Community Based F delivery Flashcards
effect of F dentally
systemic Vs topical effect
Original belief
- Beneficial effect of F- was its systemic pre-eruptive effect (strengthening enamel during tooth development)
BUT
Dental caries
dynamic process of demineralisation and remineralisation
- Therefore – constant supply of fluoride in oral cavity is most important factor to inhibit demineralisation and encourage reminerlisation
now recognised as primary mode of action of F
in reducing dental caries = post-eruptive
i.e. topical effect
vehicles for F delivery (7)
water
salt
milk
varnishes/gels
rinses
supplements i.e. drops/tablets
toothpaste
Fluoridated salt
First introduced - Switzerland (1955)
- Subsequently used in France, Colombia, Spain & Hungary + others (1960’s onwards)
Switzerland
(90mgF/kg) -> 25% caries reduction after 12 yrs
Hungary
(250-350 mgF/kg) -> 53-68% caries reduction after 10 yrs use
Previously considered most important community F- delivery system, other than water F-
- 2nd to water-F- as means of ensuring ingestion of F-
Caries-preventive effect comparable to that of water fluoridation
- Requires little conscious action by the individual
0 Provides element of choice/ but public health effectiveness diminished
disadvantages of F salt community strategy
In communities with small levels of water F- need for varying levels of F- in salt
- (? Logistics – manufacturers + distributors)
Mixed messages from health professionals
- risk of cardiovascular disease
F milk
Some public health programmes carried out (Mainly school-children)
Glasgow : 1976-1981 (1.5mg in 200ml)
- 48% diff. Mean DMFS between cases and controls
N.W. England: 1997-2001 (0.5mg in 189ml)
- No caries reduction in primary dentition (children aged 3-5 yrs) and only small reduction in permanent dentition up to 8 yrs of age (not clinically significant)
potential factors influencing results of Fluoridated Milk schemes (6)
Age at commencement
Population
F- concentration
Frequency of use
Distribution system
Compliance/drop out rate
advantages of F milk (3)
Natural healthy drink for children
Important part of child’s diet – rich in nutrients
Enables fluoride to be targeted to those who would benefit most
disadvantages of F milk
Distribution delayed until nursery/school age
Not all children drink milk
Distribution system/shelf life/cost issues (higher than water F-)
? lack of long term benefit
APF gels
acidulated phosphate fluoride gels
APF gels application
Professionally applied (or self-applied under supervision)
operator-applied fluoride gels use trays and self-applied gels use either a tray or a toothbrush
Time consuming to apply (approx. 30 mins) – up to x2 / year
Special equipment necessary, i.e. custom-made trays
High cost per tooth surface saved (£11)
APF gels F concentration
12,300 ppm
Fluoride gels must be differentiated from some fluoride toothpastes,
The ‘classical’ fluoride gels do not contain abrasives, their fluoride concentration is usually much higher than that of a fluoride toothpaste, and they are applied at relatively infrequent intervals
Acute toxicity risk
- if ingested - causes sickness (not uncommon = not recommended for young children)
probable toxic dose (PTD) of 100 mg of fluoride for a 20 kg (5-6 year-old) child is contained in only 8 ml volumes of these gels.
- Approximately 5 ml of gel is used in a topical application of APF gel in a tray
representing a potential exposure of 61.5 mg of fluoride ion
F mouth rinses
Early studies (1960’s-1970’s) effectiveness in caries reduction.
Since caries decline (1970’s), doubts about marginal benefit + cost effectiveness
Reasonable to use F- mouthrinsing in high-caries-risk populations. Benefit doubtful in low-risk groups
Not recommended for <7 yr. olds
F supplements (tablets/drops)
In use since 1940’s
Originally used :
birth to 6 yrs (previous belief in importance of systemic effect).
Later :
Proven post-eruptive topical cariostatic benefits in school-aged children > 5.5 yrs old
Systemic effect much less important than topical effect
therefore appropriate to advise continuation beyond 6yrs old for at-risk children (with additional needs / special care requirements)
F supplement dosage in Area with water F- <0.3 ppm fluoride
Age mg F- per day 0 - 6 months 0 6 months - 3 yrs 0.25 3 yrs - 6 yrs 0.50 6 yrs and over 1.00
F supplements advice now
Agreed now :
Pop. level - Tends to be poor compliance
not suitable as public health measure (Best results in school-based programmes)
- Should be directed towards “at-risk” children only
- Careful assessment of risks and benefits for children <7yrs old, i.e. risk of fluorosis
F varnish
designed to hold F- in close contact with tooth for a period of time
Proven efficacy in caries prevention via systematic reviews
(Marinho : dmfs PF = 33% in primary teeth)
PF = Incidence in Exposed – Incidence in Unexposed.
F varnish evidence
Cochrane Review 1 (Marinho et al. 2002)
- F Varnish effective for preventing decay – in patients and communities
But, more research needed
Cochrane Review 2 (Hiiri et al. 2010)
- F Varnish vs Fissure sealants
- Ltd evidence
Cochrane Review 3 (Marinho et al 2013)
- substantial caries inhibiting effect of FV in both permanent and primary teeth.
- quality of evidence moderate
SDCEP guidance on managing and preventing dental caries in children
F varnish application
professionally applied
Need to be reapplied at regular intervals
Emerging consensus re. optimum application frequency (2-4/year depending on caries risk)
- ? Cost-effectiveness
Major component of Childsmile
F toothpaste
Most widely used fluoride delivery vehicle in the world
500m of world’s pop. use F- toothpaste
Considered as single most important factor in caries decline
- Caries decline - late 70’s/early 80’s
- Sale of F- toothpaste - <5% in 1970 to >95% in 1977.
Fluoride toothpaste/brushing factors (4)
(A) Concentration (amount) of fluoride
(B) Frequency of brushing
(C) Age at commencement of brushing
(D) Post-brushing rinsing
[age, specific guidance – children / adults]
Concentration of F in toothpaste
Evidence of dose-response relationship re. caries-preventive effect
Findings : Each additional 500ppmF- over & above 1000ppmF = a cumulative 6% reduction in caries increment.
Evidence from Systematic Reviews -
- Cochrane Review (2001) : - 8% increase in DMFS prevented fraction per 1000ppmF-
- Swedish Review (2003): - Mean diff. in DMFS prevented fraction between 1500ppm & 1000ppm of 9.7%
PF = DMFS Incidence in Exposed - Unexposed
Limited evidence for caries-preventive effect of toothpaste with = 550ppmF-
Colgate children’s toothpaste + Macleans Milk Teeth
- traditionally 500ppmF-.
- more recently 1000ppmF-
Controversy re. F- dose for young children
- tendency to swallow toothpaste so risk of fluorosis
BUT - Loss of caries-preventive efficacy with 500ppmF- and lower
- Balance risk of fluorosis with benefit in caries reduction
Current evidence (no water F-) : - 1500ppmF- toothpaste & limit to pea-sized amount or smear
amount of F toothpaste on dry toothbrush
smear 0-2 (half brush length smear)
pea size 2+
frequency of brushing with F toothpaste
Good evidence from Systematic Reviews
= Morinho et al (2010) Cochrane Review
that effect of F- toothpaste inc with higher freq. of use
(i.e. 14% increase in DMFS ‘prevented fraction’ with twice-daily brushing as opposed to once daily).
Current advice = brush at least twice daily
- Pre-school children using 1500ppmF-
- Regulate quantity of toothpaste to smear or pea-sized amount
- Parental help/supervision to avoid swallowing
age at commencing brushing with F tootpaste
Agreed that toothbrushing should commence as soon as primary teeth erupt
- Approx. 6 months – could have a baby used to toothbrush in mouth prior and then introduce F toothpaste
Evidence :
“among children with visible plaque evident at visual examination at one year of age, 29% developed carious lesions by two years of age and 54% by three years of age”. (Wendt, 1994)
post brushing rinsing
Current advice for parents/children:
- Spit out excess toothpaste
- Refrain from rinsing with water post-brushing
Main evidence :
A) Swedish RCT : dec rinsing water + not eating for 2 hours post-brushing decreased amt.+ rate of fluoride removal from the mouth.
B) Scottish RCT : Caries increment using beaker = 6.84 vs. 5.84 without beaker (p<0.05)
Toothpaste adverse effects
Dental fluorosis risk - only upper anterior and canines (enamel formed in first 3 years of life)
Sig risk reduction start brushing after 12 mths
No sig risk depending on brushing freq.
F conc. >1000ppm marginally sig risk
- But ltd evidence
Precautionary advice – risk caries higher than risk fluorosis
policy developments in scotland
childsmile, oral health plan
england policy developments
oral health toolkit from Public Health England
main recommendations sources
SIGN Guidelines : http://www.sign.ac.uk/guidelines/fulltext/138/
SDCEP guidance http://www.sdcep.org.uk/published-guidance/caries-in-children/
Childsmile core
Toothbrushing Programme
Oral health pack given to children in 1st year of life, at age 3 (2 packs), 4 (2 packs) and 5 (1 pack)
All nursery schools (local authority and private) invited to participate in daily supervised brushing programme
All primary schools in most deprived local SIMD quintile invited to participate in daily supervised brushing programme (P1 & P2)
integrated childsmile programme
childsmile core
childsmile practice
childsmile nursery and school
childsmile practice
Principal Objectives:
- Raising parental awareness of good oral health behaviours and supporting parents to put them into practice
- Increasing the provision of oral health promotion and clinical prevention within dental primary care
- Every newborn routinely linked to CS via Health Visitor/ PHN
Oral health advice & clinical prevention via Primary Care Dental Services (team approach involving EDDNs)
Families requiring additional support to receive enhanced home/ community visiting via DHSW
Link families to community health improvement activity
childsmile nursery and school
Targeted to priority nurseries and primary schools (SIMD-based)
Programme of 6 monthly F varnish applications throughout nursery and primary school (via EDDNs)
Fissure sealants: (pilot NHS Fife)
Follow-up of children who are not regular GDS/CDS attenders
childsmile approach - 2 types
population
targeted
population childsmile approach
Core programme e.g. dental packs, nursery toothbrushing
Tailored programme of care within Primary Care Dental Services
targeted childsmile approach
Additional home/community support via DHSW
Enhanced programme of care within Primary Care Dental Services
Additional clinical preventive programmes targeting 20% highest need nursery and primary schools
Supervised toothbrushing P1 and P2 targeting 20% highest need primary schools (extended in some areas)
