prevention of oral disease for adults. aim provide an overview of evidence-based practical...

Prevention of oral disease for adults

Prevention of oral disease for adults

• AimProvide 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

Caries and its prevention


Risk factorsFrequent sugarsAcidogenic

bacteriaSub-normal

saliva

Caries progression

Protective factorsSalivaFluorideAntibacterials



bacteriaSub-normal

saliva

Equilibrium!



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)


Fluoride toothpaste

Fluoride conc.

Preventive effect


• 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

• ALDI – Dentitex, whitening, freshminttotal care

• Aquafresh – Extreme Clean & IntenseRush, Complete Care, Fresh & Minty,Mild & Minty, Big Teeth, Multi-active

• ASDA – Total care, Sensitive, whitening

• Boots – Sensitive• Colgate – Sensitive Fresh stripe,

Sensitive Whitening, Sensitive MultiProtection Total, Total AdvancedFresh, Total Plus Whitening,Total Professional Weekly CleanGreatRegular, Bicarb paste, Triple cool,Fresh stripe, Ultra cavity protection,Time control, Sensation Deep clean,whitening, Sensitive multi-protection

• Crest – Freshmint, mildmint, tartarcontrol, 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, PronamelSignal

• Tesco – Total care: Freshmint, Coolmintstripe

Correct in 2007!

>1500ppm F

Prescription only


• 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!


• 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)


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


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




bacteriaSub-normal

saliva

Equilibrium!

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

The KAB approachKnowledge

Attitudes Behaviour

Behaviour change

?

Knowledge

Attitudes Behaviour

“Eating 5 portionsof fruit & veg per day reduces risk of cancer & CHD”

“Fruit & veg are good for my health”

“I will eat 5 portionsof fruit & veg per day”

Behaviour change

The KAB approach




• BUT important role for dental team – caries, erosion and oral cancer


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/

http://www.eatwell.gov.uk/agesandstages/

http://www.eatwell.gov.uk/agesandstages/

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!

Prevention of periodontal disease (1)Quick revision!

Key aetiological factors– plaque– smoking

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)


Zinc Citrate

Triclosan with copolymer


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!

Oral cancer killsOral cancer killsone person every 2one person every 211//22 mins mins

(210,000 deaths pa)(210,000 deaths pa)

Oral cancer killsOral cancer killsone person every 2one person every 211//22 mins mins

(210,000 deaths pa)(210,000 deaths pa)

World WideWorld Wide481,000 new cases of481,000 new cases of

oral cancer paoral cancer pa

World WideWorld Wide481,000 new cases of481,000 new cases of

oral cancer paoral cancer 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

0 10,000 20,000 30,000 40,000 50,000

Other

Mesothelioma Cervix

Liver Multiple myeloma

Brain with CNSOral

Ovary Uterus

Leukaemias Kidney

Pancreas

Oesophagus Stomach

Melanoma N-H-L

Bladder Prostate

Colorectal Lung

Breast

Number of new cases

Male Female

The 20 most commonly diagnosed cancers, UK, 2005


UK epidemiology of oral cancer

• Incidence increasing in younger people

• Survival rates changed little in 3 decades – approx 55% at 5 years

(IV)


• Incidence is increasing in men and women

0

2

4

6

8

10

12

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

Year of diagnosis

Rat

e p

er 1

00,0

00 p

op

ula

tio

n

males females persons

Age standardised (european) incidence rates, by sex, oral cancer, GB, 1975-2005

Oral cancer worldwide

0 5 10 15 20 25

EgyptChina

MozambiqueSierra Leone

JapanSenegal

United KingdomArgentina

CameroonCzech Republic

USASloveniaAustralia

South AfricanCroatia

IndiaBangladesh

SpainPakistan

FranceHungary

BotswanaSri Lanka

Rate per 100,000 population

Oral cavity

Other pharynx

F


7+ 1 to 60

01 to10

11 to 2021+

0

5

10

15

20

25

Alcohol (oz / day)

Cigarettes / day

Relative Risk

Oral Cancer – risk factors

• Smoking/tobacco use• Alcohol• Betel quid / paan

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

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

prevention of oral disease for adults. aim provide an overview of evidence-based practical...

Documents

prevention slide

prevention of caries

behaviour slide

higher slide

oral cancer slide

reduction of caries

fluoride toothpaste

filaments v slide