Prevention of oral disease for adults

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

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

www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_078742

Oral diseases to prevent Caries Erosion Periodontal diseases Oral cancer Trauma

Oral diseases to prevent Caries Erosion Periodontal diseases Oral cancer Trauma

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

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

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!

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

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

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

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)

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

>1500ppm F Prescription only

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!

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

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

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

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!

Prevention of caries – dietary counselling (1)

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

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

Behaviour change The KAB approach ? Knowledge Attitudes Behaviour

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”

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

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

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 www.eatwell.gov.uk/agesandstages/

Oral diseases to prevent Caries Erosion Periodontal diseases Oral cancer Trauma

Oral diseases to prevent Caries Erosion Periodontal diseases Oral cancer Trauma

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.

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!

Oral diseases to prevent Caries Erosion Periodontal diseases Oral cancer Trauma

Oral diseases to prevent Caries Erosion Periodontal diseases Oral cancer Trauma

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

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

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

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” - 0.03% Triclosan with sodium fluoride (225 ppm fluoride)

Prevention of oral cancer Some more revision!

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)

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

Cancer Research UK, 2008

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

Oral cancer worldwide Cancer Research UK, 2008

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

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

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

Oral diseases to prevent Caries Erosion Periodontal diseases Oral cancer Trauma

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

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

www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_078742

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