Oral health improvement strategy for priority groups

Chapter Four Preventing Oral Diseases

This chapter considers how oral diseases can be prevented through healthy dietary choices which limit sugar consumption, good oral hygiene and abstinence from smoking. Sensible drinking also contributes to maintaining oral health.

The means by which the oral health of children in Scotland might be improved was extensively reviewed to inform the policies set out in the 2005 Dental Action Plan. The role of diet, oral hygiene and fluoride in reducing dental decay were fully explored, together with the need for dental services to be underpinned by a preventive philosophy, resulting in the development of the national preventive programme for children, Childsmile. Many of these principles, such as providing support to encourage regular toothbrushing are also applicable to adults.

In addition to personal awareness and healthy choices, achieving oral health also requires effective partnership between the individuals, health and social services, and local authorities, particularly in the care of vulnerable people. Partnership working is also of great importance in oral cancer prevention, where those at greatest risk may be unable or unwilling to access advice or examination through dental services. In such circumstances the medical practitioner and their team has a role to play in referring patients with suspicious lesions early and in the provision of smoking and alcohol advice in relation to oral cancer prevention.

We know that there are many positive steps we can take to prevent oral diseases if action is taken early.

The British Association for the Study of Community Dentistry has produced updated guidance on this issue.⁴⁶ There are steps people can take for themselves, or where they are unable to do so, carers can assist them. A number of preventive measures are outlined below. However, it is important to be aware that preventive regimes for frail vulnerable individuals should always be formulated to take account of the patient's individual medical history and in collaboration with their medical practitioner or hospital specialist.

Mouthwashes used to help prevent tooth decay and gum disease, such as fluoride and chlorhexidine, may be difficult for some patients with special needs or dementia to spit out after use, resulting in potential overdosage. The use of high dosage, 5,000 parts per million (ppm) fluoride toothpaste could also prove problematic in such circumstances and decisions on the suitability of such measures must be made with full consideration of individual patient medical history.

It is important that all vulnerable people have the opportunity to carry out routine oral care or to have assistance when this is needed. In addition, ongoing checkups with a dentist are important as these provide an opportunity to diagnose and treat oral diseases early.

4.1 Preventing Dental Decay

Core preventive messages, which should be adapted to take account of specific patient needs and the patient's medical history, include:⁴⁶

• Brushing twice daily with a fluoride toothpaste containing at least 1,350 ppm fluoride.
• Reducing the amount and frequency of consumption of sugary foods and drinks, and restricting sugary foods to mealtimes.^D
• Eating sensibly, and drinking enough water to avoid dehydration.

Adults at particularly high risk of dental decay should take additional measures to help prevent decay. This includes adults with active decay, a dry mouth or who have special needs.

• Using a fluoride mouthwash (0.05% Na F) in addition to toothbrushing if appropriate.
• Having fluoride varnish professionally applied twice yearly (2.2% F).
• People at high risk of dental decay such as those with active decay in the crown or roots of teeth should use 2,800 or 5,000 pap fluoride toothpaste prescribed professionally.

4.2 Preventing Gum Disease

All adults should have the support they require to prevent gum disease. The following measures are effective:⁴⁶

• Brushing teeth twice daily with an appropriate manual toothbrush or powered toothbrush with an oscillating/rotating action.
• Not smoking.
• Cleaning between the teeth using interdental brushes or floss.
• For short periods if people are unable to clean normally due to illness or disability, they will benefit from using Chlorhexidine mouthwashes (10 ml of 0.2% or 15 ml of 0.12%) with toothbrushing. Gel may be more appropriate for patients with difficulty expectorating.

4.3 Preventing Oral Cancer

The risk of developing oral cancer is linked to smoking and alcohol misuse. Alcohol acts together with smoking to multiply the risk of developing the disease.⁴⁶

It has also been associated with the use of smokeless tobacco products such as snuff or paan which is chewed, often incorporating other substances such as betel leaf, areca nut or lime.⁴⁷ Chewing tobacco is used more commonly in Asian communities, where the practice may be transferred down through families and cultural traditions.

Oral cancer or pre-cancerous oral conditions may be difficult for patients to detect and are often painless in the early stages, resulting in late presentation to health professionals. Homeless people and those who have worn full dentures for many years may lose contact with local dental services and therefore be less likely to attend for an oral examination, reducing the opportunity for early detection of oral cancer.

Having an examination by a suitably trained dental professional is important, both to receive advice which will help to prevent the disease, and to help detect any signs of disease as early as possible. Health professionals or carers should arrange for an early referral to a dentist for an examination of the mouth to be carried out for any patients with suspicious or unexplained symptoms.

Health professionals also have an opportunity to provide advice on smoking cessation and have a valuable role in signposting clients to smoking cessation services. A number of resources are available through the NHS Health Scotland website in the bibliography, for example, "A guide to Smoking Cessation in Scotland".⁴⁸ Any ulcer which has not healed after three weeks should be referred for further investigation.

Key messages include:⁴⁶

• Abstaining from the use of tobacco products, both smoking and smokeless tobacco.
• Avoiding excessive alcohol consumption.
• Having a regular dental examination by a trained dental professional.