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Support of prevention

Johnson & Johnson is delighted to bring you this article, with the aim of supporting the ongoing CPD needs of dental healthcare professionals in improving and maintaining the oral health of their patients.

This article is equivalent to one hour of Enhanced CPD. To provide feedback on this article, please contact dentalcpd@its.jnj.com

Learning outcomes

A,B,C,D

Aims and objectives

The aim of this article is to consider how the dental team can engage patients regarding the advantages of preventive dentistry, and effectively communicate the potential lifelong benefits of, for example, making healthy food and drink choices, and a three-step home care regimen. On completing this CPD session, the reader will:

• Understand the oral health situation in the UK among both adults and children

• Understand how dental professionals can improve their patients’ oral health through effective communication

• Understand the difference a team approach can make to raising patients’ awareness of their oral health responsibilities

• Understand the type of information patients need to know to achieve the best possible oral health outcomes.

In support of prevention

This article considers how the dental team can engage patients regarding the advantages of preventive dentistry, and effectively communicate the potential lifelong benefits of, for example, making healthy food and drink choices, and a three-step home care regimen.

According to the 2009 Adult Dental Survey, 75% of respondents brushed their teeth at least twice a day, while 78% said that they had received oral health advice from a dentist or hygienist.1 However, two-thirds of dental adults were found to have plaque on at least one tooth, while 68% had calculus in at least one sextant.1

In addition, in 2013, 31% of 5-year-olds and 46% of 8-year-olds had tooth decay.2 Further, in 2015, caries was considered to be the most common reason for 5-to 9-year-olds being admitted to hospital.3

Considered as a whole, these figures suggest that there is still work to be done in achieving the best possible results from mechanical cleaning.1,2,3

Alongside this, further education is needed in terms of issues such as food and drink choices and their potential impact on oral health, including caries and tooth wear.4 But how might the dental team go about capitalising on their knowledge to raise patients’ awareness of their own responsibilities when it comes to oral health?

Leading patient education

The General Dental Council’s Preparing for Practice guidance states: ‘Appropriate communication and good interpersonal skills are crucial to being an effective registrant. Gaining patient engagement and understanding in the delivery of their care is fundamental. This can help give patients the confidence to make decisions and manage their own oral health.’5

Considering this issue further, Waylen and colleagues (2015) expressed: ‘…good and effective communication improves patient health outcomes, patient satisfaction and adherence...’6
Horowitz and colleagues concur with this view and took the situation one step further by pondering an example in relation to caries. They wrote: ‘Dental caries can no longer be considered inevitable because measures are available to prevent or control this infectious disease. Simply put, we know how to prevent or control dental caries. Yet a large portion of the public, especially those in lower income groups, are afflicted with this disease. The gaps between how [parents] rate their children’s oral health and both their own and their children’s actual behaviour clearly illustrate the communication challenge.’7

Reflecting upon the issue from a practical perspective, Kay and colleagues (2016) shared that over the years a number of techniques have been used by the dental team, ranging from gentle persuasion to complex programmes making use of psychological and behavioural change strategies.8

They conducted a review of the approaches for dental teams in order to help promote oral health and reached the following conclusions:

• Dental health can be improved using psychological behaviour change models as the basis for intervention

• Patients’ awareness and understanding can be improved via verbal oral health messages from a dental team member

• There is strong evidence that written materials such as leaflets raise patient awareness; however, there is no evidence that they change behaviour.8
Rattan and colleagues (2002) also considered the importance of cohesive teamwork within a dental practice, stating: ‘Teams do produce better patient care than single practitioners operating in a fragmented way.’9

They continued: ‘Effective teams make the most of the different contributions of individual clinical disciplines in delivering patient care. The characteristics of effective teams are as follows:

• Shared ownership for a common purpose

• Clear goals for the contributions that each discipline makes

• Open communication between team members

• Opportunities for team members to enhance their skills.’9

Looking at the family dynamic, we know that parents’ behaviour affects their children’s health.10 Bozorgmehr and colleagues (2013) wrote: ‘It can be concluded […] that some important health behaviours in parents, such as tooth brushing habits and frequency of consumption of sweet foods, are important determinants of these behaviours in their young children. Children with high-educated mothers had lower plaque index than the others. So, promoting parents’ knowledge and attitude could affect their children oral health behaviour and status.’10

With all of this in mind, there certainly seems to be merit in dental teams considering how they − as a whole − can help to improve families’ oral health, with each health professional offering a unique set of skills to help drive the daily prevention message home.

So, what do patients need to know to achieve the best possible oral health outcomes?

Food for thought

Taking a step back for a moment, clinicians – but not necessarily patients – are well aware that susceptibility to dental caries varies depending upon the shape, structure, location and position of the teeth.11 Such susceptibility combined with the presence of acid-forming bacteria that have something to feed upon, for example fermentable carbohydrates (such as fruit and select dairy products, vegetables, and starches)12 and sugars,12 will cause the pH in the oral cavity to fall below the critical level, resulting in demineralisation.12 This is demonstrated in Keyes Concept, whereby tooth enamel, plaque biofilm and sugar metabolism leading to acid production all contribute to the development of dental caries.11

Selwitz and colleagues (2007) wrote: ‘…people are susceptible to the disease [dental caries] throughout their lifetime. It is the primary cause of oral pain and tooth loss. It can be arrested and potentially reversed in its early stages, but is often not self-limiting and without proper care, caries can progress until the tooth is destroyed.’13

In consideration of this, the challenge is communicating the issues effectively to the caries-susceptible patient, including the effect of sugary foods and drinks. To this end, the Oral Health Foundation website offers simple and easy to understand guidance covering issues such as why diet is important to oral health, what to avoid and how to make better choices.14

In the years since Keyes designed his caries model, it has been expanded to take into consideration modifying elements such as the significance of time in caries development, as well as lifestyle, for instance attitudes to oral hygiene, income and education level.11

Since patients’ lifestyles have the potential to affect such a caries prevalence, they may benefit from being educated about the importance of making tooth-friendly food and drink choices – resulting in fewer acid attacks – as well as chewing sugar-free gum or eating a piece of cheese after a meal to help with the remineralisation process.11

Organisations have not been resting on their laurels in this regard; for example, Dentaid’s educational app called Bright Bites for Key Stage 2 children was launched, ‘…to educate children about oral health so that they can establish and maintain a good oral care routine that will benefit them throughout their life.’15

Meanwhile, Public Health England’s Change4Life campaign launched Sugar Smart this year.16 As part of this, they too created an app to enable users to measure their sugar intake, not only in an effort to tackle obesity but also tooth decay.16

Wearing thin

The incidence of tooth wear in England, Northern Ireland and Wales was recorded in the Adult Dental Health Survey for the first time in 1998.1 This same coding criterion was applied to the 2009 survey, and a comparison of the two indicated that in just 11 years the prevalence of tooth wear in England increased by 10% (from 66% to 76%).1

The survey states: ‘The greatest increase was in the youngest three age groups; 15 percentage points, 10 percentage points and 13 percentage points for those aged 16 to 24, 25 to 34 and 35 to 44 years respectively. For adults under the age of 65 moderate and severe tooth wear has increased since 1998, but for those aged 65 and over, there has been a small decrease. While the increase in moderate tooth wear is small, moderate tooth wear in 16 to 34 year olds is of clinical relevance as it is suggestive of rapid tooth wear.’1

Looking at this challenge, Mehta and colleagues (2012) wrote: ‘Erosive tooth wear is caused by acidic substrates which may be either of an intrinsic origin or an extrinsic source’.17

In terms of primary prevention, they suggested that advice on reducing the amount and frequency (preferably limited to meal times) of acidic consumables such as fruits, fruit juices and sparkling drinks may be beneficial.17

In addition, Mehta and colleagues (2010) put forward that patients could eat hard cheese or another type of dairy product following the consumption of something acidic, to help promote remineralisation, as would chewing sugar-free chewing gum.17

Making simple changes such as drinking a carbonated beverage through a wide bore straw and avoiding swishing the liquid in the mouth will also help to reduce the risk or tooth erosion.17

Effectively communicating these simple steps so that patients gain a better understanding of potential for damaging tooth wear and appreciate the benefits of preventive action may well make a big difference to their level of oral health.

As easy as 1,2,3

Brushing and flossing/interdental cleaning are, of course, pivotal to oral hygiene.18 They displace and dislodge plaque bacteria from the tooth surface. However, bacteria from other areas of the mouth can recolonise on teeth quickly.18

Barnett (2006) suggested that this gap in preventive care provides: ‘[…] a clear rationale for incorporating effective antimicrobial measures, such as use of an antimicrobial mouthrinse, into daily oral hygiene regimens.’18

In 2014 Charles and colleagues sought to determine the ability to achieve gingival health in the short-term with daily rinsing with an essential oil containing antimicrobial mouthrinse.19

They concluded: ‘…virtually plaque free tooth surfaces can be achieved as early as 4 weeks with use of an essential oil antimicrobial mouthrinse. This finding continues through 6 months twice daily use as part of oral care practices compared to mechanical oral hygiene alone.’19

This is supported by Boyle and colleagues (2014), who demonstrated that quantitative assessment of data exploring mouthwash use and the risk of common oral conditions supports the use of mouthwash in preventing dental plaque, exploring the differences between chlorhexidine, cetylpyridinium and essential oils.20

They came to the conclusion that when a mouthwash is used for fewer than three months, those containing chlorhexidine are the most effective of the preparations they considered.20 However, when used for six months or longer, essential oil mouthwashes were shown to equal or exceed the effect of chlorhexidine in controlling plaque as an adjunct to standard care. 20 It was also found that mouthwashes containing cetylpyridinium may also be effective, but less so than chlorhexidine and essential oil formulations.20

In 2015, Chapple and colleagues reported on the consensus views of Working Group 2 of the 11th European Workshop in Periodontology.21 They concluded that, ‘…where improvements in plaque control are required, adjunctive use of antiplaque chemical agents may be considered. In this scenario, mouth rinses may offer greater efficacy but require an additional action to the mechanical oral hygiene regime.’21

It would seem therefore that there is a case to be made for the use of an effective antimicrobial mouthrinse as an adjunct to mechanical cleaning in some patients.

Furthering the supporting evidence is Araujo and colleagues’ (2015) meta-analysis.22 They were able to provide strong evidence that there are statistically significant greater odds of patients achieving a ‘…cleaner […] mouth, which may lead to prevention of disease progression…’ if patients add an essential oil mouthrinse to their daily mechanical cleaning regimen at home.22

Communication and teamwork

As Leonard and colleagues (2004) wrote: ‘Effective communication and teamwork is essential for the delivery of high quality, safe patient care.’23 As such, encouraging patients to change their behaviours through teamwork focused on communication, education and prevention may well lead to an improvement in oral care at home family-wide.

QUESTIONS: 

References

  1. Adult Dental Health Survey 2009. The Health and Social Care Information Centre 2011

  2. Children’s Dental Health Survey 2013. The Health and Social Care Information Centre 2015

  3. The state of children’s oral health in England. RCS Faculty of Dental Surgery 2015

  4. Cheng R et al. Dental erosion and severe tooth decay related to soft drinks: a case report and literature review. Journal of Zhejiang University SCIENCE B. 2009 10(5): 395-399

  5. Preparing for practice. Dental team learning outcomes for registration. General Dental Council 2015

  6. Waylen A et al. Patient-clinician communication in a dental setting: a pilot study. BDJ 2015; 218(10): 585-588

  7. Horowitz AM et al. Use of recommended communication techniques by Maryland dental hygienists. The Journal of Dental Hygiene 2013; 87(4): 212-223

  8. Kay EJ et al A review of approaches for dental practice teams for promoting oral health. Community Dent Oral Epidemiol 2016; doi: 10.1111/cdoe.12220. [Epub ahead of print]

  9. Rattan R, Chambers R, Wakley G. Clinical Governance in General Dental Practice. Radcliffe Publishing Ltd, 2002

  10. Bozorgmehr E. Oral health behaviour of parents as a predictor of oral health status of their children. ISRN Dentistry 2013: 741783

  11. van Loveren C et al. Functional foods/ingredients and dental caries. European Journal of Nutrition 2012; 51(2S): 15-25

  12. Touger-Decker R, van Loveren C. Sugars and dental caries. Am J Clin Nutr 2003; 78(suppl): 881S–892S

  13. Selwitz RH et al. Dentla caries. The Lancet 2007; 369: 51-59

  14. https://www.dentalhealth.org/tell-me-about/topic/sundry/diet. Accessed 29 June 2016

  15. http://www.brightbites.org/about-bright-bites/. Accessed 29 June 2016

  16. https://www.gov.uk/government/news/5-year-olds-eat-and-drink-their-body-... . Accessed 4 July 2016

  17. Mehta SB et al. Current concepts on the management of tooth wear: part 1. Assessment, treatment planning and strategies for the prevention and the passive management of tooth wear. BDJ 2012; 212(1): 17-27

  18. Barnett ML. The rationale for the daily use of an antimicrobial mouthrinse. JADA 2006; 137: 16S-21S

  19. Charles CA et al. Early benefits with daily rinsing on gingival health improvements with an essential oil mouthrinse – post–hoc analysis of 5 clinical trials. Journal of Dental Hygiene 2014; 88(Supp): 40-50

  20. Boyle et al. Mouthwash use and the prevention of plaque, gingivitis and caries. Head & Neck Oral Diseases 2014; 20(1): 1-76

  21. Chapple ILC et al. Primary prevention of periodontitis: managing gingivitis. J Clin Periodontol 2015; 42 (Suppl. 16): S71-S76

  22. Araujo MWB et al. Meta-analysis of the effect of an essential oil–containing mouthrinse on gingivitis and plaque. JADA 2015; 146(8): 610-622

  23. Leonard M et al. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004; 13(Suppl 1): i85–i90