Health Promotion and Disease Prevention are the Foundation of Community Based Health Care Joan I. Gluch, RDH, Ph.D. Director of Community Health Associate Dean for Academic Policies
Renewed Perspective Past Success Current Challenges Future Direction
Evidence Based Care Fluoride Sealants Education Community Based Dental Care Alternate Dental Providers Inter- Professional Care & Education
Is Evidence Based Decision Making A Solution? Provides Structure For Clinician & Patient Addresses Clinical Needs & Patient s Concerns Combines Research & Clinician s Experience
Five Steps in Evidence Based Decision Making Process 1. Ask a Specific Clinical Question 2. Search For Best Evidence 3. Assess the Evidence 4. Apply the Evidence to Clinical Care 5. Evaluate Outcome of Care
ADA Evidence Based Dentistry http://ebd.ada.org Research Reviews Clinical Guidelines Resources
Evidence Based Approaches to Community Based Interventions Water Fluoridation & Topical Fluorides Dental Sealants Educational Programs
Fluoride as The Major Caries Preventive Agent Caries Reduction Throughout the LifeSpan CDC 2001 Report http://www.cdc.gov/mmwr/preview/mmwr html/rr5014a1.htm Topical Fluorides and Systemic Fluorides
Systemic Fluoride Fluoridation: Adjustment of Fluoride Optimal 0.7PPM
Evidence for Recommending Systemic Water Fluoridation Code A: Good evidence Community Water Fluoridation for all areas Fluoride Supplements for Children age 6 mos-16 years Code C: Lack of evidence or mixed evidence School water fluoridation in nonfluoridated areas Fluoride supplements for pregnant women Source: Centers for Disease Control & Prevention. Recommendations for using fluoride to prevent dental caries in the United States. MMWR 2001;50(No.RR-14)
Public Health Significance of Systemic Fluoridation Single most effective preventive agent, proven caries reduction since 1945 Naturally occuring in mountainous areas, added in municipal water Benefits for both children and adults with little compliance required Antifluoridation arguments involve safety and freedom of choice
Water Fluoridation
Topical Fluoride
Fluoride Toothpaste Seventy Four Studies Pooled Together The PF of Caries Reduction was 24% Effect of Fluoride Toothpaste Increased with Higher Baseline Caries Levels, Higher Fluoride Concentration, Higher Frequency of Use & Brushing Supervision Water Fluoridation did not influence PF Source: Marinho, VCC, Higgins, JPT, Logan, S, Sheihan, A. Fluoride toothpastes for preventive dental caries in children and adolescents. The Cochrane Library, 2: 2005
Fluoride Home Rinses This review suggests that the regular and supervised use of fluoride mouthrinse by children result on average in 26% fewer decayed, missing, or filled permanent tooth surfaces We found no evidence that this relative effect was dependent on baseline caries level or exposure to other fluoride sources, fluoride concentration and mouthrinsing frequency. Source: Marinho, VCC, Higgins, JPT, Logan, S, Sheihan, A. Fluoride toothpastes for preventive dental caries in children and adolescents. The Cochrane Library, 2: 2005
Fluoride Gels Twenty Five Studies Pooled Together, with the Pooled PF of Caries Reduction was 28% Effectiveness Varied Based on Type of Gel and Specific Group Studied, with Average Caries Reduction PF 19% Source: Marinho, VCC, Higgins, JPT, Logan, S, Sheihan, A. Fluoride gels for preventive dental caries in children and adolescents. The Cochrane Library, 2: 2003, updated 2009
Professionally Applied 5.0% Sodium Fluoride Varnish 20,600 ppm Nine Studies Pooled, with a PF For Permanent Teeth of 46% and PF For Primary Teeth of 33% No Association Found Between Baseline Caries Activity OR Background Exposure to Fluoride Marinho, VCC, Higgins, JPT, Logan, S, Sheiham, A. Fluoride varnishes for preventing dental caries in children and adolescents. The Cochrane Library, 2: 2002, updated 2009 http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/cd002 279/frame.html
Multiple Fluoride Therapies This review has found that compared with fluoride toothpaste used alone, topical fluorides (mouthrinses, gels, or varnishes) used in addition to fluoride toothpaste reduce caries by 10% on average. Current clinical practice includes an additional TFT (over toothpaste) for those at higher risk of developing dental caries. Source:Marinho, VCC, Higgins, JPT, Logan, S, Sheihan, A. Fluoride gels for preventive dental caries in children and adolescents. The Cochrane Library, 2: 2003, updated 2009
Fluoride Supplement Schedule 6 months - 3 years 0.25 mg when Fl less than 0.3 ppm 3-6 years 0.5 mg when Fl less than 0.3 ppm 0.25 mg when Fl 0.3-0.6 ppm 6 to 16 years 1 mg when Fl less than 0.3 ppm 0.5 mg when Fl 0.3-0.6 ppm
School Fluoridation Programs School Water Fluoridation at 4.5 times the recommended amount for community Daily Tablet Distribution Weekly Rinses at.2% sodium
Casein Derivatives as Remineralizing Agents Evidence of short term remineralization in enamel for ACP (amorphous calcium phosphate) and CPP/ACP (casein phosphopeptides/ amorphous calcium phosphate (Yengopal, 2009) No evidence of caries reduction (CPP/ACP) Azarpazhooh, JADA, 2008 http://onlinelibrary.wiley.com/o/cochrane/mainsearch?products=all&query5=&q uery4=&fromyear=&query3=&query2=&query1=casein+phosphate&toyear= &mode=startsearch&zones5=tables&zones4=abstract&zones3=author&zones2=ar ticle-title&zones1=%28articletitle%2cabstract%2ckeywords%29&opt4=and&opt3=and&opt2=and&unitst atus=none&opt1=or&
Xylitol in Caries Prevention Evidence of caries reduction in frequent xylitol mint or gum use (Makinnen, 1989, Isokangas, 1993) AAPD policy statement, 2009 Increased salivary volume & buffering Reduction of food retention Substitution with neutral product Antibacterial properties of Xylitol Anticaries effect with 6 or more sticks per day
Evidence for Using Sealants to Prevent Occlusal Decay Eight Studies Pooled At Twelve Months, 86% Caries Reduction At Forty Eight Months, 57% Caries Reduction Source: Ahovuo-Saloranta,A, Hiiri,A, Nordblad, H, Worthington, M Pit and Fissure Sealants for preventing dental decay in the permanent teeth of children and adolescents. The Cochrane Library, 2: 2005
Clinical Guidelines for Dental Sealants Evaluate Risk for Decay Based on Tooth and Individual s Risk, Not solely age http://ebd.ada.org/clinicalrecommendations. aspx
What is the Evidence on These Five Preventive Measures For Dental Decay? 1. Use Systemic and Topical Fluoride Therapy 2. Use Sealants on Occlusal Surfaces 3. Control Bacteria Through Mechanical & Chemical Means 4. Compensate for Decreased Salivary Flow 5. Change Nutritional Patterns
Risk Assessment for Dental Decay History of Dental Decay & Dental Visits Presence of Susceptible Occlusal Grooves Salivary Status Fluoride Use Oral Hygiene Nutritional Patterns Parental Involvement Low, Moderate or High Risk Categories Look at Both Quantity & Quality of Risks
Prevention as Key for Future Challenges Oral Health Workforce Inter-Professional Education
Oral Health Workforce Integration of younger dentists in aging workforce Diversity recruitment of new dental students Quality of dental education in time of expansion and maldistribution
Oral Health Workforce Are new providers the solution to access to care? Public Health Dental Hygiene Practitioner Dental Health Aide Therapist Advanced Dental Therapist
Inter-Professional Education Health Center Model Nursing Collaboration New CODA standards
Health Promotion/Disease Prevention Provides the Foundation For Care Use Evidenced Based Perspective Explore Expanded Oral Health Workforce Work with Inter-Professional Colleagues