Students-Oral Health Education and Promotion by Kishan Sheth, BDS5 Dental Student at King’s College London and DentaltownUK student editor

Oral Health Education and Promotion

Dental diseases play a major role in general health, and what occurs in the mouth may have systemic impacts. It is well documented, however, that dental diseases are largely preventable, and in their early stages, reversible.

In recent years there has been a major shift in the paradigm, as dental treatment is now no longer the first line of defense.

The concept of minimally invasive dentistry is starting to inspire practitioners and dental schools around the world to encourage the use of behaviour change and oral hygiene education, where the profession once picked up their burs at the first sign of potential disease.

In spite of this, with the pressures of general dental practice growing, there may be minimal health promotion being undertaken in clinical practice. I would also like to point out that as final-year dental students, we are well trained in the concept of minimal intervention dentistry.

We have been trained to diagnose disease as early as possible, facilitate behaviour change, and intervene only when necessary. A number of patients who have seen me have undergone remarkable oral health changes, and all I did was engage in a conversation and promote oral health education.

It is obvious from the dental literature that dental diseases are a major burden on health at both the individual and population levels. In my opinion, the two major diseases which are causing concern around the world are caries and periodontitis, and their consequences include the likelihood of pain, impact on eating, poor quality of sleep, and compromised speaking ability and productivity.

In the United States, it is estimated that ‘more than 51 million hours of school time are lost due to dental disease’ (Bagramian et al., 2009).

Dental caries is a largely preventable disease; it is caused by bacterial biofilm gaining nutrition from free sugars and fermentable carbohydrates in the individual’s diet, and in the process acids such as lactic, propionic and acetic acid are formed. These will disrupt the organic phase and dissolve the inorganic phase of the dental hard tissues, leading to the formation of a carious lesion.

However, despite our recent advances in understanding of dental diseases and their therapeutic treatment options, dental caries remains a huge problem, and has been ever since it peaked in the 1960s. A decline was seen from the late 1970s until the 1990s in industrialized countries (Marthaler 2004).

No one single factor or intervention can take credit for this decline, but factors such as dietary changes, daily applications of fluoridated toothpaste and the use of water fluoridation may have played a part in decreasing caries rates.

These interventions have created a solid foundation for the government to push the focus in dentistry from treatment to therapy. Every active carious lesions should be stabilised and then restored for the longer term.

The use of GIC has increased, in my experience, because practitioners now appreciate its ability to release fluoride and to create a more adaptive and versatile bond to tooth structure. By doing so, it prevents the accumulation of plaque at microscopic levels.

However, in each of these cases, only the right material should be used for the right patient and the right cavity. There are several factors to consider, such as bond strength, position of application, moisture control achievement and aesthetic properties.

This shift in thinking is not new; in 1986, the World Health Organisation issued the Ottawa charter for health promotion, aiming to increase levels of education in populations and to prevent the rise of chronic diseases. It is my belief that oral health is right at the core of our general wellbeing.

In addition, oral health professionals have a backbone of professional education in elements of communication, physiology and psychology, and so are well positioned to be engaging in health behaviour modifications.

Preventing dental disease and improving oral health are key roles of dental students and dental professionals. Few other professions have the luxury of spending large amounts of time in clinic with patients, gaining their trust and confidence.

And as dental professionals, we have a major role in reinforcing the message of living well and taking care of your health (oral and general). This has been recognised by large numbers of international bodies responsible for regulation of dental professionals through the creation and championing of various competency standards focusing on both treatment and prevention.

Health promotion efforts in oral health are on the rise. This is due to the success of several health promotion initiatives that have already decreased caries rates and to the understanding that money can be saved by targeting the causes of dental disease and making it easier for people to make the right and healthy choices. Treatment is therefore no longer needed as an initial line of therapy.

If you think about it further, surely treatment should never have been our first line of therapy in early-stage lesions. Introducing a restorative/tooth interface will simply lead to an area of plaque buildup, making it harder to maintain and look after the tooth.

Some of my tutors in the past have talked about the ‘restorative spiral’—a patient comes to have a simple filling, which soon after needs to be redone, leading to the loss of more tooth structure. Soon after, the patient needs a crown, then an endodontic intervention, then an extraction, then prosthetic replacement. … It may seem exaggerated, but I’ve seen it happen over my years at dental school. Behaviour change is so important; it will influence whether the patient faces this restorative spiral problem. In patients with poor oral hygiene, this restorative spiral effect is likely.

However, health promotion has been challenging to plan, implement and execute, because the philosophy of dentistry is primarily targeted and focused on a downstream patient-centered approach. Significant other barriers to implementation of preventive care measures include the structure of dental services and government funding that reinforces clinical treatments.

This results in public funds being directed toward those in need, rather than general public engagement and education. And unless there is a financial gain and reward for dentists who engage in changing oral health behaviour, this may never come to life, because having busy practice settings and patient workflow creates barriers.

The following are some aspects I believe all dental professionals/students should keep in mind regarding oral health education and promotion:

Fluoride
Fluoride is found in minimal levels in rocks, soil and air. It forms an essential component of bones and teeth, as well as having a role in several other tissue types. Calcium fluoride occurs naturally in water supplies; sodium fluoride is used to artificially raise fluoride levels in drinking water. (London’s water network is not fluoridated; it’s far too extensive to allow for this.)

Fluoride reduces the risk and progress of dental caries by forming more acid-resistant fluoroapatite, which withstands a lower pH, rather than the normal critical pH of 5.5. Fluoride also blocks the enzymatic systems in bacteria, inhibiting their capacity to turn sugar into acid.

Fluoride is known to convert early carious lesions into arrested lesions, which appear harder, shinier and smoother than their active comparisons.

Tobacco use and smoking
Tobacco use is still a major public health concern in the UK. Although the rate of smoking has declined since the 1970s, it still remains an area of concern.

Many people want to quit smoking; the negative health effects are well known and well documented. Government and media initiatives have improved education levels.

The major reasons behind why people smoke include addiction, social habits, weight loss and stress relief.

Smoking tobacco products can have several effects on oral health, including halitosis, dry mouth (xerostomia), hairy black tongue, and increased risk of periodontitis and oral cancer.

Communication
The major component involved in health behaviour change is sending messages to patients in a way they can understand easily. This involves breaking down huge amounts of complex information into simple chunks that can be explained without the use of jargon.

Some patients may have left the clinic feeling more nervous, anxious and annoyed than when they arrived, and it’s your job to ensure that this is not the case.

It cannot be blamed upon the patients if they’ve not understood something that you’ve said. I have learnt that there are three golden rules to communicating with patients:

1. If you tell them, they’ll forget soon after.
2. If you show them, they’ll remember.
3. If you involve them, they will learn.

Communication is all about involving patients in the conversation about their health.

Prevention
I look at prevention from three angles:

1. Primary prevention is initiative, which aims to prevent disease generation in healthy individuals.
2. Secondary prevention aims to reverse lesions or disease in those with disease that has the potential to be reversed.
3. Tertiary prevention aims to stabilise disease that has led to destruction of tissue.