8: Oral Health Promotion

CHAPTER 8 Oral Health Promotion

• This chapter covers the requirements of the NEBDN syllabus Section 8: Oral health promotion and preventive dentistry.

Introduction

Oral health promotion involves educating people about how to achieve and maintain good oral health. A dental nurse should be able to provide competent and complete oral health promotion. This includes:

• Instructions in toothbrushing, flossing, use of disclosing tablets and other dental aids

• Dietary advice

• Advice on how often a dental examination (check-up or recall) is required

• Advice to mothers on preventing nursing bottle caries.

Nursing bottle caries: the decay of the upper incisors related to drinking milk through a bottle just before sleeping. The milk remains on the teeth and acts as a substrate for dental caries.

This chapter presents an overview of the oral health messages that you should know and should be able to educate patients about. It will describe the measures and oral health devices (dental care accessories) and materials and techniques that patients can use to achieve and maintain oral health.

Dental recall guidelines

Guidelines from the National Institute for Health and Clinical Excellence (NICE) and the National Collaborating Centre for Acute Care (NCAC) recommend the following general intervals between check-ups:

• Under-18s: between 3 and 12 months

• Adults: between 3 and 24 months.

NCAC: There are four national collaborating centres that help NICE to develop the clinical guidelines.

However, the interval between check-ups needs to be decided on a patient-by-patient basis. Each patient’s check-up routine should be based on their needs, their disease levels and their risk of developing dental disease. The guideline also recommends that during a check-up, the dental team should ensure that:

• A comprehensive history is taken (see Chapters 2 and 6)

• A thorough examination is conducted

• Preventive advice is reinforced.

The following issues need to be discussed or reinforced with the patient where relevant:

• Maintaining oral health by practising oral hygiene, dietary precautions, fluoride use

• Any factors that may influence the patient’s oral health, e.g. tobacco and alcohol use, and their implications for deciding the appropriate recall interval

• The outcome of previous treatments and visits and the suitability of previously recommended intervals

• The patient’s ability or desire to visit the dentist at the recommended interval

• The costs involved in having regular check-ups and any further treatments.

The oral health message

Most oral diseases, including not only the more common problems (such as tooth surface loss due to caries, trauma, abrasion, erosion and periodontal disease) but also potentially fatal diseases (such as cancer), are largely related to people’s lifestyle and habits (Table 8.1). Thus these diseases are often preventable by careful attention to lifestyle. For example, oral health can be improved by:

• Reducing frequency and amount of sugar and acidic drinks in the diet

• Using fluoride toothpaste/mouthwash regularly

• Using amorphous calcium phosphate (ACP) topically

• Practising oral hygiene at least twice daily

• Using mouth protection against trauma

• Avoiding alcohol, tobacco and betel habits

• Attending for dental professional attention as required for:

Scaling and polishing

Fissure sealing

Fluoride applications

• Using other oral hygiene measures, e.g. chewing gum.

TABLE 8.1 Oral Diseases Related to Lifestyle Habits

Disease	Risk Factor
Abrasion	Incorrect toothbrushing
Cancer	Tobacco, alcohol, betel nut use
Candidosis	Dry mouth, antibiotic use, HIV and other immunity problems
Caries	High sugar diet, low fluoride
Erosion	Soft drinks, fruit juices, alcohol
Gingivitis	Plaque accumulation
Halitosis	Plaque accumulation, tobacco use, alcohol use
Periodontitis	Plaque and calculus accumulation, tobacco use
Trauma	Alcohol use; some contact sports

This chapter is based on the toolkit ‘Delivering better oral health: An evidence-based toolkit for prevention’ by the Department of Health and British Association for the Study of Community Dentistry. See the Department of Health website for the full toolkit (http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_078742)

Diet

General advice

Refined carbohydrates and sugars, particularly non-milk extrinsic sugars in items other than fresh fruits and vegetables, are the major causes of dental caries (Chapter 5). The frequency of intake is more important than the amount. Thus to lessen the chances of accumulating dental plaque, and developing caries, it is important to limit and reduce the frequency of consumption of sugary foods, such as restricting them to meal times.

Babies

Breast-feeding is best for babies, and they should be weaned onto sugar-free foods. From 6 months of age infants should be introduced to drinking from a cup and from 1 year of age bottle-feeding should be discouraged. Drinks other than milk and water should not be given to pre-school children in feeding bottles, and should be given only at main meals. Foods should be free of or very low in sugars other than those in fresh milk and raw fruits or vegetables.

Older children and adults

• Foods and drinks for snacking should be free of sugars. Because of the risk of erosion, as well as of caries, discourage frequent consumption of carbonated, cola-type drinks and fruit juices such as grapefruit, apple, or orange. Children should preferably drink water and milk. Wine and some other alcohol-containing drinks can also cause erosion.

• Chewing sugar-free gum or cheese after meals can help by increasing salivary flow, as this helps wash off the acids in the plaque and on tooth surfaces.

• Most sugars in the diet come from consuming processed foods and drinks.

• Consumption of sugary foods and drinks should be restricted to meal times and to a maximum of four times a day.

• Sugars (excluding those naturally present in whole fruit) should provide less than 10% of total energy in the diet or less than 60 g per person per day. Note that for young children this will be around 33 g per day.

Remember that honey, fresh fruit juice and dried fruit all contain cariogenic sugars.

Sugar-Free Medicines

The National Pharmacy Association leaflet ‘sugar in medicines’, and the Delivering better oral health’ toolkit contain information about the sugar (fructose/glucose/sucrose) content of branded oral liquid medicines, both over-the-counter and prescription-only medicines. Products that do not contain these sugars are listed as being sugar-free. Preparations containing hydrogenated glucose syrup (Lycasin), maltitol, sorbitol or xylitol are also listed as sugar-free, since there is evidence that they are non-cariogenic.

Fluoride

Fluoride can protect teeth against caries by:

• Strengthening the enamel

• Inhibiting acid production by oral cariogenic bacteria

• Helping tooth remineralisation.

Water fluoridation

• Water fluoridation has consistently been shown to be the most effective, safe means of preventing caries, resulting in a decrease of approximately 50%.

• Information about the fluoride status of the water supplies can be obtained from the water supplier in your area by quoting the residential postcode.

• The West Midlands is the most extensively fluoridated area in the UK, followed by parts of the North East of England.

• In 2003 the UK law was changed to enable strategic health authorities to require water companies to fluoridate water supplies as long as there was support from the local population.

• The use of bottled non-fluoridated water in contrast may be linked with increased dental caries.

What is the level of fluoride in the drinking water supply in your area?

Fluoride supplements

• No fluoride supplements are required if the water supply contains more than 0.7 ppm of fluoride. Where the water supply contains less than 0.3 ppm of fluoride, children over the age of 6 months may benefit from taking fluoride supplements daily (see Table 8.2).

• While it is safe for pregnant women to take fluoride supplements, this has little impact on the future dental health of the child.

• Fluoride supplements should be stored out of reach of children.

TABLE 8.2 Sodium Fluoride Supplement Doses (Tablets) to Reduce Caries in Children in Relation to Water Fluoride Content

ppm: Short for ‘parts per million’; 0.7 ppm is equivalent to 700 micrograms per litre of fluoride.

Excess fluoride may cause tooth discoloration (fluorosis); the risk of this is higher from the use of fluoride supplements or topical fluorides in water-fluoridated areas.

Fluoride toothpastes

• Fluoride toothpastes have probably been largely responsible for most of the decline in caries over the past decades.

• Fluoride toothpastes are usually available over the counter in one of three strengths (Table 8.3). Toothpastes with 2800 ppm (Figure 8.1) and over 5000 ppm are considered prescription-only medicines.

TABLE 8.3 Fluoride Toothpastes

FIGURE 8.1 Duraphat by Colgate is a prescription-only toothpaste because of its high fluoride content.

Fluoride varnishes

Fluoride varnish is one of the best options for the application of topical fluoride to teeth. Fluoride varnish can also arrest existing caries (stop it spreading) on the smooth surfaces of deciduous teeth and roots of permanent teeth.

DPF: This is the abbreviation for the Dental Practitioners’ Formulary. (The BNF is the British National Formulary, which contains the DPF).

Well-Known Brands of Fluoride Varnish

• Fluorprotector – 8000 ppm (0.8% F)

• Lawefluor – 22 600 ppm (2.2% F)

• Duraphat – 22 600 ppm (2.2% F)

• Bifluorid – 56 300 ppm (5.6% F)

Sodium fluoride varnish is well accepted and considered safe. The application process is simple and requires minimal training:

1. Remove gross plaque (thorough prophylaxis is not essential)

2. Dry teeth with cotton rolls or a 3-in-1 syringe.

3. Use a microbrush to apply a small quantity of fluoride varnish to pits, fissures and proximal surfaces of primary and permanent teeth.

4. Advise the patient to avoid eating, drinking or toothbrushing for 30 minutes after application.

Prophylaxis: In the dental context prophylaxis refers to cleaning the surface of teeth with a rotary brush (see Figure 8.8 below) to remove all plaque and fine deposits before treatment.

FIGURE 8.8 (A) Latch grip rubber cup and (B) bristle brush.

Identify and Learn

Identify a microbrush in your workplace.

There is a small risk of allergy to the colophony component of Duraphat. Therefore varnish application is contraindicated for children who have a history of allergies, including asthma. Duraphat is also contraindicated in patients with ulcerative gingivitis and stomatitis (see Chapter 5).

Fluoride mouthwashes and gels

Fluoride mouthwashes or rinses can be prescribed for patients aged 8 years and above, for daily or weekly use, in addition to twice-daily brushing with toothpaste containing at least 1350 ppm fluoride. They should be used at a different time to toothbrushing to maximise the topical effect. Fluoride mouthwashes and gels are particularly recommended for people with a dry mouth (hyposalivation; see Chapter 5), who are otherwise particularly at risk of caries.

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