontal disease – to be used in
addition to caries prevention
Risk level
Advice
EB
Professional intervention
All adolescents
and adults

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

V

III
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
Brush teeth systematically twice daily
with either a
Do not smoke

I


Use toothpastes containing
triclosan with copolymer
or triclosan with zinc citrate
to improve levels of plaque control
I
I

Clean inter-dentally using inter-dental
brushes or floss
V

Eat a well balanced diet
V
EB
V
V
Prevention of oral cancer
Risk level
Advice
EB
Professional intervention
All adolescents
and adults


Do not smoke
Do not use smokeless tobacco E.g.
Paan, chewing tobacco, gutkha
III
III

Take a history of tobacco
use, give brief advice to
users and signpost to
local Stop Smoking
Service

Reduce alcohol consumption to
moderate (recommended) levels
IV
III

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
EB
V
Erosion
• Currently the evidence is based upon laboratory studies or
observational studies. No evidence could be found which
measured the effectiveness of providing preventive advice
in a clinical setting.
• Until such evidence emerges guidance will be provided in
the Appendix 8 in the Supporting Information
With acknowledgement of the
original work carried out by:
Mrs J T Duxbury
Miss M A Catleugh
Prof R M Davies
Dr 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 Implications
• Fluoride varnish costs 30 pence per
application
• 3 x per year, yields 3 UDAs
• Skill mix (hygienists & therapists)
• Effective Prevention better than Cure
Thank you