1. Prevention of oral disease for adults

2. Prevention of oral disease for adults
Aim
Provide an overview of evidence-based practical prevention for adults

3. Hierarchy of evidence Level I – Systematic review of RCTs
Level II – At least 1 RCT
Level III– Evidence from non-randomised trials
Level IV – Well designed
observational studies from >1 centre
Level V - Expert opinion, traditional reviews
Strong
Moderate
Caution

5. Oral diseases to prevent
Caries
Erosion
Periodontal diseases
Oral cancer
Trauma

6. Oral diseases to prevent
Caries
Erosion
Periodontal diseases
Oral cancer
Trauma

7. Caries and its prevention
Systematic review – 24% reduction of caries – 1000 & 1450ppm

8. Caries and its prevention
Risk factors
Frequent sugars
Acidogenic bacteria
Sub-normal saliva
Systematic review – 24% reduction of caries – 1000 & 1450ppm
Caries progression

9. Caries and its prevention
Risk factors
Frequent sugars
Acidogenic bacteria
Sub-normal saliva
Protective factors
Saliva
Fluoride
Antibacterials
Systematic review – 24% reduction of caries – 1000 & 1450ppm
Equilibrium!

10. Caries and its prevention
Protective factors
Saliva
Fluoride
Antibacterials
Systematic review – 24% reduction of caries – 1000 & 1450ppm
Remineralisation

11. Prevention of caries – Fluoride (1)
Fluoride toothpaste
Most cost-effective topical fluoride agent
Main reason for the decline in caries in the last 30 yrs – 24% reduction of caries (I)
Fluoride concentration of toothpaste more important than plaque removal (I)
Cost effective to the Government as the patient pays for the intervention!
Has become an effective personal and public health measure as toothbrushing has become a societal norm (up to a point – still predominantly middle class obsession!)
Systematic review – 24% reduction of caries – 1000 & 1450ppm

12. Prevention of caries – Fluoride (2)
Fluoride toothpaste
Fluoride
conc.
Cost effective to the Government as the patient pays for the intervention!
Has become an effective personal and public health measure as toothbrushing has become a societal norm (up to a point – still predominantly middle class obsession!)
Systematic review – 24% reduction of caries – 1000 & 1450ppm
Preventive effect

13. Prevention of caries – Fluoride (2)
How often should adults brush?
Al least twice daily (I) – and always at night (V)
What conc. of fluoride toothpaste should be recommended?
At least 1350ppm (I)
Higher conc. (>2000ppm) available for adults (II)

14. 1350-1500ppm F Correct in 2007! Crest – Freshmint, mildmint, tartar
control, 5Complete
Janina Opale Whitening Paste
LIDL – Salvamed, whitening, sensitive
and mature; Dentalux, herb and freshmint
Macleans- Total Health, Total Health
Whitening, Freshmint, Coolmint
Marks & Spencer – Protect
Mentadent SR
Morrisons – Total care, Whitening,
sensitive
Sainsbury’s – Total care, Sensitive,
Whitening
Sensodyne – Total Care Gentle
Whitening, Total Care Gel, Total Care F,
Total Care Extra Fresh, Pronamel
Signal
Tesco – Total care: Freshmint, Coolmint
stripe
ALDI – Dentitex, whitening, freshmint
total care
Aquafresh – Extreme Clean & Intense
Rush, Complete Care, Fresh & Minty,
Mild & Minty, Big Teeth, Multi-active
ASDA – Total care, Sensitive, whitening
Boots – Sensitive
Colgate – Sensitive Fresh stripe,
Sensitive Whitening, Sensitive Multi
Protection Total, Total Advanced
Fresh, Total Plus Whitening,
Total Professional Weekly CleanGreat
Regular, Bicarb paste, Triple cool,
Fresh stripe, Ultra cavity protection,
Time control, Sensation Deep clean,
whitening, Sensitive multi-protection

15. >1500ppm F
Prescription only

16. Prevention of caries – Fluoride (3)
How should the mouth be rinsed after brushing?
Discourage rinsing, just spit (IV)
How long should brushing take – what technique is best?
No clear evidence for either
2 minutes!

17. Prevention of caries – Fluoride (4)
What type of toothbrush is best?
Some powered toothbrushes are more effective than manual brushes (Oral B range) (I)
“Sonic” toothbrushes no better (I)
Normal brushes – small heads, with soft, variable length and round ended filaments
(V)
Good evidence that variable length filaments are significantly better at removing plaque

18. Prevention of caries – Fluoride (5)
Fluoride Mouthrinses
2 types
Daily (0.05% F)
Weekly (0.2% F)
Both give 26% reduction in caries (I)
Recommended for high risk patients
Active decay
Poor quantity or poor quality of saliva

19. Prevention of caries – Fluoride (6)
Fluoride varnishes
46% reduction in caries in permanent teeth (I)
Good for patients high risk of caries
Apply 6 mthly in high risk
Professional application - expensive
22600 ppm F, some higher
PH approach difficult – need surgery, hygienist or therapist, consent etc etc

20. Caries and its prevention
Risk factors
Frequent sugars
Acidogenic bacteria
Sub-normal saliva
Protective factors
Saliva
Fluoride
Antibacterials
Systematic review – 24% reduction of caries – 1000 & 1450ppm
Equilibrium!

21. Prevention of caries – dietary counselling (1)

22. Prevention of caries – dietary counselling (1)
Evidence for F>>>dietary “advice”
Providing information WILL NOT achieve sustained changes in behaviour (I)

23. Changing behaviour Previously assumed that: Providing knowledge
Change in attitudes
Change in behaviour

24. Behaviour change
The KAB approach ?
Knowledge
Attitudes
Behaviour

25. The KAB approach Behaviour change Knowledge Attitudes Behaviour
“Eating 5 portions
of fruit & veg
per day reduces risk
of cancer & CHD”
“Fruit & veg
are good for my
health”
“I will eat 5 portions
of fruit & veg per
day”

26. Prevention of caries – dietary counselling (1)
Evidence for F>>>dietary “advice”
Providing information WILL NOT achieve sustained changes in behaviour (I)

27. Prevention of caries – dietary counselling (1)
Evidence for F>>>dietary “advice”
Providing information WILL NOT achieve sustained changes in behaviour (I)
BUT important role for dental team – caries, erosion and oral cancer

28. Prevention of caries – dietary counselling (3)
Recommendations (III):
Reduce frequency & amount consumption of non-milk extrinsic sugars eg sucrose/glucose/glucose syrup – max 4 x per day

29. Oral diseases to prevent
Caries
Erosion
Periodontal diseases
Oral cancer
Trauma

30. Oral diseases to prevent
Caries
Erosion
Periodontal diseases
Oral cancer
Trauma

31. Prevention of erosion– dietary counselling (1)
Tooth erosion:
Tooth erosion is a gradual loss of the normally hard surface of the tooth due to chemical, not bacterial, processes.

32. Prevention of erosion– dietary counselling (1)
Recommendations (V)
Limit frequency of acidic drinks and foods
If do, cheese and milk afterwards
Use a straw
Don’t hold or swish acidic drinks
Don’t brush for 1 hr after exposure or vomitting
Fluoride usage!

33. Oral diseases to prevent
Caries
Erosion
Periodontal diseases
Oral cancer
Trauma

34. Oral diseases to prevent
Caries
Erosion
Periodontal diseases
Oral cancer
Trauma

35. Prevention of periodontal disease (1)
Quick revision!
Key aetiological factors
plaque
smoking
In terms of public health – general availability of stop smoking services will theoretically also bring benefits of lower perio disease levels
Establishing OHI as part of general hygiene norms – common risk factor

36. Prevention of periodontal disease (2)
All toothbrushing advice applies – removal of plaque ++ important
Stopping patients smoking – next week!
Interdental cleaning aids (floss/sticks) can be effective – but few people master
Minibrushes probably best (V)
Triclosan with copolymer or zinc citrate in toothpaste effective in reducing plaque and improving gingival health (I)
In terms of public health – general availability of stop smoking services will theoretically also bring benefits of lower perio disease levels
Establishing OHI as part of general hygiene norms – common risk factor

37. Prevention of periodontal disease (2)
Triclosan with
copolymer
Zinc Citrate
In terms of public health – general availability of stop smoking services will theoretically also bring benefits of lower perio disease levels
Establishing OHI as part of general hygiene norms – common risk factor

38. Prevention of periodontal disease (2)
Mouthrinses
Chlorhexidine reduces plaque and improves gingival health – 0.12% and 0.2% (II)
Others probably effective at reducing plaque (II)
“Plax” % Triclosan with sodium fluoride (225 ppm fluoride)

39. Prevention of oral cancer
Some more revision!

40. World Wide Oral cancer kills 481,000 new cases of
oral cancer pa
Oral cancer kills
one person every 21/2 mins
(210,000 deaths pa)

43. UK epidemiology of oral cancer
Incidence – approx 5000 new cases per year (2005)
15th most common cancer – 1.7% of all cancers
In UK, similar incidence to brain, liver and cervical cancers and melanoma
(IV)
Cancer Research UK, 2008

44. Cancer Research UK, 2008

45. UK epidemiology of oral cancer
Incidence is increasing in men and women
Incidence increasing in younger people
Survival rates changed little in 3 decades – approx 55% at 5 years
(IV)
Cancer Research UK, 2008

46. Oral cancer worldwide
Cancer Research UK, 2008

47. Oral Cancer – risk factors
Smoking/tobacco use
Alcohol
Betel quid / paan
Alcohol (oz / day)
Cigarettes / day
Relative Risk

48. Oral Cancer – other risk factors
Sunlight
Diet
Human papilloma virus
Previous cancer

49. Prevention of oral cancer
Record smoking/tobacco use status
Help patients to stop smoking/using tobacco (III) – again, more next week
Advise moderation of alcohol (IV)
Record alcohol consumption
21 units for men (no more than 4 units/day)
14 units for women (no more than 3 units/day)
Advise diet high in fruit and vegetables, low in fat (III)
Early referral of suspicious lesions

53. Oral diseases to prevent
Caries
Erosion
Periodontal diseases
Oral cancer
Trauma

54. Prevention of trauma Sport related – recommend mouthguards (IV)
Maxillofacial injuries – alcohol related – advise to moderate consumption – research underway

55. Take home messages Fluoride, in all forms, works
Changing (dietary) behaviour is difficult
Helping patients to stop smoking is very important
Some electric toothbrushes are better than manual
Some toothpastes and mouthwashes will reduce plaque and improve gingival health

57. Any questions?