Prevention Flashcards
Define 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.
What does it mean if the GDG makes a strong recommendation?
The GDG is highly confident that desirable consequences outweigh undesirable or undesirable consequences outweigh desirable, typically based on high or moderate certainty evidence.
What does it mean if GDG makes condtional recommendation?
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.
What does the GDG mean by ‘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
All children aged up to 3 years
Advice:
For parents or carers feeding babies by bottle:
• only breastmilk, infant formula or cooled boiled water should be given in a bottle
• babies should be introduced to drinking from a free-flow cup from the age of 6 months
• feeding from a bottle should be discouraged from the age of 1 year
Strength of recommendation?
Strong
All children aged up to 3 years
Advice:
For parents or carers feeding babies by bottle:
• only breastmilk, infant formula or cooled boiled water should be given in a bottle
• babies should be introduced to drinking from a free-flow cup from the age of 6 months
• feeding from a bottle should be discouraged from the age of 1 year
Strength of recommendation?
Good practice
All children aged up to 3 years
Advice
Gradually introduce a wide variety of solid foods (of different textures and flavours) from around the age of 6 months. Sugar should not be added to food or drinks given to babies and toddlers
Strength of recommendation?
Good practice
All children aged up to 3 years
Advice:
Parents or carers should brush their children’s teeth:
• as soon as they erupt
• twice a day
• last thing at night (or before bedtime) and on one other occasion
• with a toothpaste containing at least 1000 ppm fluoride
• using only a smear of toothpaste
Strength of recommendation?
Strong
All children aged up to 3 years
Advice:
Minimise consumption of sugar-containing foods and drinks
Strength of recommendation?
Strong
All children aged up to 3 years
Advice:
Use sugar-free versions of medicines if possible
Strength of recommendation?
Good practice
All children aged up to 3 years
Advice:
Avoid sugar-containing foods and drinks at bedtime when saliva flow is reduced and buffering capacity is lost
Strength of recommendation?
Good practice
All children aged up to 3 years
Professional intervention:
Assign a recall interval ranging from 3 to 12 months based on oral health needs and disease risk
Strength of recommendation?
Conditional
All children aged 3 to 6 years
Advice:
Teeth should be brushed by a parent or carer. As the child gets older, a parent or carer should assist them to brush their own teeth:
• on all tooth surfaces
• at least twice a day
• last thing at night (or before bedtime) and on at least one other occasion
• with toothpaste containing at least 1,000 ppm fluoride
• using a pea-sized amount of the toothpaste
• spitting out after brushing rather than rinsing, to avoid diluting the fluoride concentration
Strength of recommendation?
Strong
All children aged 3 to 6 years
Advice:
Minimise amount and frequency of consumption of sugar-containing food and drinks
Strength of recommendation?
Strong
All children aged 3 to 6 years
Advice:
Use sugar-free versions of medicines if possible
Strength of recommendation?
Good practice
All children aged 3 to 6 years
Professional intervention:
Apply fluoride varnish (2.26% NaF) to teeth 2 times a year
Strength of recommendation?
Strong
All children aged 3 to 6 years
Professional intervention:
Assign a recall interval ranging from 3 to 12 months based on oral health needs and disease risk
Strength of recommendation?
Conditional
Children aged 0 to 6 years giving concern because of dental caries risk
Advice:
Use toothpaste containing 1,350 to 1,500 ppm fluoride
Strength of recommendation?
Strong
Children aged 0 to 6 years giving concern because of dental caries risk
Advice:
For children taking medication frequently or long term, choose or request sugar-free medicines if possible
Strength of recommendation?
Good practice
Children aged 0 to 6 years giving concern because of dental caries risk
Proessional intervention:
Where the child is prescribed medication frequently or long term, liaise with medical practitioner to request that it is sugar free
Strength of recommendation?
Good practice
Children aged 0 to 6 years giving concern because of dental caries risk
Proessional intervention:
Investigate diet and assist adoption of good dietary practice in line with the Eatwell Guide
Strength of recommendation?
Good practice
Children aged 0 to 6 years giving concern because of dental caries risk
Proessional intervention:
Assign a shortened recall interval based on dental caries risk
Strength of recommendation?
Conditional
All children from 7 years and young people up to 18 years
Advice:
Brush teeth at least twice daily (with assistance from parent or carer if required):
• last thing at night (or before bedtime) and on at least one other occasion
• with toothpaste containing 1,350 to 1,500 ppm fluoride
• spitting out after brushing rather than rinsing with water, to avoid diluting the fluoride concentration
Strength of recommendation?
Strong
All children from 7 years and young people up to 18 years
Advice:
Minimise amount and frequency of consumption of sugar-containing food and drinks
Strength of recommendation?
Strong
All children from 7 years and young people up to 18 years
Advice:
Avoid sugar-containing foods and drinks at bedtime when saliva flow is reduced and buffering capacity is lost
Strength of recommendation?
Conditional
All children from 7 years and young people up to 18 years
Professional intervention:
Apply fluoride varnish to teeth 2 times a year (2.26% NaF)
Strength of recommendation?
Strong
All children from 7 years and young people up to 18 years
Professional intervention:
Assign a recall interval within the range of 3 to 12 months based on oral health needs and disease risk
Strength of recommendation?
Conditional
Children from 7 years and young people up to 18 years giving concern because of dental caries risk
Advice:
Parent or carer to assist and supervise toothbrushing if required
Strength of recommendation?
Good practice
Children from 7 years and young people up to 18 years giving concern because of dental caries risk
Advice:
Use a fluoride mouth rinse daily (0.05% NaF; 230 ppmF) at a different time to brushing
Strength of recommendation?
Conditional
Children from 7 years and young people up to 18 years giving concern because of dental caries risk
Professional intervention:
Apply resin sealant to permanent teeth on eruption
Strength of recommendation?
Strong
Children from 7 years and young people up to 18 years giving concern because of dental caries risk
Professional intervention:
Apply fluoride varnish to teeth 2 or more times a year (2.26% NaF)
Strength of recommendation?
Strong
Children from 7 years and young people up to 18 years giving concern because of dental caries risk
Professional intervention:
For those 8 years and above with active dental caries, consider recommending or prescribing daily fluoride mouth rinse (0.05% NaF; 230ppm F), to be used at a different time from brushing, until dental caries risk is reduced
Strength of recommendation?
Conditional
Children from 7 years and young people up to 18 years giving concern because of dental caries risk
Professional intervention:
For those 10 years and above with active dental caries, consider prescribing 2,800ppm fluoride toothpaste until dental caries risk is reduced
Strength of recommendation?
Conditional
Children from 7 years and young people up to 18 years giving concern because of dental caries risk
Professional intervention:
For those 16 years and above with active dental caries, consider prescribing either 2,800ppm or 5,000ppm fluoride toothpaste until dental caries risk is reduced
Strength of recommendation?
Conditional
Children from 7 years and young people up to 18 years giving concern because of dental caries risk
Professional intervention:
Where a child or young person is prescribed medication frequently or long term, liaise with medical practitioner to request that it is sugar free
Strength of recommendation?
Good practice
Children from 7 years and young people up to 18 years giving concern because of dental caries risk
Professional intervention:
Investigate diet and assist adoption of good dietary practice in line with the Eatwell Guide
Strength of recommendation?
Good practice
Children from 7 years and young people up to 18 years giving concern because of dental caries risk
Professional intervention:
Assign a shortened recall interval based on dental caries risk
Strength of recommendation?
Conditional
All adults
Advice:
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
Strength of recommendation?
Strong
All adults
Advice:
Minimise the amount and frequency of consumption of sugar-containing food and drinks
Strength of recommendation?
Strong
All adults
Advice:
Avoid sugar-containing foods and drinks at bedtime when saliva flow is reduced and buffering capacity is lost
Strength of recommendation?
Conditional
All adults
Professional intervention:
Assign a recall interval ranging from 3 to 24 months, based on oral health needs and disease risk
Strength of recommendation?
Conditional
Adults giving concern because of dental caries risk
Advice:
Support toothbrushing where required (for example carer assistance, specialised brush, non-foaming toothpaste)
Strength of recommendation?
Good practice
Adults giving concern because of dental caries risk
Advice:
Use a fluoride mouth rinse daily (0.05% NaF; 230 ppmF) at a different time to toothbrushing
Strength of recommendation?
Conditional
Adults giving concern because of dental caries risk
Professional intervention:
Apply fluoride varnish to teeth 2 times a year (2.26% NaF)
Strength of recommendation?
Strong
Adults giving concern because of dental caries risk
Professional intervention:
For those with active coronal or root caries, consider recommending or prescribing daily fluoride rinse (0.05% NaF; 230 ppmF, to be used at a different time from toothbrushing) until dental caries risk is reduced
Strength of recommendation?
Conditional
Adults giving concern because of dental caries risk
Professional intervention:
For those with obvious active coronal or root caries, consider prescribing 2,800 or 5,000ppm fluoride toothpaste until dental caries is stabilised and risk is reduced
Strength of recommendation?
Conditional
Adults giving concern because of dental caries risk
Professional intervention:
Investigate diet and assist adoption of good dietary practice in line with the Eatwell Guide
Strength of recommendation?
Good practice
Adults giving concern because of dental caries risk
Professional intervention:
Assign a shortened recall interval based on dental caries risk
Strength of recommendation?
Conditional
Adults giving concern because of dental caries risk
Professional intervention:
Assign a shortened recall interval based on dental caries risk
Strength of recommendation?
Conditional
All patients
Advice:
Self-care plaque removal:
- daily, effective plaque removal is critical to periodontal health
Strength of recommendation?
Conditional
All patients
Advice:
Self-care plaque removal:
- 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
Strength of recommendation?
Good practice
All patients
Advice:
Toothbrushing and toothpaste:
- brush gum line and each tooth at least twice daily (last thing at night or before bedtime and on at least one other occasion)
Strength of recommendation?
Conditional
All patients
Advice:
Toothbrushing and toothpaste:
- brush gum line and each tooth at least twice daily (last thing at night or before bedtime and on at least one other occasion)
Strength of recommendation?
Conditional
All patients
Advice:
Toothbrush type
- use a manual or powered toothbrush
Strength of recommendation?
Strong
All patients
Advice:
Toothbrush type
- use a small toothbrush head, medium texture
Strength of recommendation?
Conditional
All patients
Advice:
Around orthodontic appliances and bridges, plaque control should be undertaken using the aids suggested by the orthodontic or dental team
Strength of recommendation?
Good practice
All patients
Professional intervention:
Use behaviour change methods with oral hygiene instruction
Strength of recommendation?
Conditional
All patients
Professional intervention:
Correct factors that impede effective plaque control including supra and subgingival calculus, open margins and restoration overhangs and contours, which prevent effective plaque removal
Strength of recommendation?
Good practice
All patients
Professional intervention:
For people with extensive inflammation, start with toothbrushing advice, followed by interdental plaque control
Strength of recommendation?
Good practice
All patients
Professional intervention:
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
Strength of recommendation?
Good practice
All adults (and young people aged 12 to 17 years with evidence of periodontal disease)
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
Strength of recommendation?
Conditional
All adults (and young people aged 12 to 17 years with evidence of periodontal disease)
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
Strength of recommendation?
Good practice
All adults with dental implants
Advice:
Dental implants require the same level of oral hygiene and maintenance as natural teeth
Strength of recommendation?
Good practice
All adults with dental implants
Advice:
Clean around and between implants carefully with interdental aids and toothbrushes
Strength of recommendation?
Conditional
All adults with dental implants
Advice:
Attend for regular checks of the health of gum and bone around implants
Strength of recommendation?
Conditional
Control of specific risks for periodontitis
Professional intervention:
Ask, Advise, Act: at every opportunity, ask patients if they smoke and record smoking status, advise on the most effective way of quitting and act on patient response, such as refer to local stop smoking support (see Table 3 tobacco section of oral cancer below for more detail)
Strength of recommendation?
Strong
Control of specific risks for periodontitis
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
Strength of recommendation?
Conditional
Control of specific risks for periodontitis
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)
Strength of recommendation?
Good practice
Control of specific risks for periodontitis
Advice
Some medications can affect gingival health
Strength of recommendation?
Strong
Control of specific risks for periodontitis
Professional intervention:
For patients who use medications that cause dry mouth or gingival enlargement:
- explain oral health findings and risk related to medication
- assess and discuss clinical management (see Chapter 5)
Strength of recommendation?
Good practice
All adults and young people
Professional intervention
Ask, advise, act on patients’ tobacco use
Strength of recommendation?
Strong
All adults and young people
Ask
At every opportunity, ask patients if they smoke and record smoking status (smoker, ex-smoker, never smoker)
Strength of recommendation?
Strong
For those who smoke
Advise
Explain that a combination of behavioural support and the medication varenicline, or short-acting with long-acting Nicotine Replacement Therapy, are likely to be most effective.
Strength of recommendation?
Strong
For those who smoke
Act
Act on patient response:
- refer people who want to stop smoking to local stop smoking support, preferably where behavioural support and prescribed stop smoking medicines are available.
Strength of recommendation?
Strong
For those who smoke
Act
Acknowledge that e-cigarettes may be helpful for some smokers for quitting or reducing smoking.
Strength of recommendation?
Conditional
For those use smokeless tobacco
Ask
Ask patients if they use smokeless tobacco, using the names that the various products are known by locally. It may be helpful to show a picture of what the products look like (Chapter 11).
Strength of recommendation?
Strong
For those use smokeless tobacco
Advise
If someone uses smokeless tobacco, ensure they are aware of the health risks and provide very brief advice.
Strength of recommendation?
Strong
For those use smokeless tobacco
Act
Refer patients who want to quit to specialist support services.
Strength of recommendation?
Strong
All adults and young people
Ask
Use the AUDIT-C tool (or similar) to assess a patient’s level of risk of alcohol harm by completing 3 consumption questions:
Strength of recommendation?
Strong
All adults and young people
Advise and Act
If AUDIT C score is 4 or below, give positive feedback and encourage your patient to keep their drinking at lower risk levels.
If score is 5 to 10, give brief advice to encourage a reduction in alcohol consumption and reduce the risk of alcohol harm.
Feedback to the patient that their level of drinking is putting them at risk of developing a range of health problems (including cancers of the mouth, throat and breast) and this increases the more you drink and the more frequently you drink.
Highlight ‘low risk’ guidelines for alcohol consumption from UK Chief Medical Officers:
- to keep health risks from alcohol to a low level, it is safest not to drink more than 14 units a week on a regular basis
- if you regularly drink as much as 14 units per week, it’s best to spread your drinking evenly over 3 or more days
- if you wish to cut down the amount you drink, a good way to help achieve this is to have several drink-free days a week
- Give a leaflet
Strength of recommendation?
Strong
All adults and young people
Advise and Act
For those who are pregnant or think they could become pregnant, the safest approach is not to drink alcohol at all, to remove the risk of alcohol-related harm to the baby.
Strength of recommendation?
Strong
All adults and young people
Recommendation
Promote increased consumption of non-starchy vegetables and fruit.
Strength of recommendation?
Good practice
All patients (with and without teeth)
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.
Strength of recommendation?
Good practice
All patients (with and without teeth)
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.
Strength of recommendation?
Good practice
All patients (those giving concern)
Recommendation:
In line with national referral recommendations, patients should be referred on an urgent or suspected cancer pathway if they have any of the following:
- an unexplained ulceration in the oral cavity lasting for more than 3 weeks
- a persistent and unexplained lump in the neck
- a lump on the lip (inner or outer) or in the oral cavity consistent with oral cancer
- a red patch in the oral cavity consistent with erythroplakia
- a red and white patch in the oral cavity consistent with erythroleukoplakia
- persistent unexplained hoarseness
- persistent pain in the throat or pain on swallowing lasting for more than 3 weeks
Strength of recommendation?
Good practice
All patients (those giving concern)
Recommendation:
It’s not recommended to use vital staining, oral cytology or light‐based detection and/or oral spectroscopy for evaluating lesions for malignancy.
Strength of recommendation?
Strong
All patients
Recommendation:
Maintain standard oral hygiene practices.
Strength of recommendation?
Good practice for preventing tooth wear
All patients
Recommendation:
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
Strength of recommendation?
Strong recommendation for preventing dental caries
All patients
Recommendation:
Maintain good dietary practice in line with the Eatwell Guide including avoiding or minimising sugar sweetened drinks (especially carbonated) and fruit juice and/or smoothies (limited to 150ml per day).
Strength of recommendation?
Good practice
All patients
Recommendation:
Assess tooth wear using a validated tool (for example Basic Erosive Wear Examination (BEWE) at the start of any new course of treatment.
Strength of recommendation?
Good practice
Patients at higher risk (those with accelerated tooth wear)
Recommendation:
- Identify possible sources of risk: intrinsic, extrinsic and mechanical (see Chapter 7).
- Support patient in risk reduction and management.
Strength of recommendation?
Good practice
What is the percentage equivalent of sodium fluoride 2,800 ppm fluoride toothpaste
0.619% (2.8 mg per gram)
