BETTERING ORAL HEALTH TOOLKIT

Question 1

Population advice and support on lowering risK

Answer 1

• patients should receive advice and support to lower their risk of oral and general disease and promote health.
• behaviour change as outlined in Chapter 3 of the toolkit, + professional interventions, such as applying fluoride varnish to all teeth that reduce the risk of dental caries. - reflected in the summary guidance tables (Chapter 2) as advice or professional intervention for all patients.
• For those patients about whom there is greater concern, because they are at higher risk of oral disease, there are recommendations on increasing the intensity of general care and additional actions for dental teams and their patients to take (Chapter 2).

Question 2

Risk identification and management is essential for prevention

Answer 2

Risks and benefits must be ‘balanced’.

This is where we in the dental profession must promote a healthy diet for everyone, while also providing our patients with specific advice about the pattern and volume of acidic fruit consumption when there is accelerated tooth wear, and only when this has been identified as the most likely risk factor.

Question 3

Assessing risk status

Answer 3

The range of oral diseases to which people are susceptible, and their personal risk factors, change across the life course

The role of dental team members is, therefore, based on risk to provide the most relevant support, care, and advice to patients throughout their life.

Assessing and categorising each patient’s individual risk status should therefore be part of each course of care across the life course

In using this toolkit, it is easiest to consider whether patients are at the general level of population risk, in which case they receive the general advice or at higher risk. The latter may be because of their disease history (medical or dental ), the context in which they live or their health behaviours and indicate that additional support is required

Question 4

Assessing risk status - dental recall

Answer 4

Consideration of risk also has implications for dental recall periods which should be assessed in line with NICE guidance [footnote 8], and shortened for those thought to be at higher risk.

The shortest interval between oral health reviews for
- all patients should be 3 months
The longest interval
- under 18 years should be 12 months
- over 18 years 24 months.

Question 5

Encountering high risk patients

Answer 5

When encountering patients who are at higher risk, it is an important to explore if they can be supported to lower their risk(s) or need special preventive care for the rest of their life.

Question 6

Stages of prevention

Answer 6

Primary - Reducing the incidence of disease and health problems within the population, either through universal measures that reduce lifestyle risks and their causes or by targeting high-risk groups.

Secondary - Detecting the early stages of disease and intervening before full symptoms develop

Tertiary - Softening the impact of an ongoing illness or injury that has lasting effects. This is done by helping people manage long-term, often complex health problems and injuries.

Question 7

Chapter 2 summary tables

Answer 7

These summary tables list the advice and actions that should be provided for all patients to maintain good oral health.

They also outline the additional support that should be offered to people identified as being at higher risk of dental disease.

All patients should be given the benefit of advice, care and support to improve their general and oral health, not just those thought to be at risk.

Question 8

What do the tables do

Answer 8

The grading of the quality of evidence and strength of recommendations in the summary tables is based on GRADE (Grading of Recommendations, Assessment, Development and Evaluations).

It reflects the extent to which the relevant disease-based Guideline Development Group (GDG) is confident that desirable effects of an intervention outweigh undesirable effects across the range of patients for whom the recommendation is intended.

Question 9

Strong recommendations

Answer 9

Strong recommendations – the GDG is highly confident that desirable consequences outweigh undesirable or undesirable consequences outweigh desirable, typically based on high or moderate certainty evidence.

Question 10

Conditional recommendations

Answer 10

Conditional recommendations – the GDG is less confident of the effectiveness of an intervention (low or very low certainty evidence) or the balance between benefits and harms is unclear.

It is important to recognise that where a recommendation is conditional rather than strong, this does not mean that the intervention does not work but simply that the current evidence supporting it is not of the highest certainty.

Question 11

Good practice .

Answer 11

Good practice – clinical opinion suggests this advice is well established or supported.
No robust underpinning research evidence exists.
Good practice points are primarily based on extrapolation from research on related topics and/or clinical consensus, expert opinion and precedent, and not on research appropriate for rating the certainty or quality of the evidence

Question 12

Prevention of dental caries in adults

Answer 12

Brush teeth at least twice daily:
• last thing at night (or before bedtime) and on at least one other occasion
• with toothpaste containing 1,350 to 1,500ppm fluoride
• spitting out after brushing rather than rinsing with water, to avoid diluting the fluoride concentration (strong)

Minimise the amount and frequency of consumption of sugar-containing food and drinks (strong)

Avoid sugar-containing foods and drinks at bedtime when saliva flow is reduced and buffering capacity is lost (conditional)

Assign a recall interval ranging from 3 to 24 months, based on oral health needs and disease risk - professional intervention (conditional)

Question 13

Prevention of dental caries in adults - high risk patients

Answer 13

Advice - OHI refinement
Intervention - fluoride varnish 2x year, short recall

Question 14

Table 2: Prevention of periodontal diseases (in addition to caries prevention)

Answer 14

Self-care plaque removal:
• daily, effective plaque removal is critical to periodontal health Conditional
• remove plaque effectively using methods shown by the dental team. This will prevent gingivitis (gum bleeding or redness) and reduces the risk of periodontal disease Good practice
• brush gum line and each tooth at least twice daily
- Around orthodontic appliances and bridges, plaque control should be undertaken using the aids suggested by the orthodontic or dental team

Intervention
- Advise best methods of plaque removal to prevent gingivitis and achieve lowest risk of periodontitis and tooth loss
- Use behaviour change methods with oral hygiene instruction
- Correct factors that impede effective plaque control including supra and subgingival calculus, open margins and restoration overhangs and contours, which prevent effective plaque removal
- For extensive inflammation, start with toothbrushing advice, followed by interdental plaque control
- Assess patient, parent or carer’s preferences for plaque control:
• decide on manual or powered toothbrush
• demonstrate methods and types of brushes
• assess plaque removal abilities and confidence with brushing
• patient sets SMART goals (see chapter 3) for toothbrushing for next visit

Question 15

All adults (and young people aged 12 to 17 years with evidence of periodontal disease)

Answer 15

Advice
Interdental plaque control:
• clean daily between the teeth to below the gum line before toothbrushing
• where there is space for an interdental or single-tufted brush, this should be used
• for small spaces between teeth, use dental floss or tape

Professional intervention
Assess patient’s preferences for interdental plaque control:
• decide on appropriate interdental aids
• demonstrate methods and types of aids
• assess plaque removal abilities and confidence with aids
• patient sets SMART goals (see chapter 3) for interdental plaque control

Question 16

Control of specific risks for periodontitis
Diabetes

Answer 16

Advice
Patients with diabetes should try to maintain good diabetes control as they are:
• at greater risk of developing serious periodontitis and
• less likely to benefit from periodontal treatment if the diabetes is not well controlled

Professional intervention
For patients with diabetes:
• explain risk related to diabetic control; ask about HbA1c (glycated haemoglobin) levels
• assess and discuss clinical management (see Chapter 5)

Question 17

Early detection of oral cancer

Answer 17

Professional intervention
Obtain an updated medical, social and dental history and perform an intraoral and extraoral visual and tactile examination for all patients at each oral health assessment visit.

In line with national referral recommendations, patients should be referred on an urgent or suspected cancer pathway if they have lump, inconsistencies, pain

Question 18

Table 4: Prevention of tooth wear

Answer 18

Brush teeth at least twice daily:

• last thing at night (or before bedtime) and at least on one other occasion
• with toothpaste containing fluoride (appropriate to age – see dental caries table)
• spitting out after brushing, rather than rinsing with water, to avoid diluting the fluoride concentration

Assess tooth wear using a validated tool (for example Basic Erosive Wear Examination (BEWE)) at the start of any new course of treatment.

Question 19

Patients at higher risk (those with accelerated tooth wear)

Answer 19

Identify possible sources of risk: intrinsic, extrinsic and mechanical (see Chapter 7).

Support patient in risk reduction and management.

Question 20

Behaviours that support oral health

Answer 20

improving oral hygiene (Chapter 8)
optimising exposure to fluoride (Chapter 9)
reducing sugar intake and healthier eating (Chapter 10)
stopping smoking and tobacco use through very brief advice (Chapter 11)
reducing harmful alcohol consumption through identification and brief advice (Chapter 12)

Question 21

What is important for behaviour change to occur?

Answer 21

One of the most helpful recent models is COM-B

This model proposes that for behaviour change to occur, a person must have Capability, Opportunity and Motivation to change Behaviour as outlined below:

Capability - physical or psychological ability to change to the desired behaviour. This includes a person’s knowledge of what the desired behaviour is and why it is important, the skills required to make the change and the self-control needed to start and maintain that desired behaviour over the long-term.

Opportunity - environment in which the person lives, which may include the social environment required to support the behaviour, eg, income; the physical environment; or the facilities available.

Motivation - motivation to adopt new behaviour, which would require the desire, and intention, to change and to stop or adapt their existing habits.

Question 22

What can dental professionals do to support behaviour change

Answer 22

Changing behaviour should be considered as a cycle.

It may start with patients being unaware of the issue, through a time when they are thinking about making a change, to when they are actively preparing to change by planning and setting goals, to when they are ready to act, and then trying to maintain the change avoiding relapse.

Dental professionals can start conversations with patients by providing information about the specific behaviour which needs to be addressed, and its link to oral and general health

This can also mean discussing what will happen if the person does (or does not) perform the behaviours. To build motivation further, the dental team members can help patients feel positive about the benefits of changing one or more of these behaviours.

It is important to assess a patient’s readiness to take action to change.

discuss with the patient which behaviour they feel most ready to change, and work with this, even if it is not what you as a health professional would prioritise.

Instead, dental professionals should show empathy, discuss the patient’s views, provide support, and keep the opportunity for further discussions open for the future.

Question 23

How to support patients in taking next step - SMART

Answer 23

From NICE behaviour change overview

Working with the patient to show them how to perform the behaviour and provide tailored instruction

work out a plan together in terms of simple tasks over time, using SMART goals:
Specific – clear and precise goals provide focus and clarity of purpose
Measurable – goals that can be easily measured and quantified
Achievable – goals that are challenging, but within the patient’s reach – this will increase their self-confidence in making these changes (setting unachievable goals merely demotivates people)
Relevant – to the patient’s circumstances, motivations and needs
Timely – check that it is the right time to work on the goal. Setting a clear time frame is also important to help maintain motivation and to monitor progress
help identify barriers to making changes and how they might be overcome
plan together how they might cope if there is a relapse in their behaviour
provide encouragement and praise the patient’s efforts at subsequent appointments
help identify motivating rewards for any progress achieved to help maintain motivation
signpost or refer patients to other local services or digital resources

Question 24

When using behaviour change techniques and delivering behaviour change interventions, consider the source of the intervention (who delivers it), the mode of delivery (how it is delivered) and the schedule (timing – when it is delivered)

Answer 24

Source
rapport and empathy is important so that conversations with patients about their oral health behaviours can be supportive and conducive to change.
Effective communication during brief interventions uses a range of skills, which can be remembered using the acronym ‘OARS’ - from NHS Scotland
O- Open questions to explore patients’ feelings and values
A - Affirmations that you as the dental professional can see the patient’s point of view, understand the difficulties involved and recognise the patient’s successes
R - Reflective listening and clarifications
S - Summarising the patient’s thoughts and feelings about making changes to their oral health behaviours

Mode
how the behaviour change intervention is to be delivered, should also be considered. Different modes of delivery are appropriate
- face to face
- printed leaflets / resources

Schedule
- consideration of their frequency, duration, and timing
- The ‘Making Every Contact Count’ approach requires health professionals to make use of every encounter with patients. For dental professionals, recall appointments offer the ideal opportunity to highlight behaviours to change with patients or reinforce earlier interventions.
- The timing of behaviour change discussions is important because, as previously mentioned, assessing the patient’s readiness to change will influence the type of support the professional provides

Question 25

Examples of behaviour change interventions
OHI for plaque removal

Answer 25

oral hygiene for plaque removal (Chapter 8) – OH-TIPPS – a behaviour change strategy for patients to feel more confident in their ability to perform effective plaque removal and help them plan how and when they will look after their teeth and gums

Question 26

Examples of behaviour change interventions
Fluoride

Answer 26

regular use of fluoride (Chapter 9) – resources to support behaviour change conversations with parents of young children to promote parental supervision of tooth brushing with a fluoride toothpaste as part of oral hygiene (Chapter 8)

Question 27

Examples of behaviour change interventions
Reducing sugar

Answer 27

reducing sugar as part of a healthier diet (Chapter 10) – use of diet diaries and other resources, for example Food Scanner App)

Question 28

What is dental caries

Answer 28

Dental caries is one of the most prevalent non-communicable diseases nationally[footnote 1][footnote 2] and globally[footnote 3]. The disease is caused by dietary sugars that are broken down by micro-organisms in the biofilm on a tooth surface, which produces acids that, over time, demineralise tooth enamel

The process of de- and re-mineralisation is dynamic. In the early stages of the disease, dental caries can be reversed. However, when factors promoting demineralisation exceed those favouring remineralisation, dental caries progresses (unless checked) into dentine to a point where the tooth surface breaks down and ultimately a cavity forms

Question 29

How do we go about treating dental caries

Answer 29

Effective patient care involves first diagnosing the presence and recording the extent of disease, using contemporary dental caries management tools such as the International Caries Classification and Management System (ICCMS)[footnote 6],
encouraging a reduction of factors that cause demineralisation, notably sugar consumption; and, enhancement of those favouring remineralisation, particularly the availability of fluoride and mineral ions.

This may be achieved by a combination of preventive actions taken by patients, patient carers and healthcare professionals, supported by higher-level actions that promote policies and active change to facilitate a less cariogenic social environment.

Question 30

Risk and protective factors

Answer 30

The main modifiable risk factors for dental caries are diet, consuming too much cariogenic sugar too often, and lack of optimal fluoride.

The key recommendations and good practice points to prevent dental caries are in the summary guidance (Chapter 2: Table 1) with further details in the following chapters:

Fluoride and Oral hygiene (Chapters 9 and 8)
Healthier eating (Chapter 10)

Other dental caries risk and protective factors, including addressing medicine containing sugars or reducing salivary flow, placing fissure sealants, chewing sugar-free gum and using topical remineralising agents and varnishes, are addressed below.

Question 31

Re-mineralising agents other than fluoride

Answer 31

Typical constituents include casein phosphopeptide (an amorphous calcium phosphate) that helps bind the re-mineralising ions to the biofilm as well as modulating biofilm pH and bacterial colonisation.

Question 32

Common form of perio

Answer 32

periodontal diseases, called ‘gingivitis’ (inflammation of the gums that can be reversed) and ‘periodontitis’ (inflammation that results in loss of periodontal attachment)

Gingivitis and periodontitis are separate conditions, although both are initiated by plaque in susceptible people. Gingivitis is a risk factor for periodontitis, although not all people or sites with gingivitis go on to develop periodontitis.

The prevention and management of periodontitis is described here in terms of primary, secondary, and tertiary prevention as shown in Chapter 1 (Table 1.1). Because both conditions are initiated by plaque, the primary prevention of periodontitis will also prevent gingivitis.

Question 33

What is periodontal health

Answer 33

Periodontal health is the absence of clinically detectable inflammation (<10% of sites bleeding on probing), on an intact periodontium, or a reduced periodontium where attachment loss has resulted from anything other than periodontitis.

Question 34

What is gingivitis

Answer 34

Gingivitis is an inflammatory condition resulting from interactions between the dental plaque and the host’s immune response, which remains contained within the gingiva and does not extend to the periodontal attachment (cementum, periodontal ligament, and alveolar bone).

Such inflammation is reversible by reducing levels of dental plaque at and below the gingival margin.

Question 35

What is periodontitis

Answer 35

Periodontitis is a microbially-associated, host-mediated inflammation that results in loss of periodontal attachment. A patient is said to have periodontitis if:

• interdental clinical attachment loss (CAL) is detectable at ≥2 non-adjacent teeth
  or
• buccal or oral CAL ≥3 mm with pocketing ≥3 mm is detectable at ≥2 teeth, where the lost clinical attachment cannot be ascribed to another cause

Periodontitis causes progressive destruction of the tooth‐supporting tissues. Signs of the disease include clinical attachment loss, manifested as interdental recession and/or periodontal pocketing and alveolar bone loss.

This chronic and inflammatory disease is caused by a complex interplay of risk factors, with dental plaque being the most important.

Question 36

Periodontitis - Risk or susceptibility and protective factors

Answer 36

Conversely, there are risks to general health resulting from having active periodontal diseases.

Some systemic disorders, such as diabetes and cardiovascular diseases, share similar genetic and/or environmental influences with periodontal diseases, thus affected people may have signs of either or both

International consensus of joint dental and medical experts, based upon evidence from systematic reviews, recommends the importance of periodontal therapy in reducing the risks of diabetes and its complications

There is ongoing debate about the role of periodontitis in cardiovascular diseases, but at present no firm conclusions can be drawn.

Also, there is insufficient information to determine the true relationship between rheumatoid arthritis and periodontitis.

Likewise, the evidence linking lifestyle factors such as stress, poor diet, being overweight, or cannabis use, is insufficient to suggest a clear association with periodontal diseases.

Question 37

What is plaque

Answer 37

Dental plaque is a highly organised and specialised film of bacteria in an organic matrix that forms on the teeth. The intercellular matrix consists of various micro‐organisms and their by‐products. The bacteria mutually support each other, using chemical messengers, in a complex and highly evolved community, that can protect them from an individual’s immune system and chemical agents.

Normally, small amounts of bacteria cause only minimal inflammation, but a disruption in the balance (dysbiosis) between the plaque and person’s immune system can lead to the initiation of gingivitis and progression to periodontitis

Question 38

Periodontal disease and diabetes

Answer 38

Glycaemia in those without a diagnosis of diabetes, and hyperglycaemia in those with diabetes are both risk factors for poor periodontal health[footnote 29] and also impair the response to its treatment. While well-controlled diabetes is not a risk factor, many people oscillate between different levels of control. Therefore, it is best to assume an increased risk of periodontal diseases for anyone who has diabetes

Question 39

Primary prevention of periodontitis

Answer 39

• control any risk factors - plaque, diabetes
• plaque control - Oral Hygiene TIPPS (Talk, Instruct, Practice, Plan, Support) is a behaviour change strategy
• removal of plaque retentive factors

Question 40

Diabetes control

Answer 40

Discuss how diabetes control affects periodontal health and ask about their level of glycaemic control, also known as HbA1c. Levels consistently below 7.0% (8.6 mmol/L) indicate good control.

Question 41

Secondary prevention of periodontitis

Answer 41

Early detection and management pathways: basic periodontal examination

Early detection and treatment of periodontitis increases the likelihood of tooth retention

One screening tool that is well known and quick to use is the Basic Periodontal Examination (BPE)

The BPE uses the WHO BPE probe and is suitable for routine assessment of all dentate adults (Table 5.1).

Question 42

Managing periodontitis

Answer 42

will depend on its extent, severity and rate of progression.

Patients with BPE scores of 3 or 4 may have periodontitis. Preventive care may therefore involve secondary (detecting the early stages of periodontitis and intervening before full symptoms develop) or tertiary prevention (softening the impact of periodontitis by helping people manage its long-term consequences with Supportive Periodontal Care (SPC)).

Secondary prevention will involve more detailed periodontal charting to identify affected sites, as patients with these BPE codes will have pockets of ≥4mm or ≥6mm respectively[footnote 50]. Plaque scores may identify areas with specific oral hygiene problems to be managed

Question 43

Managing perio - evidence based

Answer 43

The European Federation of Periodontology has developed S3 level evidence-based clinical practice treatment guidelines for periodontitis, which have been adapted and adopted by the BSP for implementation in the UK.

Once the patient has an established diagnosis of periodontitis, it may be managed by a stepwise approach

Sextants coded 3 (BPE 3 - 4-5.5mm) should receive initial therapy including self-care advice (oral hygiene instruction and risk factor control).

After the patient has had time to respond to this, a 6-point pocket chart should be recorded in the affected sextant to monitor progress and advise the patient accordingly.

If there is a code 4 (>5.5mm) in any sextant then record a 6-point pocket chart to identify affected sites throughout the entire dentition.

Tertiary prevention in patients who have undergone initial therapy for periodontitis, and who are now in the maintenance phase of care will require full probing depths throughout the entire dentition recorded at least annually. It is important to support patients with clear advice as part of supportive periodontal care Chapter 2: Table 2.

The 2017 World Workshop on Classification of Periodontitis is useful in classifying the stage and speed of breakdown of periodontitis as part of the detailed assessment required in patients with the disease.

Question 44

New classification of periodontitis

Answer 44

describes the historical degree of periodontal breakdown (stage) and the speed of the breakdown (grade)

The BSP adaptation classifies the disease into 4 stages based on severity (I, II, III or IV) and 3 grades based on disease susceptibility (A, B or C). The stage of periodontitis cannot reduce, because the bone loss is largely irreversible, but may increase

I agree with my patients diagnosis because the greatest level of bone loss is in the apical third of the root suggesting it is ‘very severe’ and Stage 4 by BSP staging grading perio table.
More than 30% of teeth are affected suggesting it is generalised and Grade C as the amount of bone loss is greater than 1 when divided by the patients age.

Question 45

Tertiary prevention of periodontitis

Answer 45

Supportive periodontal care (SPC) after treatment for periodontitis

Periodontitis is a chronic disease that will recur and worsen without good plaque control.
This is the basis for providing SPC, which involves a long-term commitment from the patient and an intensive level of support, monitoring and care from the dental team.

Question 46

Components of SPC include:

Answer 46

1. setting expectations – advice about the importance of SPC and the commitment required and need for patient adherence
2. regular monitoring of plaque and gingival inflammation to guide oral hygiene advice
3. probing depths and bleeding on probing to guide: evaluation of health and stability treatment
4. OH advice Chapter 8 and behaviour change Chapter 3 intervention as appropriate;
   - debridement or (PMPR): removal of supra and subgingival plaque and calculus (PMPR)
   - RSD of pockets 5mm and deeper with bleeding on probing

Question 47

SPC and diabetes

Answer 47

In patients with type 2 diabetes, there is evidence that SPC improves metabolic control and reduces systemic inflammation

Question 48

Oral cancer

Answer 48

Risk factor - smoking over a long period of time is a higher risk factor than smoking more frequently over a short period of time

Question 49

Tooth loss definition

Answer 49

Tooth wear is the cumulative loss of mineralised tooth substance due to chemical and/or mechanical factors

Its components are:

• dental erosion (chemical loss due to exposure to either intrinsic or extrinsic non-bacterial acids)
• dental attrition (physical loss due to tooth-to-tooth contact)
• dental abrasion (physical loss caused by objects other than teeth, such as a toothbrush, hard object, or the tongue)

Question 50

Dental erosions definition

Answer 50

By definition, dental erosion is the dissolution of tooth mineral where plaque is not involved in its aetiology[footnote 4]. Remineralisation is possible only in enamel, provided there is no corresponding mechanical loss; once tissue is lost, tooth wear becomes irreversible[footnote 5]. As the condition progresses, which is not inevitable, visible changes to the tooth shape occur

Question 51

Implications of tooth wear

Answer 51

Severe tooth wear may lead to poor aesthestics and a reduced lifespan of the teeth involved.

Sensitivity is not necessarily an indication of progression.

Sensitivity occurs when there is stimuli of patent dentinal tubules, and this can occur with minimal wear, particularly in the cervical region.

Question 52

The Basic Erosive Wear Examination (BEWE) index

Answer 52

BEWE Score 1
First tooth wear signs. Initial loss of surface texture (brightness loss, opaque surface or ‘frosted glass’ appearance) but with a discrete area on the buccal (facial) surface and minimal loss of the incisal edge.

BEWE Score 2
Distinct defect. Hard tissue loss less than 50% of the surface area. Dentine is often involved. Loss of clinical crown height less than 50% from the buccal aspect.

BEWE Score 3
Hard tissue loss signs, with more than 50% of the surface area. Dentine is often involved but is not a prerequisite for a BEWE score of three. For restored teeth, the tooth wear can only be scored provided that the size of the restoration does not exceed 50%.

Question 53

Increased erosive potential of extrinsic acids occurs when there is:

Answer 53

lower pH value
lower salivary flow
lower buffering capacity (takes longer for saliva to neutralise the acid)
higher titratable acidity (more available H+ ions in solution)
lower calcium and phosphate content in saliva (influences degree of saturation)
lower fluoride content
higher temperature (that is, if drinks are warmed, erosive potential is increased)

Question 54

Saliva

Answer 54

Saliva may be a very important biological factor affecting the progression of dental erosion[footnote 26], playing a role in dilution, buffering (chemically lessening the impact) and clearance of dietary acids and supporting re-mineraliation after an erosive challenge. Patients with reduced salivary flow, of any aetiology, may therefore be at increased risk of tooth wear. Active encouragement in seeking medical support and considering saliva or medication substitutes will be important.

Question 55

Chapter 8 - oral hygiene

Oral hygiene principles for health

Answer 55

Toothbrushing is important throughout life. The overall goal is to achieve and maintain good oral hygiene as follows:

clean all tooth surfaces, and the gum line, thoroughly with a toothbrush and fluoride-containing toothpaste at least twice a day (last thing at night or before bed and one other time), spitting out the excess toothpaste
use additional cleaning aids to reach interproximal surfaces, as appropriate

The risk of dental caries (Chapter 4) and periodontal diseases (Chapter 5) can both be reduced by the practice of regular careful oral hygiene involving toothbrushing with fluoride toothpaste. The particular benefit in preventing dental caries, relates to the fluoride in toothpaste (Chapter 9). Good oral hygiene reduces the risk of periodontal diseases; however, periodontal health also requires effective interproximal plaque removal.

Question 56

Dental caries

Answer 56

For caries prevention, it is the application of fluoride in toothpaste that is the most important aspect of brushing, as fluoride helps prevent, control, and arrest caries (Chapter 2: Table 1). Higher concentration of fluoride in toothpaste leads to better caries control. Family or standard fluoride toothpaste at 1,350 to 1,500 parts per million fluoride (ppmF) is recommended, although in very young children, where the ability to control swallowing is limited, a toothpaste containing a lower amount (at least 1,000 ppmF) can be used

Question 57

Gingivitis

Answer 57

Physical removal of plaque is the important element of toothbrushing for preventing or controlling periodontal (gum) diseases for the general population (Chapter 2: Table 2). Self-care is important to maintain healthy gums and manage any gingivitis; it reduces inflammation of the gingivae. It is important to advise and instruct patients on good plaque removal from, and just into, the gingival crevice, including interdental areas, which takes around 2 minutes.

Question 58

Periodontitis

Answer 58

For people with periodontal diseases this becomes vitally important throughout the rest of life and good oral hygiene may take longer than the recommended 2 minutes. The patient’s existing method of brushing may need to be modified to clean all tooth surfaces systematically, maximise plaque removal and to brush the gum line carefully

Disclosing tablets can help to indicate areas that are being missed.

For people with extensive inflammation, it is good practice to start with toothbrushing advice, followed by interdental plaque control

Cleaning between teeth, with interdental brushes, is recommended prior to toothbrushing as a habit-forming approach, which is considered to be good practice

Question 59

Toothwear - high risk

Answer 59

Higher risk of tooth wear
For those at higher risk, changing to a low abrasive toothpaste or specially reformulated toothpaste for tooth wear alone may be considered

Question 60

Advice for those with evidence of periodontitis or higher risk (secondary and tertiary prevention)

Answer 60

Advice should include the following:

• cleaning at the gum level is particularly important for people with experience of periodontitis
• interdental cleaning aids help reach interproximal surfaces and it may possibly be helpful to use them before toothbrushing
• in general, people with, or treated for, periodontitis will have larger interdental spaces due to tissue loss, and should use interdental brushes, which are more effective than dental floss or tape
• the interdental brush should fit snuggly in the interdental space; therefore, many people with periodontitis will require different sizes for smaller and larger spaces – where the teeth are closer together, floss or tape can be used for interdental cleaning
• regular re-evaluation of oral hygiene will be helpful for some patients with appropriate level of support from dental professionals

Question 61

Chapter 9 - Fluoride and dental caries prevention

Answer 61

Regular exposure to fluoride maintains a concentration in the plaque biofilm that encourages remineralisation of the tooth surface. This can be achieved by a range of methods, but similar principles apply to all. Fluoride delivery using vehicles that can be incorporated into aspects of everyday living are more likely to be effective and they avoid increasing inequalities.

Question 62

Fluoride varnish

Answer 62

The dental caries-preventive effectiveness of fluoride varnish in both permanent and primary dentitions is clear

Several systematic reviews conclude that applications twice a year produce an average reduction in dental caries increment of 37% in the primary and 43% in the permanent dentition