Oral health education for caries prevention
Objective Understand the fundamentals that inform oral health education programmes. Understand how to segment oral health information for preventive purposes in children. Emphasis the important of evidence based dentistry.
Introduction A child s risk of developing new caries depends the following factors: Load of cariogenic bacteria, especially Streptococcus mutans, in the mouth and in mother s mouth Presence of active caries
Introduction - 2 A child s risk of developing new caries depends the following factors: Poor oral hygiene Frequency and consistency of exposure to refined carbohydrates More than 24 months exposure to breast milk
Strategies for caries prevention Community active measures, which need approval to be adopted, endorsed, funded, and carried out nationwide.
Strategies for caries prevention - 2 Dental professional-active measures, which are those taken by dentists, hygienists, and dental assistants to help individuals on a one-to-one basis.
Strategies for caries prevention - 3 Individual-active measures, which may be a wide variety of oral hygiene measures. These measures are instituted by the patient. It requires educating the patient to enable them institute the right behaviour.
Community active measures Water fluoridation Salt and milk fluoridation Dental professional active measures Fluoride varnishes Professionally applied fluoride gels and foam Pits and fissure sealants Antimicrobial agents Individual active measures Fluoridated toothpastes Fluoride supplements Fluoride mouth rinses Self applied fluoride gels Self applied chlohexidine gels and rinses Slow release fluoride devices Restriction of sugar consumption Use of non-cariogenic sweeteners Khami MR, 2007
Approaches for prevention Focus on both the whole population and individual levels (persons at risk).
Approaches for prevention - 2 Population strategy attempts to promote health and control the causes of the incidence of dental disease. Feasible when the diseases prevalence in a population is high.
Approaches for prevention - 3 Where the caries prevalence for a population is low, targeting people at risk is the more appropriate approach.
Battsetseg Tseveenjav, 2004
Targeted approach This implies targeting caries prevention services to those individuals at high risk for caries. Targeting individuals at risk seems to fail even in some countries with a skewed distribution of caries, thus suggesting basic prevention for all children.
Targeted approach - 2 Appears to work most efficiently when a geographic localities rather than individuals are targeted. For Nigeria where caries severity in children is low and prevalence are significantly higher in children, it is best to implement a mix method. This consists of both population and individual strategies.
Mix method approach School based programmes A limited form of population based intervention. Allows for surveillance of disease Allows for institution of preventive programmes and prompt detection of lesions
Mix method approach (2) Individual programme (dental health professionals driven) One-to-one basis Application of fluoridated (varnish, gels, and rinses) and antimicrobial (chlorhexidine) compounds and placement of sealants, based on an assessment of each individual s risk, taking into consideration his or her current fluoride exposure.
Mix method approach (3) Individual programme (by individuals) Oral hygiene measures such as tooth brushing and interdental cleaning performed by individuals, the home use of fluoridated toothpaste, fluoride compounds, antimicriobal agents, and xylitol, and adoption of sensible use of sugary food.
Oral health education Dental professionals are responsible for providing information on healthy habits for dental well-being and for instructing and motivating individuals in order to modify detrimental behaviours and lifestyles toward oral health and to encourage healthy ones.
Oral health education - 2 Dentists therefore need to acquire skills that ensures: Effective communication so as to motivate for change Being able to provide factual information Being able to identify the caries risk of each individual patient and manage appropriately
Effective communication skills Attending Skills Eye contact Body language Trunk lean, gestures, facial expressions Vocal qualities and appearance
Effective communication skills (2) Use encouragers Reflect and summarise information Ask open ended questions Terminate session effectively
Motivation Patient education would improve oral hygiene only for a short period of time. Regression to baseline value occur as the length of time after instruction increases. One teaching session would not alter performance.
Motivation - 2 Disclosing materials will motivate only for a few weeks. Closely supervised teaching on a multiple visit basis allows for reinforcement and produces best result.
Motivation - 3 Educator s attitude can impact on effective communication. Educator needs to show keen interest in the topic being discussed Educator s instructional approach. Use as many visual and educational aids as possible. Also encourage and praise positive efforts and attitudes.
Motivation - 4 Timing of message before prenatal and infant care produces effective result. Least effective is pre-treatment educational approach. Could delay education till when treatment is complete.
Messages Educational messages must include information on what the problem is, how the problem occur, why there is a need to address the problem and how to address the problem.
Messages - 2 Information shared must be factual and not given to cause fear. Individualise education is more effective. There must be opportunities to reinforce the messages and so the need to recall patients.
Messages -3 Discuss about: Tooth brushing Interdental cleaning Home use of fluoridated toothpaste and fluoride compounds where indicated Adoption of sensible use of sugary food. Use of antimicriobal agents Use of xylitol
Low risk patients Advice and recommend fluoride toothpaste Giving instruction on tooth brushing Giving instructions on flossing Adjusting check-up intervals to 12 months
Medium risk caries patients Advice and recommend fluoride toothpaste Giving instruction on tooth brushing Giving instructions on flossing Instructing in use of NaF mouth rinse Doing professional prophylaxis Dietary counselling Adjusting check-up interval to 6-12 months
High risk caries patients Advice and recommend fluoride toothpaste Giving instruction on tooth brushing Giving instructions on flossing Instructing in use of NaF mouth rinse Doing fluoride therapy Doing professional prophylaxis Dietary counselling Adjusting check-up interval to 3-6 months
Use of fluoride toothpaste The evidence of the caries-inhibiting effect of fluoridated toothpaste is clear and strong for permanent dentition but incomplete for primary teeth. There is no logical reason, however, to assume that it is less effective.
Use of fluoride toothpaste - 2 The preventive effect of fluoridated toothpaste increase with higher baseline levels of caries, higher fluoride concentration, higher frequency of use, and supervised brushing.
Use of fluoride supplements Fluoride dietary supplements has an estimated effectiveness of 20% to 30% reduction in dental caries. Developed to benefit populations with no access to water-borne fluoride.
Use of fluoride supplements - 2 Caries prevention emphasis is now on topical rather than systemic exposure to other sources of fluoride. This reduces the importance of fluoride supplement for public health use.
Use of fluoride supplements - 3 Also, the potential risk of fluorosis in permanent dentition further weakened the role of fluoride supplements as a public health measure. Used as preventive measure for compliant high-risk children.
Flouride mouth rinses Fluoride mouth rinses are available at 0.2% and 0.05% concentration for weekly and daily use respectively. Supervised regular use of fluoride mouth rinse and rinsing frequencies is associated with a reduction in caries increment in the permanent dentition.
Flouride mouth rinses - 2 Rinses should not be used when brushing. so as to maintain a constant concentration of fluoride throughout the day.
Self applied fluoride gel Caries reduction following their use has been reported to be 32% in fluoride-deficient communities, and 7% to 35% in optimally fluoridated areas.
Use of antimicriobal agents Chlorhexidine gel shown to prevent caries by 47%. Effective in high-risk children. Evidence for the anti-caries effect of the chlorhexidine-containing varnishes is inconclusive.
Use of antimicriobal agents - 2 10% povidone iodine solution increase the time of "disease-free survival" in 91% high-risk children. Triclosan, a broad-spectrum biocide, has been incorporated into dentifrices together with a copolymer. Not shown to enhance anti-caries effects.
Use of xylitol Effective in preventing mother to child transmission of cariogenic organisms. It is a naturally occurring sugar substitute, has anticariogenic properties and reduces Streptococcus mutans levels in saliva and plaque. Its use is limited due to its low versatility and high cost.
Slow-release fluoride devices 67% fewer new carious teeth has been observed in children wearing a fluoride-releasing glass device in their mouths. Such devices would be beneficial to prevent dental caries in non-compliant high-risk children.
Restriction of sugar consumption Restriction of sugar consumption remains an essential, if not the most important, aspect of caries prevention. Efforts should aim at reducing the frequency and amount of sugar consumption by limiting it to mealtimes.
Restriction of sugar consumption - 2 The acceptable level of non-milk extrinsic sugar consumption, based on the availability of the fluoride in the community, lies in a range from 10 to 15 kg/person/year.
Challenges These measures always require an active role and responsibility from individuals. Behaviour change is often challenging. It is therefore important to build habits rather than change. School oral health programmes can serve as a vehicle through which appropriate oral health behaviours are built.
Challenges - 2 Factors that affect compliance with required behaviour changes include age, gender, socioeconomic class, peer pressure, parental compliance, country sugar policies.
Challenges - 3 Children s health-related attitude and behaviours are taught and adopted at home and are modelled on the parental and family example. This process is called primary socialization.
Challenges - 4 Later, these attitude and behaviours are influenced by their teachers, friends, and peers, and shaped and formalized in a community-based network when children become socialized; this process is called secondary socialization.
Challenges - 5 When a child s adopted norms within a family differ greatly from those adopted in a school, he or she faces difficulty, resulting in what is called cultural clash.
Challenges - 6 In adulthood, psycho-social factors serve to sustain pressure on individuals which affects their dental health. This process is called tertiary socialization.
Caries prevention programmes Four distinct oral health behaviours of value in controlling caries: use of fluoridated toothpaste oral hygiene practices dietary habits utilization of oral health services
Plaque removal and caries control Unless in combination with the use of fluoridated toothpaste, from a public health perspective, mechanical removal of dental plaque alone is not of significant value in reducing dental caries on a population basis.
Plaque removal and caries control - 2 Plaque removal is necessary to yield the optimum effect from fluoride. Improved oral hygiene and fluoride have a synergistic effect against tooth decay.
Caries prevention for children in Nigeria Caries prevalence and incidence is low. The main challenge is with the primary dentition. The prevalence and severity of caries in the primary dentition is significantly higher than in the permanent dentition.
Caries prevention for children in Nigeria - 2 For children with untreated caries, the risk of developing new lesions is five times higher when compared with children with no lesion. Lots of children have untreated caries.
Caries prevention for children in Nigeria - 3 Fluoride toothpaste use is high. Home use of fluoridated toothpaste would not pose a challenge to caries prevention programme.
Caries prevention for children in Nigeria - 4 There is a strong association between oral hygiene and caries for children in Nigeria. The oral hygiene status of most children in Nigeria falls between fair and poor.
Caries prevention for children in Nigeria - 4 Utilisation of oral health services is low. However, evidence show that school visit programmes and referrals for dental treatment can increase dental service utilisation.
Caries prevention for children in Nigeria - 5 Sugar intake is high. The risk of having caries is increased when children take sugary snacks at least once daily. The risk of having rampant caries increases when children takes sugary snacks at least three times daily.
Caries prevention for children in Nigeria - 6 Caries prevention programmes in Nigeria should be directed at key target population. The key target population in Nigeria are children with primary dentition.
Caries prevention for children in Nigeria - 7 Mixed method approach may be best. This would mean implementing school based programmes, identifying children at high risk for caries and appropriately managing these children.
Caries prevention for children in Nigeria - 8 Caries prevention programmes should develop mechanisms to ensure treatment of decay teeth. The possible use of Atraumatic Tooth Restoration (ART) should be given due attention.
Caries prevention for children in Nigeria - 9 Public health messages should promote oral hygiene measures, reduction of sugar consumption in between meals, and discourage poor breastfeeding habits.
Quiz 1 For low caries risk patients, consider the following: Advice and recommend fluoride toothpaste Giving instruction on tooth brushing Doing professional prophylaxis Dietary counselling Adjusting check-up interval to 6-12 months
Quiz 2 For patients with high caries risk: Instruct on use of NaF mouth rinse Do fluoride therapy Do professional prophylaxis Counsel the patient on appropriate diet Adjust check-up interval to 6-12 months
Quiz 3 Caries risk factors for children in Nigeria include: Poor oral hygiene habits Poor access to flouride toothpastes Poor utilisation of dental services High sugar intake
Acknowledgement Slides were developed by Morenike Ukpong, Associate Professor in the Department of Paediatric Dentistry, Obafemi Awolowo University, Ile-Ife, Nigeria. The slides was developed and updated from multiple materials over the years. We have lost track of the various references used for the development of the slides We hereby acknowledge that many of the materials are not primary quotes of the group. We also acknowledge all those that were involved with the review of the slides.