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National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people


Chapter 8: Oral and dental health
☰ Table of contents


Recommendations: Oral and dental health

Preventive intervention type

Who is at risk?

What should be done?

How often?

Level/ strength of evidence

References

Screening

Children aged 0–5 years Undertake an oral health review including the assessment of teeth, gums and oral mucosa, as part of a regular health check (Box 1)



 
Opportunistic and as part of an annual health check GPP 8
People aged 6–18 years Annually GPP 9
Adults with poor oral health and/or risk factors for dental disease (Box 2)

People with diabetes, immunosuppression, haematological conditions, bleeding disorders or anticoagulant therapy
Annually GPP 9
All pregnant women At first antenatal visit (refer to Chapter 2: Antenatal care) GPP 8
Adults with good oral health Two-yearly GPP 9
Those with past history of rheumatic heart disease and cardiovascular abnormalities Undertake an oral health review as part of a regular health check (Box 1) and offer appropriate oral hygiene advice to minimise oral bacterial levels Six-monthly GPP 7

Chemo-prophylaxis

Children aged 0–5 years Recommend use of fluoride-containing toothpaste at least once daily, from the time the teeth start to erupt* Opportunistic IA 8, 10
Children aged 0–5 years where families have evidence of dental caries and/or poor oral hygiene Application of fluoride varnish from the age of two years, by dental team or trained GP where appropriate

If resources do not permit, then recommend daily use of fluoride toothpaste and provide dietary advice
 
At least every six months and for a period of not less than 24 months IB 4, 5, 10
People aged >5 years at high risk of dental caries (Box 2) 2–4 times per year for professional application IB 10
People at high risk of endocarditis (rheumatic heart disease, previous infective endocarditis, prosthetic cardiac valves, certain forms of congenital heart disease, cardiac transplantation) Recommend antibiotic prophylaxis prior to dental procedures – refer to management guidelines for specific advice13 Opportunistic GPP 7

Environmental

Communities Advocate for fluoridation of community water supply   IB 11,12,13
*Use a smear of paste for children aged <2 years and a pea-size amount for children ≥2years. Toothpaste with a fluoride concentration of 1000 parts per million (ppm) is recommended unless there is a risk of fluorosis.


 

Box 1. Advice for good oral health practices26

While review with dental professionals is recommended to comprehensively assess for caries risk and the presence of disease, the following general principles are recommended for non-dental professionals:

Assessment

  • Visually inspect teeth for evidence of caries, periodontal disease, assessment of maternal caries and/or poor oral hygiene
  • Assess oral hygiene practices and consumption of sucrose and sweetened drinks, especially in baby bottles, ‘honey on the dummy’ or other sweet substances such as glycerine on the dummy, and intake of sugared medicines
  • Assess access to fluoridated water supply
 

Advice

  • Brush teeth twice daily with a soft toothbrush and fluoride toothpaste and advise to spit, not rinse, excess paste
  • Advise about the hazards of high carbohydrate and acidic snacks and drinks taken between meals
  • Advise against high and regular consumption of black cola, sweetened fizzy drinks and sports drinks, with water being the preferred drink
  • Promote breastfeeding, with weaning to a baby cup, not a bottle
  • If bottles are used, advise against the use of any fluid apart from water and do not put baby to sleep with a bottle
  • Advise about smoking cessation and limiting alcohol consumption
  • Use sugar-free chewing gum for saliva stimulation
  • Use a mouth guard when playing contact sport
  • Recommend regular dental check-up

Box 2. Risk factors for dental disease

  • Poor oral hygiene practices – for example, no/irregular toothbrushing, use of hard toothbrush, no use of fluoride toothpaste, incorrect brushing technique
  • Poor diet and nutrition – for example, high and regular consumption of sucrose-and-carbohydratecontaining foods and drinks, especially black cola, sweetened fizzy drinks
  • Salivary composition and flow: if poor, there is less protective effect from saliva
  • Low exposure to fluoride
  • Xerostomia or dry mouth can also contribute to development of dental caries. Risk factors for xerostomia include use of common medications, including antidepressants, antihypertensives, anticoagulants, antiretrovirals, hypoglycaemics, non-steroidal anti-inflammatory drugs, and steroid inhalers; radiotherapy and chemotherapy for cancers of the head and neck; Sjogren’s syndrome; human immunodeficiency virus (HIV) infection; and diabetes, particularly in people with poor glycaemic control
  • High consumption of acidic foods and drinks such as sports drinks and juices, can contribute to tooth erosion; bulimia is also an erosion risk factor
  • General risk factors for periodontal disease include smoking, diabetes, advancing age, stress, and poor oral hygiene
  • Tobacco smoking and alcohol consumption are risk factors for the development of oral cancer; the risk is enhanced when smoking and alcohol consumption occur at the same time
  • HIV infection can also contribute to a greater risk of periodontal disease, oral ulceration and cancer
  • Other modifying risk factors can include age, socio-economic status and access to oral health services



Background


Poor oral and dental health can affect quality of life by causing pain, infection, difficulties with speech and eating, and embarrassment about appearance. The two main dental diseases are dental caries (tooth decay) and periodontal (gum) disease. Dental caries is a localised infection and destruction of the hard tissues of the teeth that starts when organic acids cause demineralisation of tooth enamel. Dental plaque, a complex biofilm that builds up on teeth, contains bacteria that produce acids after fermenting the carbohydrates found in food and drinks. The rate of enamel destruction increases with frequent exposure to fermentable carbohydrates and poor oral hygiene.

Dental caries is considered to be a multifactorial disease, with some of the contributing factors being diet (especially high and regular consumption of sugar and carbohydrates in food and drinks such as black cola, sweetened fizzy drinks and sports drinks), inadequate exposure to fluoride, poor oral hygiene practices, and salivary composition and flow. Xerostomia or dry mouth may also contribute to dental caries development. Risk factors for xerostomia include use of certain medications including antidepressants, antihypertensives, anticoagulants, antiretrovirals, hypoglycaemics, non-steroidal anti-inflammatory drugs, and steroid inhalers; radiotherapy and chemotherapy for cancers of the head and neck; and Sjogren’s syndrome.1 Human immunodeficiency virus (HIV) infection can also contribute to a greater risk of periodontal disease, oral ulceration and cancer.

Nationally, Aboriginal and Torres Strait Islander adults have greater levels of dental caries than non-Indigenous Australians, with higher levels of untreated caries and missing teeth and lower numbers of filled teeth. For Aboriginal and Torres Strait Islander children, the rate of current or past caries in deciduous (first) teeth and adult teeth is at least two and 1.5 times greater respectively than for non-Indigenous children. Overall, caries rates are higher in rural and remote areas compared to metropolitan areas. The proportion of untreated dental caries is higher among Aboriginal and Torres Strait Islander children, which often reflects a lack of access to dental services.2

Important general risk factors for periodontal disease include poor oral hygiene, smoking, diabetes, hormonal imbalances, poor diet, and stress. Although data are limited, the prevalence of periodontal disease appears to be greater in Aboriginal and Torres Strait peoples compared to non-Indigenous people.2 Treatment of pre-existing periodontal disease has demonstrated small but significant improvements in glycaemic control for people with type 2 diabetes, underscoring the importance of regular oral health assessments in this population. There is growing evidence to suggest periodontal disease may be associated with systemic conditions such as cardiovascular disease, stroke, obesity and cancer; however, causal links are yet to be proven. Holistic approaches to risk factor reduction that address smoking cessation, reduced sugar consumption and weight control are likely to confer multiple health benefits related to periodontal disease, dental caries, diabetes, heart disease and some cancers.3

Other major oral and dental conditions of concern are oral cancer, tooth erosion (hard tissue degradation of the teeth by acids such as those found in acidic foods and drinks, and in patients with bulimia, whose teeth are susceptible to acid attacks from frequent vomiting), and oral trauma (eg through sports injuries). Tobacco smoking and alcohol consumption are risk factors for the development of oral cancer, and the risks from these two behaviours are additive.


Interventions


Standard preventive measures against dental caries, such as twice-daily use of fluoride-containing toothpaste and minimising sugar consumption, are advised, along with referral for a professional dental check. Toothbrushing with a fluoridated toothpaste cleans the teeth and removes food particles, while the fluoride works to strengthen the enamel against demineralisation by bacteria-related acids. Drinking fluoridated water is also effective in preventing enamel demineralisation.

Fluoride varnish is a resin paste with a high fluoride concentration (5% sodium fluoride, 22,500 F parts per million [ppm]), which, when applied six-monthly over at least two years, is effective in preventing tooth decay.4,5 It is applied as a thin coating to the tooth surface that provides a highly concentrated, temporary dose of fluoride to the tooth. Medical general practitioners participating in early childhood programs have been trained to apply the fluoride varnish in coordination with the dental team.

Since dental caries is considered to be a bacterial infection, the improvement in oral health of a pregnant woman can lower the risk of transmitting harmful oral bacteria to a newborn.6 During pregnancy there may also be a greater risk of tooth erosion from nausea and vomiting, and progression of periodontal disease. The use of fluoride supplements is not recommended in pregnancy as there is no evidence of effectiveness.
Twice-daily toothbrushing with a fluoridated toothpaste and attention to diet, along with other interventions as recommended by dental practitioners such as dental flossing, are also recommended for people at risk of periodontal disease.

Guidelines on prevention of infective endocarditis recommend antibiotic prophylaxis prior to specific dental procedures in Aboriginal and Torres Strait Islander people with rheumatic heart disease,7 in addition to general recommendations for all people with prosthetic valves, previous infective endocarditis, certain congenital heart conditions and cardiac transplantation. Maintenance of good oral health, combined with sixmonthly checks and oral hygiene guidance, are advised to reduce the risk of infective endocarditis.7
 

 

Resources

General oral health promotion information:

National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people

 





 
 
  1. Villa A, Connell CL, Abati S. Diagnosis and management of xerostomia and hyposalivation. Ther Clin Risk Manag 2014;11:45–51.
  2. Williams S, Jamieson L, MacRae A, Gray C. Review of Indigenous oral health. HealthInfoNet, 2011.  [Accessed 16 March 2017].
  3. Genco RJ, Genco FD. Common risk factors in the management of periodontal and associated systemic diseases: The dental setting and interprofessional collaboration. J Evid Based Dent Pract 2014;(Suppl 14):S4–16.
  4. Roberts-Thomson KF, Slade GD, Bailie RS, et al. A comprehensive approach to health promotion for the reduction of dental caries in remote Indigenous Australian children: A clustered randomised controlled trial. Int Den J 2010; 60:245–49.
  5. Arruda AO, Senthamarai KR, Inglehart MR, Rezende CT, Sohn W. Effect of 5% fluoride varnish application on caries among school children in rural Brazil: A randomized controlled trial. Community Dent Oral Epidemiol 2012;40(3):267–76.
  6. Berkowitz RJ. Mutans Streptococci: Acquisition and transmission. Pediatr Dent 2006;28(2):106–09.
  7. Oral and Dental Expert Group. Therapeutic guidelines: Oral and dental. Version 2. Melbourne: Therapeutic Guidelines Limited, 2012.
  8. NSW Department of Health. Early childhood oral health guidelines for child health professionals. Sydney: Centre for Oral Health Strategy NSW, 2009.
  9. National Institute for Health and Care Excellence. Dental recall: Recall interval between routine dental examinations. London: NICE 2014.
  10. Twetman S. The evidence base for professional and self-care prevention – Caries, erosion and sensitivity. BMC Oral Health 2015;15(Suppl 1):S4.
  11. Iheozor-Ejiofor Z, Worthington HV, Walsh T, et al. Water fluoridation for the prevention of dental caries. Cochrane Database Syst Rev 2015;(6):CD010856.
  12. Rugg-Gunn AJ, Spencer AJ, Whelton HP, et al. Critique of the review of ‘Water fluoridation for the prevention of dental caries’ published by the Cochrane Collaboration in 2015. Br Dent J 2016;220(7):335–40.
  13. National Health and Medical Research Council. Information paper: Water fluoridation: Dental and other human health outcomes, report prepared by the Clinical Trials Centre at University of Sydney. Canberra: NHMRC, 2017.