Preventing caries in children: Giving families the best advice

OK, hello, my name is Paul Ashley and welcome to this talk on preventing caries in children. So we’re talking today really about stuff you can do. Not more broader issues around prevention like water fluoridation et cetera. We broke it into two elements, things we can say and things we can do. I’ve got two documents on the screen for you there. I know both are kind of UK focused but I think they’re quite useful to look at. The first one, the white one, is delivering better oral health and that’s an NHS document for England for evidence based. Lots of really good information in there. And the second one is going to be even more information.

It is a Scottish document and essentially it’s like a handbook or really a book on managing young children. So I think I’ll be referring to these as we go on but both I think are really, really, good reading for you. OK, so let’s start off with things we can say. And I’ve broken down things we can say down into three sections. The first is dietary advice, the second is oral hygiene instruction, and the third is what I’m calling fluoride advice, and by that I mean things you can say to parents in regards to toothpaste usage. So let’s start with dietary advice.

And we can really look at children as being a sort of an under five age group, and an older over five age group. Now, in the younger five age group there is good evidence to show that if you give parents or caregivers, or whatever you want to say, advice about weaning, or what kind of things to put in a bottle, when to move from milk at night to not milk at night, all these sorts of pieces of information, there’s good evidence to show that if you make those sorts of interventions then that can lead to less caries in those children. So it’s really strong with regards to the under 5’s.

Where things start to fall apart a little bit is when you get to older children. And I’m not saying you shouldn’t give dietary advice for older children but the evidential link between giving advice and less caries breaks down. And it’s not because sugar isn’t important, of course it’s important, but it’s much harder to get older children to essentially do what you want, OK? And then the other thing when we’re thinking about diet advice is really the broader issue of health and obesity, diabetes, these are the sort of lifestyle diseases. And where does our diet advice in regards to decay fit in with the broader advice with regard to general health?

So I think in terms of diet advice I think what I’d say is it’s really important to target your advice for those young children, particularly at risk children. So if you have a family where an older siblings had significant levels of decay and you know that there’s a new child coming to the family you’ve got to really go for that family. Go for advice around feeding, around weaning, around breastfeeding, all these sorts of things. So really target them. With regards to older children, clearly we should give diet advice. But I think you need to be realistic firstly, about what it’s going to achieve. Unless you want to use techniques like motivational interviewing, et cetera.

It may be that your advice is falling on perhaps, deaf ears. I think the other thing as well is put your advice into a broader context. And I like to use the advice that WHO gives. And they break it down into several key messages, and the first is reducing the overall amount of sugars consumed. So you’ll note there’s less evidence there based on frequency. A lot more evidence on the total amount. So less sugar, overall. Make sure your advice is tailored to the patient’s body mass status. So if somebody is overweight then clearly you’re going to push that message a little bit harder as opposed to somebody who might be at goal weight or underweight.

I think, think about the broader diet like I say. So don’t just say no sugar but do say more fresh fruit, more vegetables, more nuts, more wholegrain foods. So you may as well be talking about a healthy plate type approach. Discourage the consumption of foods that are high in fats, high in salt. And discourage the consumption of all drinks containing free sugars. And increasingly we’re starting to realise that fruit juices and smoothies in particular can be quite troublesome with advanced decay. So that’s diet. What about oral hygiene instruction? Oral hygiene instruction is clearly really important.

And we know that if we show someone how to clean their teeth they can repeat that and they can show that learning at some point in the future. But do remember that toothbrushing on its own without fluoride toothpaste is not preventive for dental caries, OK? So you must view toothbrushing as a fluoride toothpaste or fluoride delivery device, not as a means on its own to reduce caries. That brings me to the final bit of stuff we can say. And that is fluoride advice. And if you’re going to give any kind of evidence or advice to families really spend most of your time talking about what toothpaste they should be using and how often they should be using it.

Must be twice a day. Three a day doesn’t make as much difference as you might think. Twice a day is really important. And you’ll find a lot of families are only doing it once a day. Must be the right amount. So if you’re worried about fluorosis, a pea or smear, we tend to recommend that for under six-year-olds. But if you’re not worried about fluorosis in an older child a good amount on the brush and there’s no point in messing around. And finally, concentration is really important. Clearly no fluoride, we want to avoid that. See 50 PPM probably doesn’t even work that well, either. And interestingly now in the UK we’ve moved to 1,000 PPM as a bare minimum, OK?

So where you live in the world, what regulations influence you will influence you, what strengths you give, also the level of fluoride in the water, will also influence what strengths you give. But it’s important given the right strength and as I say in the UK that starts at 1,000 PPM. If your local regulation allows it at age 10 you might think about 2,800 PPM in an at risk child and actually over 16 we can even think about 5,000 PPM but maybe save that for the real at risk groups. One other important thing to remember is the benefits of not rinsing with water after fluoride toothpaste usage.

So if you use the fluoride toothpaste and you rinse with water you remove it and you don’t get any benefits. I think discourage your patients from doing that. If they only rinse with fluoride mouth rinse, that’s fine, and we’ll touch on that in the latest slide.