Prevention Modalities
Maximizing the effectiveness of the hygiene team
Beth Kornegay, RDH, MSDH, CDA
Prevention is key to precluding the occurrence and progression of diseases. However, in the United States, there is a disparity in oral healthcare and a lack of education about oral diseases. Healthy People 2020 addressed these issues in their Report on Oral Health, stating a need to increase awareness of both oral health and education.1 The Report highlighted dental caries as the most common chronic childhood and adolescent disease, affecting 1 in 5 children (5-11 years old) and 1 in 7 adolescents (12-19 years old). In addition, 27% of adults have untreated decay and 47.2% live with chronic periodontitis.1,2
The average annual cost for dental care is $685 per patient.3 Children miss more than 51 million school hours, and adults miss more than 164 million work hours due to dental-related causes annually.4 Prevention benefits not only the patient but also the healthcare system, with a reduction of costs, missed school and workdays, and emergencies.
In 2000, the Surgeon General published its first report on oral health, expounding on its connection with overall health.4 Research studies have found that chronic periodontitis may be associated with numerous systemic diseases, including diabetes, cardiovascular disease, and low birth weight. Maintaining optimal oral health status could help reduce the severity of systemic diseases.
Prevention in dentistry encompasses patient education, treatment, and products to help prevent oral diseases such as dental caries, periodontal disease, and oral cancer.
Prevention Modalities
Sealants and fluoride are two modalities that have been found to prevent or halt the demineralization process.5 The four types of sealant products include resin-based, glass ionomer, polyacid-modified resin, and resin-modified glass ionomer. Currently, there is limited evidence demonstrating one material superior to the others.6 Studies have shown that sealants can reduce decay by about 80% in permanent molars.1,5 Sealants are not recommended for all patients: It is the dentist’s clinical judgment on when to seal a patient’s tooth.
The most effective fluoride treatment for caries prevention is frequent exposure at low concentrations. Water fluoridation is considered the most efficient, reliable, and inexpensive means for improving and maintaining oral health in a community, preventing tooth decay by 18-40%.1 Research shows that individuals with naturally fluoridated water have less dental caries than individuals with unfluoridated water.
There are many over-the-counter products that contain fluoride. The dental professional should provide instructions or advise the patient to review instructions prior to use, to gain the most benefit. For example, the user should not eat or drink for 30 minutes after swishing with a fluoride mouthwash. Otherwise, the fluoride will be removed from the tooth surface and not produce the optimal results. For children, the American Academy of Pediatric Dentistry (AAPD) recommends a smear of fluoride-containing toothpaste at eruption of the first primary tooth up to the age of 3. After the child is 3 years old, a pea-sized amount of fluoride-containing toothpaste should be used.7 Supervision of children or any individual who has difficulties expectorating is important, due to the risk of swallowing the product and causing a toxic reaction. Additionally, small children who are still in tooth development should limit fluoride uptake due to the possible development of fluorosis.
Fluoride can also be supplied by in-office treatments. The dental professional is responsible for evaluating and recommending fluoride application to an adult who could benefit. Examples include patients with recession, incipient carious lesions, erosion, or sensitivity. The two options for in-office application of fluoride are varnish and trays. Widely used, fluoride varnish has a higher concentration of fluoride than gel or foams that are used with the trays. Varnish is safe and effective, setting quickly and remaining on the teeth for 4-6 hours after application. Post-treatment instructions, which should be given at time of application, include not brushing or flossing the area until the next morning, while also avoiding hard and tacky food (ie, biting into an apple, eating caramel), alcoholic drinks, and anything hot (ie, hot coffee) during the treatment time. Fluoride trays are given with acidulated phosphate fluoride (APF) or neutral sodium fluoride gel or foam. A neutral sodium gel should be used on patients with tooth-colored restorations, as APF is too abrasive for them. Because trays do not cover root surfaces, they are not recommended for patients with recession. If a tray is indicated, then the dental professional must stay in the operatory during the application and the saliva ejector needs to be in the patient’s mouth. These two actions can prevent the patient from digesting the fluoride product and a medical emergency from occurring. Post-treatment instructions for the trays are to not eat or drink anything for 30 minutes after application.
Dental Office Visits
Regular visits to the dental office play a critical role in the prevention of oral disease. The frequency of recall appointments depends largely on a patient’s caries and periodontal risk. At minimum, a patient should be seen once a year, and the AAPD recommends a child should have a dental home by 12 months of age.7
During these appointments, the dental professional should involve patients, so they are better informed about their status and options. At each recall appointment, a thorough assessment, including an oral cancer screening, periodontal assessment, and clinical examination, should be completed. The American Dental Association has issued recommendations for prescribing radiographs based on patient age and disease risk.
The dental professional should provide patient-centered and evidence-based education, including oral hygiene instruction, tobacco and alcohol cessation, and nutritional counseling. The patient must be motivated to make lifestyle changes in these areas. The more motivated a patient is, the more likely that the change will occur and last.
Oral hygiene instructions are not “one-size fits all” and should be individualized to best meet patients’ needs and status. When giving oral hygiene instructions, a dental professional should focus on one to two recommendations per visit. The conversation should be patient centered, utilizing open-ended questions and creating a nonjudgmental environment. Each dental appointment should assess how a patient is doing with her or his oral hygiene routine and adjustments made when needed.
Homecare
A survey found that individuals brush their teeth for 112 seconds on average, and a third do not brush their teeth enough.8 Toothbrushing should be done, at minimum, for 2 minutes each morning and night. Manual toothbrushes should have extra-soft or soft bristles and used with a light pressure. Most powered toothbrushes have sensors indicating when too much pressure is applied on the tooth surface, along with timers measuring brushing time. Several manufacturers have created technology using phone applications to document use of a powered toothbrush. While there is a plethora of options, research has shown that the most effective powered toothbrush heads are oscillating.
Consumers are overwhelmed by the number and types of oral care products. Helping to identify the best type of toothpaste and mouthwash for patients should be based on their individual risks and needs. For example, if a patient experiences sensitivity, recommend toothpaste containing stannous fluoride or potassium nitrate. Fluoride-containing toothpastes and mouthrinses are appropriate for those with a moderate-high caries risk. Products containing Cetylpyridinium chloride can help when a patient has halitosis. The dental professional should direct the patient to read the instructions before use of a toothpaste and mouthwash.
Diet can have a major impact on overall and oral health. Many commercial drinks such as sodas and sports drinks contain hidden sugars in large quantities and are acidic in nature. With an acidic drink (ie, orange juice), the pH lowers in the oral cavity and creates an environment that promotes bacterial growth. To prevent the acidity from spreading, patients should not brush their teeth immediately after eating or drinking something acidic. Drinking something that is acidic should be done in one sitting and while eating a meal. A patient should not sip on an acidic drink throughout the day and instead should substitute water. Cariogenic foods (ie, candy, breakfast cereals) lower the pH and promote caries formation, initiating around 5 minutes after consumption and lasting up to 30 minutes. These foods should be eaten during meals rather than as a snack. Anti-cariogenic foods (ie, cheese) prevent plaque from recognizing an acidic food, and therefore should follow the consumption of cariogenic food or replace cariogenic food as snacks.
Conclusion
Prevention modalities in oral healthcare not only reduce the amount and severity of oral disease but also of systemic diseases. Sealants, fluoride, regular recall appointments, and proper homecare play a fundamental role in the prevention of oral diseases.
References
1. Healthy People 2020. Oral Health. Office of Disease Prevention and Health Promotion website. https://www.healthypeople.gov/2020/topics-objectives/topic/oral-health. Accessed May 16, 2017.
2. Eke PI, Dye BA, Wei L, Thornton-Evans GO, Genco RJ. Prevalence of periodontitis in adults in the United States: 2009 and 2010. J Dent Res. 2012;91(10):914-920.
3. Wall T, Guay A. The Per-Patient Cost of Dental Care, 2013: A Look Under the Hood. Health Policy Institute Research Brief. American Dental Association. March 2016.
4. U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.
5. Wilkins EM. Clinical Practice of the Dental Hygienist. 12th ed. Philadelphia, PA: Wolters Kluwer; 2016.
6. Wright JT, Crall JJ, Fontana M, et al. Evidence-based Clinical Practice Guideline for the Use of Pit-and-Fissure Sealants. American Academy of Pediatric Dentistry, American Dental Association. Pediatr Dent. 2016;38(5):E120-E36.
7. American Academy of Pediatric Dentistry. Guideline on Infant Oral Health Care. American Academy of Pediatric Dentistry Reference Manual. 2014;37(6):146-150. https://www.aapd.org/media/policies_guidelines/g_infantoralhealthcare.pdf. Accessed May 30, 2017.
8. Delta Dental. 2014 Oral Health and Well-Being Survey. 2014. https://www.deltadental.com/DDPAOralHealthWellBeingSurveyBrochure2014.pdf. Accessed May 30, 2017.
About the Author
Beth Kornegay, RDH, MSDH, CDA
Clinical Assistant Professor
Department of Dental Ecology
University of North Carolina at Chapel Hill
Chapel Hill, NC
