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NICE has issued new guidelines on the oral health advice given by dentists and dental care professionals that could benefit pharmacy.

 

 

Based on the oral health messages in Public Health England's ‘Delivering Better Oral Health’ toolkit, the new NICE guidelines for dentists and dental care professionals include advice on oral hygiene practices, such as fluoride use, as well as guidance about diet, smoking, smokeless tobacco and alcohol intake.

Dental staff, it says, should ask and record whether a person uses alcohol, tobacco or smokeless tobacco and, if necessary, offer brief advice and a referral to their local stop smoking service – all of which could see more people coming into pharmacies seeking advice about oral health. So what might they be asking?

Use of fluoride

Some people are concerned about the use of fluoride in toothpaste, especially for children, so you might need to reassure them that it is not only safe, but also beneficial.

Fluoride is a mineral that is naturally found in teeth, which combines with calcium to remineralise the teeth and plug any holes that have appeared due to acid erosion. It also reduces acid production by interfering with the growth of bacteria and is therefore essential for maintaining good dental health.

“Fluoride toothpaste should not be used excessively as it can cause mottling of the teeth – so it is important that people use the right concentration,” says Michael Stewart, information pharmacist at Numark.

Packaging details the amount of fluoride a toothpaste contains. According to current advice:

• Children under three years old should brush twice daily with a smear of toothpaste containing no less than 1,000ppm fluoride
• Children between three and six years old should brush at least twice daily with a pea-sized amount of toothpaste containing more than 1,000ppm fluoride
• Adults should brush at least twice daily with a toothpaste containing 1,350-1,500ppm fluoride.

For more clinical advice, Steve Williams, clinical services director at mydentist, one of Europe’s largest dental care providers, recommends the Department of Health’s guide for practitioners and patients: ‘Delivering Better Oral Health – Version 3’.

“In this guide, the optimum level of fluoride toothpaste is discussed, which is dependent on age. In addition, fluoride applications [by a dental care professional] are recommended, with the frequency dependent on the individual risk of the patient, and these can help dramatically in reducing dental cavities in children.”

“Higher concentration fluoride toothpastes are also available as POMs and these are recommended for adults with a high risk of decay as the ageing population retain their teeth for longer.”

Routines and products

There is more to oral hygiene than a toothbrush and some toothpaste. Pharmacy teams need to be able to advise on brushing technique (see box below), as well as the types of product available to manage specific oral health problems, such as acid erosion, staining and gum disease.

Oral-B ambassador Dr Uchenna Okoye calls oral hygiene “the ultimate beauty routine”. It is important to brush twice daily for two minutes each time with an electric toothbrush and a good whitening toothpaste, and to floss at least three times a week to prevent dark stains between the teeth, she says.

Dr Okoye says using an electric toothbrush is “the most effective way of removing plaque bacteria. This is important because bacteria that builds up on teeth make gums prone to infection. The immune system moves in to attack the infection and the gums become inflamed. Over time, inflammation and the chemicals it releases destroys the gums and bone structure that hold teeth in place. The result is severe gum disease, known as periodontitis, while inflammation can also cause problems in the rest of the body.” 

In fact, poor gum health has been linked with systemic disorders such as diabetes and heart conditions, so pharmacy teams should be aware of the link and the need to remind customers to have regular dental check-ups.

Reinforcing the message about twice-daily brushing remains the most important priority, according to periodontist Soha Dattani, area medical director Northern Europe for GSK Consumer Healthcare. “Brushing twice daily with a fluoride toothpaste is one of the most effective ways of preventing dental decay, but we still don’t do it. One in four people – one in three men – don’t brush twice a day, and if you only brush once a day you are a third more likely to get decay,” she says. “It is that reinforcement of the oral care message, and compliance, that pharmacy can help with, particularly as it is really important for children to get that behavioural message at a young age.”

She also stresses that one area where pharmacists have the biggest potential role is with the ageing population: “By 2030 we are going to have nearly 30 per cent of people over 65 years of age. Yes, we are keeping our teeth for longer, but with that comes problems. Number one, multiple medications mean more susceptibility to dry mouth (xerostomia). If someone takes three or more medicines there is an even greater chance of dry mouth, and if it is affecting the salivary flow there can be problems because saliva is essential for remineralising the teeth.

“Advice should be given when medicines have that side-effect but, even before that, if three prescription items are being given out to a patient, this should be a sign to pharmacy staff to ask customers if their mouth is feeling sore or dry. If the dry mouth is very severe and they are unable to swallow, they are at significant risk of decay and should be referred back to their dentist.”

Lifestyle factors

Good oral hygiene is the cornerstone of dental health, but there are other lifestyle factors that also have an effect, such as diet, smoking, smokeless tobacco and alcohol.

Dentist and bacteriologist Dr Harold Katz is the founder of the California Breath Clinics and the professional oral healthcare range The Breath Company. Most people don’t realise that their diet can have a significant impact on their oral health, he says. “Crash dieting, fasting and low-carbohydrate diets can have nasty side-effects on breath due to acetone caused by ketosis, or an excess of protein in the diet producing volatile sulphur compounds in the breath.”

Certain types of food can also feed the bacteria in the mouth that cause bad breath. Hard sweets are a major culprit, he says. “From bad breath to yellow teeth, these sugary treats should be avoided at all costs. Similarly, ice lollies are known to stain the teeth because of the amount of sugar they contain.”

Dr Katz recommends sweets that contain xylitol as an alternative to sugar. “Those who suffer with dry mouth and need saliva stimulation throughout the day should avoid so-called ‘breath mints’, which may contain sucrose or glucose, and use alternatives that are sugar-free,” he says.

Smoking is, unsurprisingly, another no-no for healthy mouths. “Smoking quickly dries out the mouth and introduces nicotine and tar,” says Dr Katz, “which contribute to making an even more complex unpleasant odour and also adhere to your teeth, causing discolouration.”

For customers who do smoke but want to mask bad breath, he recommends an “alcohol-free mouthwash to kill bacteria, because anything containing alcohol will dry the mouth even more”.

And if customers think vaping might be a better alternative, Dr Katz has some disappointing news. “Mouth ulcers are not caused by e-cigarettes, but because the switch from smoking to vaping causes the mouth environment to change from being alkaline, due to the tobacco content, to being more acidic, the mouth has to take time to rebalance. Mouth ulcers can be the result, while an increase in oral acids leads to rapid tooth decay and gum disease.”

Alcohol is also a drying agent and will reduce saliva flow, in turn creating a perfect breeding ground for bacteria. “Certain alcoholic beverages like red wine can also discolour and stain the teeth,” explains Dr Katz, “as chromogens in the wine [also found in tea, coffee and tomato sauce] can stick to the dental enamel, causing deep stains. Coffee is another culprit due to its acidity. When coffee is very hot, it can also cause tiny fractures on the teeth, making them more susceptible to stains – so the mouth should be rinsed out with water after consuming these types of drinks.”

With the new NICE guidelines likely to lead to more customers asking about oral health, now is the time to consolidate your pharmacy’s position in the community as the expert in oral care.

Poor gum health has been linked with systemic disorders such as diabetes and heart conditions

Teeth should be brushed twice daily to prevent decay