Oral Health Messages for the Australian Public. Findings of a National Consensus Workshop
Aust Dent J 2011; 56:331-335
Reproduced with permission from the Australian Dental Journal
National Oral Health Promotion Clearing House*
*Australian Research Centre for Population Oral Health, School of Dentistry, The University of Adelaide, South Australia.
The Australian National Oral Health Plan 2004–2013 noted the importance of oral health promotion in improving oral health and stated that broad agreement was required on a consistent suite of evidence-based oral health promotion messages. Consistent messages are needed to avoid confusion among the public and to assist the advocacy for oral health being integrated into general health promotion. A workshop was held to examine the scientific evidence and develop consensus oral health messages for the Australian public which are in line with the general health messages recommended by Australian health authorities.
Keywords: Oral health messages, consensus, evidence-based.
(Accepted for publication 14 December 2010.)
The National Oral Health Plan 2004–20131 noted the importance of oral health promotion in improving oral health, and stated that broad agreement was required on a consistent suite of evidence-based oral health promotion messages. Consistent messages are needed to avoid confusion among the public and to assist the advocacy for oral health being integrated into general health promotion.
The aim of the workshop was to examine the scientific evidence and develop consensus oral health messages for the Australian public which are in line with the general health messages recommended by Australian health authorities.
In late 2009, a workshop was held in Adelaide by the National Oral Health Promotion Clearing House to develop a national consensus on oral health messages for the public. Speakers, who were experts in their field of general health and oral health, were asked to summarize the published scientific evidence on various topics. Workshop participants were from dental schools around Australia, professional organizations and oral health departments of state and territory jurisdictions. The workshop was moderated on the first day by the Director of Health Promotion from the South Australian Department of Health, Ms Michelle Herriot, and on the second day by Associate Professor Julie Satur of the University of Melbourne.
Invited speakers reviewed the published scientific literature on their topic, and presented their findings both in written form prior to the workshop and verbally at the workshop. Based on these presentations, recommendations were developed using a consensus model. The recommendations addressed diet, tooth cleaning, mouthrinses, chewing gum, safety, age of first visit, frequency of dental visiting and smoking. In the few instances where scientific evidence was not available, the consensus of those attending is reported. The workshop did not address messages relating to use of fluorides explicitly as these had been the subject of a workshop in 2005.2
Four major reviews of the relationship between diet and dental caries have been published since 2001.3–6 The findings from these reviews were not consistent. However, there were a number of problems, including:
• dietary data being notoriously difficult to measure accurately;
• study populations and designs varying;
• studies being conducted in populations with overall high sugar intake and low inter-individual variation, leading to weak associations; and
• methodological flaws in some studies.
Notwithstanding these factors, there is strong evidence from multiple epidemiological and interventional studies for an association between the amount and frequency of free sugar intake and dental caries7. Evidence on the relationship between soft drinks and dental caries is mixed, with different results for different age groups and populations. Evidence of an association is stronger in young children,8,9 with children consuming soft drinks more regularly having higher rates of dental caries.
Based on the evidence, the members of the workshop decided that the following recommendations should be accepted:
(1) Breast milk is best for babies10–17 and is not associated with an increased risk of dental caries.18–20
(2) After 6 months of age, infant feeding cups rather than infant feeding bottles are preferred for drinks other than formula or breast milk. Sugary fluids should not be placed in infant feeding bottles. Comfort sucking on a bottle should be discouraged.15
(3) Follow the Australian dietary guidelines.21 Focus on:
• drinking plenty of tap water;
• limiting sugary foods and drinks; and
• choosing healthy snacks, e.g. fruits and vegetables.
The effectiveness of twice daily use of fluoride toothpaste in reducing caries has been shown in a number of studies.22,23
Evidence that toothbrushing per se reduces caries is equivocal.24 However, cleaning teeth with a toothbrush at least every two days is effective in reducing gingivitis.25 The general consensus is that twice daily brushing is suggested for gingival health. Rotation oscillation powered toothbrushes remove more plaque than manual brushes, and reduce plaque and gingivitis in both the short and long term.26
The current low-level evidence about flossing and caries shows that regular and meticulous supervised flossing can lower the risk of interproximal caries in young children with poor toothbrushing habits and low fluoride exposure. Better toothbrushing and ⁄ or enhanced topical fluoride exposure may attenuate or eliminate this flossing effect.27 Further, in populations where there is widespread use of fluoride toothpaste, self-performed flossing was not found to be effective in the prevention of dental caries.2
In terms of plaque and gingivitis, self-performed flossing has not been shown to remove additional plaque or benefit gingival health compared with brushing alone.28
As Hujoel et al. suggest, the advocacy of flossing as a caries-prevention method hinges on a common sense argument; plaque causes caries, flossing removes plaque, therefore flossing reduces caries.27 Such common sense arguments represent the lowest level of scientific evidence and use of such evidence has led to incorrect patient management in other areas.29 Several trials have failed to support the common sense argument that removal of dental plaque lowers caries risk.30–34 Common sense arguments should not be used to justify flossing when other, evidence-based caries prevention interventions exist.2
Slot et al. found that interdental brushing removed more dental plaque than toothbrushing alone when the gingival papilla did not fill the interdental space, but did not reduce interdental bleeding or gingivitis.35
On the basis of the above it is suggested that people speak to oral health professionals about whether interdental cleaning is necessary. The following is recommended:
(4) Brush teeth and along the gum line twice a day with a soft brush.25
(5) People over 18 months of age should use an appropriate fluoride toothpaste.2,23,36–38
Regular use of a fluoride mouthrinse is effective in reducing decay. The effect is greater in high-risk populations and smaller in low-risk populations.23,36 Antibacterial mouthrinses with chlorhexidine are effective as a short-term solution to gingivitis.39,40 On this basis the following is recommended:
(6) Fluoride mouthrinses can be effective in reducing decay. Speak with your oral health professional about whether fluoride mouth rinsing is appropriate for you.
Recent reviews have consistently supported the use of xylitol and sorbitol in chewing gum for the prevention of caries as part of an oral hygiene routine.41,42 One randomized controlled trial found that addition of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) to sugar-free gum increases the preventive effect.43The following is recommended:
(7) Chewing sugar free gum can reduce dental decay.41,42
Several studies show that use of a mouthguard when playing sport effectively reduces the incidence of dental and ⁄ or facial injuries.44–48 This suggests that mouthguards should be used in contact, combative and some non-contact sports. The evidence shows that both ‘boil-and-bite’ and custom-fitted guards are effective. However, no study has compared the preventive effects of one type with the other so it cannot be stated which is better at reducing injury. Custom-fitted guards may prove more comfortable to wear while playing sport.49
The following recommendation includes the sports listed by Sports Medicine Australia for which mouthguards should be worn:
(8) Mouthguards should be worn for all sports where there is a reasonable risk of a mouth injury. This includes football, rugby, martial arts, boxing, hockey, basketball, netball, baseball, softball, squash, soccer, BMX bike riding, skateboarding, in-line skating, trampolining, cricket (wicket keeping), water skiing and snow ski racing.
Age of first oral health visit
Little data were available on the best age for first visit and oral health outcomes. Ismail et al.50 found no difference in oral health between children who first visited a dentist before age 2 and those who visited later. This finding is supported by Nainar51 who found that the evidence did not support an oral health visit before the age of 1 for all children.
Thus, the recommendation for the Australian public is:
(9) Children should have an oral health assessment by age 2.
Frequency of oral health visits
Regular oral health check-ups are important for oral health.52 however very little high quality scientific evidence exists on the appropriate frequency of routine oral health check-ups. A Cochrane review found the evidence for recall intervals insufficient ‘to support or refute the practice of six-monthly recalls’.53 A report from the UK National Institute for Clinical Excellence54 concluded that recall periods should be based on individual risk assessment. Recall periods should also be guided by the appropriateness of intervals needed for preventive interventions. Therefore, there is no evidence that any particular interval between check-ups is more effective than another, or that six-monthly recalls are more appropriate than other longer intervals. The recommendation is:
(10) Everyone has different oral health needs and risk levels which should be reflected in the frequency of check-ups. Talk with your oral health professional about your risk level and how frequently you need to visit for an oral health check.
Smoking results in more disease and injury than any other single risk factor.55 Smoking is a causative factor for periodontal disease and oral cancer and a risk factor for other oral mucosal lesions.55–58
The recommendation on smoking is:
(11) Quit smoking to improve oral and general health55 You can ask your oral health professional about quitting.59
Consensus was agreed on a set of 11 health messages for oral health which complement those for general health following literature reviews and discussion at a national workshop.
We would like to thank Dr Alexis Zander for her contribution to researching and writing this article, and Dr Leonard Crocombe for his assistance in organizing the workshop.
The following people reviewed the literature and presented at the workshop:
Dr DL Bailey, University of Melbourne
Ms Su-yan L Barrow, University of Melbourne
Professor Anthony Blinkhorn, University of Sydney
Dr Leonard Crocombe, University of Adelaide
Dr Loc Do, University of Adelaide
Mr David Edwards, Cancer Council, South Australia
Associate Professor Andrew McIntosh, University of New South Wales
Ms Jenny Miller, University of Adelaide
Ms Christine Morris, SA Dental Service
Associate Professor Jane Scott, Flinders University
Professor John Spencer, University of Adelaide
Associate Professor Nicola Spurrier, Department of Health South Australia
Dr Margaret Stacey, University of Melbourne.
In addition, the following people participated in the consensus decision-making process:
Ms Sue Aldenhoven, Dental Hygienists’ Association of Australia Inc. (day two)
Ms Linda Bertram, Queensland Health
Ms Amanda Blyton, Australian Capital Territory Health
Ms Emma Bridge, Department of Health and Human Services, Tasmania
Dr Penny Brown, Northern Territory Department of Health and Families
Professor Hanny Calache, Dental Health Services, Victoria
Associate Professor Cheryl Chapple, Charles Sturt University
Dr Felicity Croker, James Cook University
Ms Annette Davey, Oral Health Services Tasmania
Associate Professor Peter J Dennison, University of Sydney
Dr Martin Dooland, SA Dental Service
Ms Michele Herriot, Department of Health South Australia
Ms Bronwyn Johnson, Australian Dental and Oral Health Therapy Association
Professor Newell Johnson, Griffith University
Associate Professor Nicky Kilpatrick, Royal Children’s Hospital, Melbourne
Professor David Manton, Australian Dental Association
Ms Vicky Mason, Department of Health, Victoria
Mr Andrew McAuliffe, Department of Health and Community Services, Northern Territory
Professor Ian Meyers, Queensland Health
Dr Andrew Neil, Department of Health Victoria
Ms Jennifer Noller, Centre for Oral Health Strategy, New South Wales
Dr Kamila Plutzer, University of Adelaide
Dr Suzette Porter, Queensland Health
Elisha Riggs, University of Melbourne
Professor Kaye Roberts-Thomson, University of Adelaide
Associate Professor Julie Satur, University of Melbourne
Stephanie Scallion, Australian Dental Association
Dr Barbara Shearer, Colgate Palmolive
Ms Leonie Short, Griffith University
Dr Bruce Simmons, Oral Health SIG Convenor, Public Health Association of Australia
Ms Janet Weeks, SA Dental Service
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Address for correspondence:
Professor Kaye Roberts-Thomson
School of Dentistry
The University of Adelaide
122 Frome Street
Adelaide SA 5005
Reproduced with the permission from the Australian Dental Journal