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

2. 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?

3. 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

4. September 2007

5. Contents 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

6. Distribution General practices Salaried services
Consultants in Dental Public Health
Also available online

7. Development of ‘Delivering Better Oral Health’

8. 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

9. 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

10. 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

11. The outputs

12. 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.

13. Prevention of caries in children age 0 – 6 years
Advice to be given EB
Professional intervention
Children aged up to 3 yrs
All children aged 3-6 yrs
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 V IV
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 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
V, I
Apply fluoride varnish to teeth twice yearly (2.2% F-)
Children giving concern; E.g those likely to develop caries,
those with special needs
All advice as above plus:
Use a smear or pea size amount of toothpaste containing 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
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 II

14. Prevention of caries in children aged from 7 years and young adults
Advice EB
Professional intervention
All children and young adults
Brush twice daily I
Apply fluoride varnish to teeth twice yearly (2.2% F-)
Brush last thing at night and on one other occasion V
Use fluoridated toothpaste (1350 ppm F or above)
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
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

15. Prevention of caries in adults
Advice EB
Professional intervention
All adult patients
Brush twice daily with fluoridated toothpaste I
Use fluoridated toothpaste with at least ppm F-
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 brushing
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 or 5000 ppm toothpaste
Investigation of diet and assistance to adopt good dietary practice II

16. Prevention of periodontal disease – to be used in addition to caries prevention
Risk level
Advice EB
Professional intervention
All adolescents and adults
Brush teeth systematically twice daily with either a V
Demonstrate methods of improving plaque control
- 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 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
Do not smoke
III
Use toothpastes containing
triclosan with copolymer
or triclosan with zinc citrate
to improve levels of plaque control
Clean inter-dentally using inter-dental brushes or floss
Eat a well balanced diet

17. 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
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 IV
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

18. 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

20. Brand ppm fluoride 1450 Colgate – Sensitive – Fresh stripe, whitening
Crest Range – (Freshmint, mildmint, tartar control,) 5Complete
1450
Colgate – Sensitive – Fresh stripe, whitening
ASDA range – Total care, Sensitive, whitening
Boots’ Sensitive
Pearl Drops – Daily whitening
1300
Aquafresh multi-action whitening
1100
Oral B Stages
Tesco’s Daily care range
1090
Mentadent P
1000
Morrison’s Kids – Strawberry and milk teeth
Boots’ Smile
500
Crest milk teeth
250
Sensodyne original
None
Boots fluoride free
Mu’min Halal Health and Beauty

21. 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

22. Thank you