Prevention in practice an initiative between BASCD and

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					 Prevention in practice –
an initiative between BASCD and
       Department of Health


Sue Gregory
Consultant in Dental
Public Health
             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?
     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
September 2007
                             Contents
1.       Reference cards - Summary guidance
2.       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
                Distribution
•   General practices
•   Salaried services
•   Consultants in Dental Public Health
•   Also available online
   Development of
‘Delivering Better Oral
        Health’
                     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
            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
                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
The outputs
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.
               Prevention of caries in children age 0 – 6 years
                  Advice to be given                                             EB      Professional intervention               EB

Children aged     •Breast feeding is best for babies                            I
up to 3 yrs       From 6 months of age infants should be introduced to         III
                  drinking from a cup, and from age one year feeding from a
                  bottle should be discouraged
                  Sugar should not be added to weaning foods                   V
                  Parents should brush / supervise toothbrushing               V
                  Use only a smear of toothpaste containing no less than       I
                  1000 ppm fluoride
                  As soon as teeth erupt in the mouth brush them twice daily   IV

                  Brush last thing at night and on one other occasion,         I        Apply fluoride varnish to teeth        I
                  Brushing should be supervised by an adult                    V        twice yearly (2.2% F-)
                                                                                V, I
All children      Use a pea size amount of toothpaste containing 1350-1500
aged 3-6 yrs      ppm fluoride
                  Spit out after brushing and do not rinse                     IV
                  The frequency and amount of sugary food and drinks           III
                  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
Children          All advice as above plus:                                              Apply fluoride varnish to teeth 3-4    V
giving            Use a smear or pea size amount of toothpaste containing           I   times yearly (2.2% F-)
concern; E.g      1350-1500 ppm fluoride                                                 Prescribe fluoride supplement and      II
those likely to   Ensure medication is sugar free                                  V    advise re maximising benefit
                                                                                                                                 V
develop caries,   Advise that dietary supplements containing sugar and             V    Reduce recall interval
those with        glucose polymers are given at mealtimes when possible and              Investigate diet and assist to adopt
                                                                                                                                 III
special needs     not last thing at night                                                good dietary practice
                                                                                         Ensure medication is sugar free or     V
                                                                                         given to minimise cariogenic effect
Prevention of caries in children aged from 7 years and young adults
                     Advice                                   EB    Professional intervention                       EB

  All children and       Brush twice daily                   I        Apply fluoride varnish to teeth twice             I
       young                                                            yearly (2.2% F-)
                     •    Brush last thing at night and       V
       adults
                          on one other occasion
                     •    Use fluoridated toothpaste          I
                          (1350 ppm F or above)
                     •    Spit out after brushing and do      IV
                          not rinse
                     •    The frequency and amount of         III
                          sugary food and drinks should
                          be reduced and, when
                          consumed, limited to
                          mealtimes. Sugars should not
                          be consumed more than four
                          times per day
  Those giving       All the above, plus :                             Fissure seal permanent molars with          I
       concern –          Use a fluoride mouth rinse         I         resin sealant
       E.g. those          daily (0.05% NaF) at a different            Apply fluoride varnish to teeth 3-4 times   I
       likely to           time to brushing                             yearly (2.2% F-)
       develop
                                                                       For those 8+ years with active caries       I
       caries,
                                                                        prescribe daily fluoride rinse
  those undergoing
       orthodontic                                                     For those 10+ years with active caries      I
       treatment                                                        prescribe 2800 ppm toothpaste
       and                                                             For those 16+ years with active disease     I
  those with                                                            consider prescription of 5000 ppm
       special                                                          toothpaste
       needs                                                           Investigation of diet and assistance to     III
                                                                        adopt good dietary practice
                         Prevention of caries in adults
                     Advice                                          EB    Professional intervention          EB


All adult patients      Brush twice daily with fluoridated          I
                         toothpaste
                        Use fluoridated toothpaste with at least    I
                         1350 ppm F-
                        Brush last thing at night and on one        V
                         other occasion
                        Spit out after brushing and do not rinse    IV


                        The frequency and amount of sugary          III
                         food and drinks should be reduced and,
                         when consumed, limited to mealtimes.
                         Sugars should not be consumed more
                         than four times per day
Those giving         All the above, plus :                                    Apply fluoride varnish to      I
    concern – E.g.        Use a fluoride mouth rinse daily (0.05%   I         teeth twice yearly (2.2% F-)
    those with             NaF) at a different time to brushing               For those with active          I
    current active                                                             caries prescribe daily
    caries,                                                                    fluoride rinse
    exposed roots,                                                            For those with active          II
    dry mouth,                                                                 disease prescription of        II
    other                                                                      2800 or 5000 ppm
    predisposing                                                               toothpaste
    factors, those                                                            Investigation of diet and      III
    with special                                                               assistance to adopt good
    needs                                                                      dietary practice
     Prevention of periodontal disease – to be used in
                            addition to caries prevention
Risk level        Advice                                           EB    Professional intervention       EB
All adolescents         Brush teeth systematically twice daily    V        Demonstrate methods of      V
     and adults          with either a                                       improving plaque control
                  - manual brush with a small head and round       V        Investigate possible        V
                       end filaments, a compact angled                       improved control of
                       arrangement of long and short filaments               predisposing systemic
                       and a comfortable handle                              conditions
                  OR                                                        Take a history of tobacco   V
                  - a powered toothbrush with an oscillating/      I         use, give brief advice to
                       rotating head                                         users and signpost to
                                                                             local Stop Smoking
                        Do not smoke                              III
                                                                             Service
                                                                            Investigate diet and        V
                                                                             assistance to adopt good
                         Use toothpastes containing                         dietary practice
                            triclosan with copolymer               I
                         or triclosan with zinc citrate            I
                      to improve levels of plaque control
                        Clean inter-dentally using inter-dental   V
                         brushes or floss
                        Eat a well balanced diet                  V
                           Prevention of oral cancer
Risk level        Advice                                       EB    Professional intervention       EB

All adolescents      Do not smoke                             III      Take a history of tobacco   V
     and adults      Do not use smokeless tobacco E.g.        III       use, give brief advice to
                      Paan, chewing tobacco, gutkha                      users and signpost to
                                                                         local Stop Smoking
                                                                         Service




                     Reduce alcohol consumption to            IV       Signpost to local Alcohol
                      moderate (recommended) levels            III       Misuse Support Services



                     Maintain good dietary practice in line   V
                      with Balance for Good Health
                     Increase fruit and vegetable intake to   III
                      at least 5 portions per day
                                  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
Brand                                                            ppm
                                                                 fluoride
Crest Range – (Freshmint, mildmint, tartar control,) 5Complete   1450

Colgate – Sensitive – Fresh stripe, whitening                    1450
ASDA range – Total care, Sensitive, whitening                    1450
Boots’ Sensitive                                                 1450
Pearl Drops – Daily whitening                                    1300
Aquafresh multi-action whitening                                 1100
Oral B Stages                                                    1100
Tesco’s Daily care range                                         1090
Mentadent P                                                      1000
Morrison’s Kids – Strawberry and milk teeth                      1000
Boots’ Smile                                                     500
Crest milk teeth                                                 250
Sensodyne original                                               None
Boots fluoride free                                              None
                                                                 None
Mu’min Halal Health and Beauty
   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
Thank you

				
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