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Prevention of oral disease for adults
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Prevention of oral disease for adults
• AimProvide an overview of evidence-based
practical prevention for adults
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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
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www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_078742
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Oral diseases to prevent
• Caries• Erosion• Periodontal diseases• Oral cancer• Trauma
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Oral diseases to prevent
• Caries• Erosion• Periodontal diseases• Oral cancer• Trauma
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Caries and its prevention
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Caries and its prevention
Risk factorsFrequent sugarsAcidogenic
bacteriaSub-normal
saliva
Caries progression
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Protective factorsSalivaFluorideAntibacterials
Caries and its prevention
Risk factorsFrequent sugarsAcidogenic
bacteriaSub-normal
saliva
Equilibrium!
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Protective factorsSalivaFluorideAntibacterials
Caries and its prevention
Remineralisation
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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)
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Prevention of caries – Fluoride (2)
Fluoride toothpaste
Fluoride conc.
Preventive effect
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Prevention of caries – Fluoride (2)
• 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)
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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!
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>1500ppm F
Prescription only
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Prevention of caries – Fluoride (3)
• 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!
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Prevention of caries – Fluoride (4)
• 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)
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Prevention of caries – Fluoride (5)
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
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Prevention of caries – Fluoride (6)
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
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Protective factorsSalivaFluorideAntibacterials
Caries and its prevention
Risk factorsFrequent sugarsAcidogenic
bacteriaSub-normal
saliva
Equilibrium!
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Prevention of caries – dietary counselling (1)
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Prevention of caries – dietary counselling (1)
• Evidence for F>>>dietary “advice”• Providing information WILL NOT
achieve sustained changes in behaviour (I)
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Changing behaviour
• Previously assumed that:
Providing knowledge
Change in attitudes
Change in behaviour
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The KAB approachKnowledge
Attitudes Behaviour
Behaviour change
?
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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
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Prevention of caries – dietary counselling (1)
• Evidence for F>>>dietary “advice”• Providing information WILL NOT
achieve sustained changes in behaviour (I)
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Prevention of caries – dietary counselling (1)
• Evidence for F>>>dietary “advice”• Providing information WILL NOT
achieve sustained changes in behaviour (I)
• BUT important role for dental team – caries, erosion and oral cancer
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Prevention of caries – dietary counselling (3)
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/
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Oral diseases to prevent
• Caries• Erosion• Periodontal diseases• Oral cancer• Trauma
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Oral diseases to prevent
• Caries• Erosion• Periodontal diseases• Oral cancer• Trauma
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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.
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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!
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Oral diseases to prevent
• Caries• Erosion• Periodontal diseases• Oral cancer• Trauma
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Oral diseases to prevent
• Caries• Erosion• Periodontal diseases• Oral cancer• Trauma
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Prevention of periodontal disease (1)Quick revision!
Key aetiological factors– plaque– smoking
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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)
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Prevention of periodontal disease (2)
Zinc Citrate
Triclosan with copolymer
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Prevention of periodontal disease (2)
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)
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Prevention of oral cancer
Some more revision!
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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
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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
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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
Cancer Research UK, 2008
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UK epidemiology of oral cancer
• Incidence increasing in younger people
• Survival rates changed little in 3 decades – approx 55% at 5 years
(IV)
Cancer Research UK, 2008
• 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
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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
Cancer Research UK, 2008
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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
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Oral Cancer – other risk factors• Sunlight• Diet• Human papilloma virus• Previous cancer
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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
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Oral diseases to prevent
• Caries• Erosion• Periodontal diseases• Oral cancer• Trauma
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Prevention of trauma
• Sport related – recommend mouthguards (IV)
• Maxillofacial injuries – alcohol related – advise to moderate consumption – research underway
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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
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www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_078742
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