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Clinical guidelines

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

Dental health

Author Dr Sandra Meihubers
Expert reviewer Professor Kaye Roberts-Thomson

Overview

Poor 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 considered to be a multifactorial disease, with some of the contributing factors being diet and nutrition (especially high and regular consumption of 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 common medications, particularly antidepressants, antihistamines and antihypertensives
  • radiotherapy and chemotherapy for cancers of the head and neck
  • Sjögren syndrome
  • HIV infection
  • diabetes, particularly in people with poor glycaemic control.1,2 

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.3 In children, the number of both deciduous (first) and permanent (adult) teeth with caries (ie. teeth that have past and/or present caries) is about twice the number than in non-Indigenous children. The proportion of untreated dental caries is also higher among Aboriginal and Torres Strait Islander children, which often reflects a lack of access to dental services.4

There is little data on the prevalence of periodontal disease in Aboriginal and Torres Strait Islander populations, however, important general risk factors for periodontal disease include smoking, diabetes, advancing age, stress and poor oral hygiene.5–8 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.9 There is growing evidence to suggest periodontal disease may be associated with cardiovascular disease, stroke and pre-term low birthweight babies, however causal links are yet to be proven, and there is insufficient evidence to show that treatment of periodontal disease can reduce cardiovascular events.10–12 

Other major conditions of concern are oral cancer, tooth erosion (wearing away of the hard tissues of the teeth by acids such as those found in acidic foods and drinks, and in bulimic patients), and oral trauma (eg. through sports injuries). Tobacco smoking and alcohol consumption are risk factors for the development of oral cancer.

Interventions

Recent guidelines on prevention of infective endocarditis recommend antibiotic prophylaxis prior to dental procedures in Aboriginal and Torres Strait Islander people with rheumatic heart disease in addition to general recommendations for all people with prosthetic valves, previous infective endocarditis, certain congenital heart conditions and cardiac transplantation.13,14 Maintenance of good oral health, combined with regular checks and guidance, is more effective in reducing the risk of infective endocarditis.

Since dental caries is considered to be a bacterial infection, the improvement in oral health of a pregnant woman would lower the risk of transmitting harmful oral bacteria to a newborn.15 During pregnancy there may also be a greater risk of tooth erosion from nausea and vomiting, and progression of periodontal disease. Standard preventive measures such as drinking fluoridated water, twice daily use of fluoride containing toothpaste and minimising sugar consumption are advised.16 The use of fluoride supplements is not recommended in pregnancy as there is no evidence of its effectiveness.

Recommendations: Dental health
Preventive intervention typeWho is at risk?What should be done?How often?Level/strength of evidence
Screening Children aged 0–5 years Recommend regular review with a dental health professional
Non-dental health professionals are encouraged to undertake an oral health review including the assessment of teeth, gums and oral mucosa as part of a regular health assessment (see Table 4.1)
Opportunistic and as part of an annual health assessment IVC17
People aged 6–18 years Annually IVC18
Adults with poor oral health and/or risk factors for dental disease (see Table 4.2)
People with diabetes, immunosuppression, haematological conditions, bleeding disorders or anticoagulant therapy
Annually IVC18
All pregnant women At first antenatal visit (see Chapter 9: Antenatal care) IVC17
Adults with good oral health 2 yearly IVC18
Those with past history of rheumatic heart disease and cardiovascular abnormalities Refer to a dental professional and undertake an oral health review as part of a regular health assessment (see Table 4.1) with appropriate oral hygiene advice to minimise oral bacterial levels 6–12 monthly IVC13,19,20
Chemoprophylaxis Children aged 0–5 years Recommend use of fluoride containing toothpaste at least once daily, from the time the teeth start to erupt
Use a smear of paste for children under 2 years and a pea-size amount for children 2+ years. Toothpaste with a fluoride concentration of 1000 ppm is recommended unless there is a risk of fluorosis
Opportunistic IA17,21–23
Children aged 0–5 years where families have evidence of dental caries, poor oral hygiene Refer to dental professional for regular application of fluoride varnish
If resources do not permit then continue daily use of fluoride toothpaste and provide dietary advice as per Table 4.1  
At least every 6 months from when the teeth erupt, and for a period of not less than 24 months IB23,24
People aged >5 years at high risk of dental caries (see Table 4.2) 2–4 times per year for professional application IA25,26
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. See management guidelines for specific advice13 Opportunistic GPP13,14
Environmental Communities Advocate for fluoridation of community water supply   1A16
Table 4.1. Advice for good oral health practices
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 health professionals
Assessment
Visual inspection of teeth for evidence of caries, periodontal disease, assessment of maternal caries and/or poor oral hygiene
Assess oral hygiene practices, consumption of sucrose and sweetened drinks especially in baby bottles, ‘honey on the dummy’ or other sweet substances such as glycerine on the dummy, 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 between meal snacks and drinks
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
Source: The RACGP 200927
Table 4.2. Risk factors for dental disease
  • Poor oral hygiene practices (eg. no/irregular toothbrushing, use of hard toothbrush, no use of fluoride toothpaste, incorrect brushing technique)
  • Poor diet and nutrition (eg. high and regular consumption of sucrose and carbohydrate containing foods and drinks, especially black cola, sweetened fizzy drinks)
  • Salivary composition and flow: if poor then 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, particularly antidepressants, antihistamines and antihypertensives; radiotherapy and chemotherapy for cancers of the head and neck; Sjögren syndrome; 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
  • HIV infection can also contribute to a greater risk of periodontal disease, oral ulceration and cancer
  • Other modifying risk factors can include age, socioeconomic status and access to oral health services

Resources

Lift the lip and see my smile brochures (NSW Government)
www.health.nsw.gov.au/ resources/pubs/orderform_pdf.asp

Information pamphlets for oral health and smoking, erosion, diabetes, pregnancy (Dental Practice Education Research Unit)
www.arcpoh.adelaide.edu.au/dperu/special/

General oral health promotion information (various sources)
www.healthinfonet.ecu.edu.au/ health-resources/ promotion-resources
www.adaq.com.au
www.dhsv.org.au/ oral-health-resources/guides-and-resources/
www.adelaide.edu.au/ oral-health-promotion/

Learning modules on oral health for health professionals (Smiles for Life)
www.smilesforlifeoralhealth.com.

References

  1. Rayman S, Dincer E, Almas K. Xerostomia: diagnosis and management in dental practice. New York State Dental Journal, March 2010.
  2. Walsh L. Dry mouth: a clinical problem for children and young adults. Journal of Minimum Intervention in Dentistry 2009;2(1):55–6.
  3. Australia’s Dental Generations. The National Survey of Adult Oral Health 2004–06. Cat. no. DEN 165. Canberra: Australian Institute of Health and Welfare, 2007.
  4. Australian Institute of Health and Welfare. Oral health of Aboriginal and Torres Strait Islander children. AIHW cat. no. DEN 167. Canberra: AIHW, 2007.
  5. Do LG, Slade GD, Roberts-Thomson KF, Sanders AE. Smoking-attributable periodontal disease in the Australian adult population. J Clin Periodontol 2008;35(5):398–404.
  6. Mealey BL, Oates TW. Diabetes mellitus and periodontal diseases. J Periodontol 2006;77(8):1289–303.
  7. Ng SK, Keung Leung W. A community study on the relationship between stress, coping, affective dispositions and periodontal attachment loss. Community Dent Oral Epidemiol 2006;34:252–66.
  8. Taylor GW, Burt BA, Becker MP. Severe periodontitis and risk of poor glycaemic control in subjects with non-insulin dependent diabetes mellitus. J Periodontol 1996;67:1085–90.
  9. Simpson TC, Needleman I, Wild SH, Moles DR, Mills EJ. Treatment of periodontal disease for glycaemic control in people with diabetes. Cochrane Database Syst Rev 2010;May 12;(5):CD004714.
  10. Genco RJ, Williams RC, editors. Periodontal disease and overall health: a clinician’s guide. Pennsylvania: Professional Audience Communications, 2010.
  11. Friedewald VE, Kornman KS, Beck JD, et al. The American Journal of Cardiology and Journal of Periodontology Editors’ Consensus: periodontitis and atherosclerotic cardiovascular disease. Am J Cardiol 2009;104(1):59–68.
  12. Helfand M, Buckley DI, Freeman M, et al. Emerging risk factors for coronary heart disease: a summary of systematic reviews conducted for the US Preventive Services Task Force. Ann Intern Med 2009;151(7):496–507.
  13. Antibiotic Expert Group. Therapeutic guidelines: antibiotic. Version 14. Melbourne: Therapeutic Guidelines Limited, 2010. Cited October 2011. Available at www.tg.org.au/?sectionid=41.
  14. Farbod F, Kanaan H, Farbod J. Infective endocarditis and antibiotic prophylaxis prior to dental/oral procedures: latest revision to the guidelines by the American Heart Association. Int J Oral Maxillofac Surg 2007;38:626–31.
  15. Berkowitz RJ. Mutans Streptococci: acquisition and transmission. Pediatr Dent 2006 28(2):106–9.
  16. Truman BI, Gooch BF, Sulemana I, et al. Reviews of evidence on interventions to prevent dental caries, oral and pharyngeal cancers, and sports-related craniofacial injuries. Am J Prev Med 2002;23(Suppl 1):21–54.
  17. NSW Department of Health. Early childhood oral health guidelines for child health professionals. NSW: Centre for Oral Health Strategy, 2009.
  18. National Institute for Health and Clinical Excellence. Dental recall: recall interval between routine dental examinations. London: NICE, 2004.
  19. Central Australian Rural Practitioners Association. CARPA standard treatment manual, 5th edn. Alice Springs: CARPA, 2009.
  20. Oral and Dental Expert Group. Therapeutic guidelines: antibiotic. Version 1. Melbourne: Therapeutic Guidelines Limited, 2007.
  21. Walsh T, Worthington HV, Glenny AM, Appelbe P, Marinho VCC, Shi X. Fluoride toothpastes of different concentrations for preventing dental caries in children and adolescents. Cochrane Database Syst Rev 2010;Jan 20;(1):CD007868.
  22. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database Syst Rev 2003(1):CD002278.
  23. Scottish Intercollegiate Guidelines Network. Prevention and management of decay in the preschool child. Guideline No. 83. London: SIGN, 2005. Cited October 2011. Available at www.sign.ac.uk/pdf/sign83.pdf.
  24. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database Syst Rev 2002(3):CD002279.
  25. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Topical fluoride (toothpastes, mouthrinses, gels or varnishes) for preventing dental caries in children and adolescents. Cochrane Database Syst Rev 2003(4):CD002782.
  26. Griffin SO, Regnier E, Griffin PM, Huntley V. Effectiveness of fluoride in preventing caries in adults. J Dent Res 2007;86(5):410-5.
  27. The Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice (red book), 7th edn. Melbourne: RACGP, 2009. Cited October 2011. Available at www.racgp.org.au/ your-practice/guidelines/redbook/.
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