Prevention

Introduction

This article discusses how to prevent dental disease by applying our current knowledge to the population as a whole.

As a profession, we need to rethink what we do as well as what we don’t do. We need a comprehensive strategy, which is sadly lacking from both the government and the representatives of the dental profession.

Prevention has long been the holy grail of medical and dental care for humans, and has a long history dating back at least to Edward Jenner’s vaccination discoveries at the end of the 18th century to prevent smallpox. Since then, many vaccines have been developed against a long list of diseases. Despite this, we do not currently have workable vaccines to prevent the two most common dental diseases: caries and periodontal disease.

Two models of care for patients can be considered. The ideal is called ‘upstream’, when we apply all the available preventive measures to prevent disease developing in the first place before potential patients drift ‘downstream’, when they are rescued and we try to treat the diseases that have occurred. However many resources of people, time and money we throw at treatment, it can never be enough or as good as well designed, targeted preventive programmes. This has been recognised at last by the health minister, Matthew Hancock. Time alone will tell whether he can deliver the necessary changes to achieve an upstream model of healthcare in the UK.

We know that caries can be controlled by limiting the amount and frequency of sugar consumption as well as by adding controlled doses of fluoride ions to water and toothpaste. Both caries and periodontal disease can be controlled by effective, efficient personal removal of plaque on a daily basis. Consequently, there is a public health as well as a personal health approach to consider.

Caries

The public prevention story has depended on the addition of fluoride to toothpastes, and the ongoing advertising programmes by toothpaste and mouthwash manufacturers. On a historical note, the first ever advert shown on an independent television channel was for toothpaste. Following the McColl case in Scotland and Lord Jauncey’s judgment that water fluoridation was both safe and effective, the 1985 Water (Fluoridation) Act was passed, giving health authorities the power to request water suppliers to implement this public health measure. To date, no new areas have been fluoridated although some authorities have put in a great deal of effort. Unfortunately, given the widespread, vocal and (at times) ill-informed public opposition, I believe it is unlikely that further fluoridation schemes will ever be implemented.

Government departments in the constituent countries of the UK have a role to play in prevention such as instituting the soft drinks sugar levy, removing confectionary displays at supermarket checkout lines and its publication of Childhood Obesity:

A Plan for Action – Chapter 2 in June 2018. It remains to be seen what effect this will have on reducing the statistic that nearly a quarter of five year olds have decayed teeth and the problem is worse in some areas. At the very least, these areas should be targeted first. It cannot be appropriate that the most common reason for hospitalisation for general anaesthesia in children is for dental extractions, with numbers growing annually.

We need to ask ourselves why this is. How often do we see children in the street, some in pushchairs, eating from a whole packet of sweets? This is a recipe for rampant caries. The population at large does not know better; we, as a profession, have not taught them. Exhortations to consume less sugar miss the point because we are not explaining why. It is important to get the message across that eating one sweet after another simply bathes teeth in acid. The Stephan pH curve shows that tooth decalcifying acids are produced within 2–3 minutes of sugar intake and persist for about 20 minutes, but the implications for continuous eating of sweets are not in the public domain. They should be.

This leaves:

• Local dental public health campaigns such as the ones I developed in Salisbury 30 years ago. By agreement with my consultant gynaecologist colleagues, a dental health educator visited antenatal classes to explain how to prevent caries in children, supplemented by a suitable leaflet for all the new parents. Such approaches have the advantage of teaching prevention at a time when the audience is receptive to messages.
• Changing the basic science teaching in schools to add modules about teeth, dental diseases and their prevention.
• If public dental awareness is limited in its impact, then we have to focus on improving personal dental awareness in those patients who do seek dental care (which inevitably means seeking ways to change personal habits) and attracting those who do not seek regular care. Both options are likely to be time consuming.

Cleft Palate Patients

Recent figures suggest that the incidence of cleft palates in the UK is rising from the 1 in 900 births from my student days to 1 in 600. As a result, the suggestion has been made to add folic acid to flour as a possible preventive agent.

It is pleasing to see that there are plans afoot to develop specialist centres for the care of these children by teams consisting of maxillofacial surgeons, plastic surgeons, speech therapists, paedodontists and general dentists. However, I feel this team is inadequate. One of the most important aspects of care is preserving an intact dentition. When I was treating these patients, those children who had had teeth extracted to treat caries turned from potentially difficult cases to near nightmares because there was a mistaken perception among some parents that sweets were in some way a compensation for these disabilities.

How might prevention best be achieved? I propose a cheap solution: employ a fulltime dental health educator and make sure parents see this member of the team on each appointment. The costs for the additional staff member (on a salary of £20,000 per annum) would be easily offset by the enormous savings gained with regard to travelling costs to appointments and time off work for parents, lost school time for children, restorative materials, admissions for extractions under general anaesthesia and the added opportunity costs* of professional time when treatment becomes more complex as a direct result of preventable tooth loss.

*If you have to do something twice, then you need to factor in not only the time it takes to make corrections but also the time lost from the previous treatment. Consequently, when charging £100 per hour, the real loss is £200.

Diabetic Patients

We have known for 90 years that patients with diabetes are at greater risk of developing periodontal disease than non-diabetics and for 10 years that if periodontal disease is controlled, then the requirements for drug therapy in this group can fall. Despite this, when I talk to doctors, they have no idea about this relationship and are not advising their diabetic patients to seek dental care or sharing glycated haemoglobin (HbA1C) results with their patient’s general dental practitioner (GDP). This needs to change. What about a simple poster campaign in each doctor’s surgery and a requirement that diabetics are advised to seek dental advice if they have not already done so? We, as dentists, need to go further and should ask for HbA1C results from each patient’s doctor as another monitoring tool.

Periodontal Disease

In respect of periodontal disease, the basic periodontal examination (BPE) has been in place for about 20 years but in truth, this is just a screening rather than a sufficiently detailed system of defining periodontal disease. Just collecting these data is not enough. We are in a digital age with increasing patient awareness and understanding (particularly if we have given timely, coherent and clear advice, both orally and in writing).

By way of example, my cousin’s wife has type 2 diabetes with ongoing high HbA1C levels indicating that she is at risk of continuing periodontal breakdown, but her dentist does not know the results of her blood tests and has not asked her about them. Worse, when she attends for regular dental checkups, she has her BPE score recorded and hears the numbers called out but is neither told what they are or what they mean. This is not how to practise prevention in such a high risk (or any) patient group.

Looking at the latest BPE score is insufficient; unless this is compared with the previous score or scores, there is no way to establish any trends (whether there is improvement, no change or deterioration). Unfortunately, dentists are generally not using this information as a teaching aid for patients. I think it should be mandatory that dentists give each patient a printout with their scores and an explanation of what the numbers mean. Otherwise, patients might think that a BPE score of two is twice as bad as a score of one. The numbers refer to different clinical entities. Perhaps the inventors of the method, Ainamo and Ainamo, should have used letters instead?

It follows that the only reliable periodontal baseline is a six point pocket measurement of every tooth. Luckily, there are now computerised charting systems for this and (more importantly), in order to remove operator bias in pocket measurement, there are electronic devices such as the Florida Probe (Gainesville, FL, US). One of the most useful prevention tools is to ask patients to bring their current toothbrush at their next visit, where they are asked to demonstrate how they brush their teeth. I find this extremely instructive. There are brushes of inappropriate size or shape for their mouth, and brushing methods with a bit here, then a bit there and no systematic method of plaque control. It is hardly surprising that wholly preventable dental problems develop over time.

Can someone please explain why the usual prescription of interspace brushes is just for two sizes: one with a larger and one with a smaller diameter? This cannot be effective. A brush that is too small will not remove all the plaque and may create a false sense of security while too large a brush can damage the soft tissues. In addition, leaving patients to decide for themselves which of the two sizes to use could be regarded as a failure in the duty of care. Among my own patients, every one has a unique pattern of interproximal bone loss and the number of different brush diameters required varies from a minimum of two to a maximum of seven.

Following a patient complaint about which brush to use where, the Spacemark Dental (Stroud, UK) computerised charting system was developed for the most commonly prescribed TePe (Malmö, Sweden) brushes. The dentist checks each interdental space manually for the correct brush size needed and then clicks on the relevant spaces on the chart in the computer program followed by the colour for the brush size required in those spaces. The program inserts these colours by the correct spaces on the chart. The chart is saved as proof that the dentist has given prevention advice.

In order to make the chart ‘patient friendly’, the program can switch from ‘dentist view’ to ‘patient view’, which means that the upper and lower left quadrants are located on the left hand side of the chart, this being what the patient sees when looking in the mirror. This chart can be printed out for the patient to take home or the patient can take a photograph of it. Each chart costs only £1 and if you are in private practice, you may choose to charge the patient a fee for this service.

Funding

A fundamental question to consider is how to fund preventive care. There are two principal methods of funding dentistry:

• Fee per item of service: This has the advantage that it is easy to fund and monitor, but only where there is physical evidence in the patient’s mouth. On the otherhand, it can lead to overtreatment. Another disadvantage is that prevention is hard to prove. Furthermore, it is easy for public funders to reduce the individual fee, leading to a downward spiral of working faster for less to maintain income, and it takes no account of the difficulties of either the dentition or the individual patient in providing that service.
• Capitation: This blanket fee to cover all treatment requirements can result in undertreatment and ‘supervised neglect’ if uneconomic treatments are required.

The real issue is one of time. How can you devise a scheme that allows professionals to spend more time on a more difficult procedure or patient and be remunerated appropriately for their expertise? I am not an advocate of the ‘swings and roundabouts’ concept – one size cannot fit all.

Record Keeping

Traditionally, when patients change their dentist, the new GDP starts again from scratch and does not have access to previous records. This is in contrast to the medical setting, where doctors’ records follow the patient. I believe it should be mandatory that copies of previous records are sent between colleagues. It might even reduce the number of complaints along the lines of: ‘My old dentist said I was OK but you have found
X problems.’

In this digital age where patients can easily access their own records (thanks to the Access to Health Records Act 1990), each patient should have a CD with all their charts, pocket measurements etc. This CD would be updated at each visit so the patient can also see what is happening in their mouth. If they change their GDP, the information from the CD can be uploaded on the new dentist’s computer to continue the monitoring process.

My Ten Point Prevention Plan:

1. Target nursing mothers and use a dental health educator at antenatal clinics.
2. Devise and circulate leaflets showing the Stephan pH curve with the damaging effects of constant sugar consumption.
3. Develop a dental module for science teaching in schools.
4. Recruit a dental health educator into the cleft palate teams.
5. Prepare a poster campaign for doctors’ surgeries about diabetic patients needing to see a dentist, and make it a requirement that doctors advise diabetics about the link between their condition and periodontal disease.
6. Make it a requirement of NHS dental examinations that brushing techniques are checked.
7. Make it a requirement that each patient receives a printout of the current and previous BPE scores with an explanation of the results.
8. Stop prescribing just two sizes of interspace brush, and customise brush sizes for each space (and yes, I know I have an interest to declare here as the inventor of the Spacemark Dental chart!).
9. Make it a requirement that copies of NHS dental notes are sent from the previous to the new GDP.
10. The Department of Health needs to publicise the upstream/downstream models of care and use them to explain to the public why there will never be enough resources to treat all the diseases of modern lifestyles in the absence of individuals taking more responsibility for their own health.

Summary

The aim of this article was to open up the debate about prevention. As a profession, we need to rethink what we do as well as what we don’t do. We need a comprehensive strategy, which is sadly lacking from both the government and representatives of the dental profession.

We still have a long way to go to achieve Aneurin Bevan’s original concept of a national health service. All we have achieved is NITS – an Illness Treatment Service, where the N stands not for ‘National’ but ‘Notional’, dependant on a postcode lottery and the professional knowledge and ability of the clinician providing the treatment.

The issue is quite clear and has been known for a long time. If we can persuade, educate and control personal plaque levels, then we can prevent the two most common dental diseases.