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Importance of oral health
Oral health, as defined by the World Dental Federation, is “multi-faceted and includes the ability to speak, smile, smell, taste, touch, chew, swallow and convey a range of emotions through facial expressions with confidence and without pain, discomfort and disease of the craniofacial complex”.¹ This wide-reaching definition captures the impact of oral health on a range of functions and highlights why achieving oral health is so important.
Dental disease can have a significant impact on a patient’s health and quality of life. It can induce pain and carry a significant financial or time burden. Patients often comment on having to miss school or work, or feeling embarrassed about their teeth. It is not just a short-term problem. Once a tooth becomes compromised, it will often need more prolonged, complicated, and costly treatment in the future. There are also many direct links between oral health and systemic conditions such as pregnancy, diabetes, Down’s syndrome and cardiovascular disease.
For dental professionals, it is important to promote oral health as well as recognising and treating dental disease. We have a duty to educate patients, equipping them to take responsibility for their own self-care.
Largely preventable oral conditions
Dental caries is a highly prevalent yet preventable disease affecting both children and adults. It occurs when plaque (a white bacterial biofilm) grows over the tooth surface over time and interacts with substrates, such as food debris. This interaction produces acids that demineralise the protective enamel layer, eventually resulting in a cavity.
Periodontal disease occurs primarily by poor plaque control and results in irritated, inflamed and bleeding gingivae. Over time, the harmful bacteria may progress subgingivally, forming deeper pockets which can lead to loss of attachment, infection, mobility and bone loss around affected teeth. The prevalence of periodontal disease increases with age and other risk factors such as smoking, diabetes or immunosuppression. It is important to note that individual susceptibility to periodontal disease is highly variable between patients.
Tooth wear is the loss of dental hard tissue through non-cariogenic processes and can result in pain, sensitivity, loss of function and aesthetic issues. Preventative measures include identifying and reducing causative factors such as acidic food and drink, traumatic toothbrushing, grinding, gastroesophageal reflux, eating disorders, stress and nail-biting.
Oral cancer is the uncontrolled growth of malignant cells within the mouth and is the 10th and 15th most common cancer amongst men and women, respectively. Oral cancer cases are higher in males, the over 60s, heavy smokers or alcohol consumers. Other risk factors include UV light and viruses such as HPV or EBV. There is an average 50% 5-year survival rate as lesions are often advanced at presentation and spread easily to regional lymph nodes. ² ³ ⁴
The risk of developing caries and periodontal disease can be decreased by effective plaque removal via toothbrushing and interdental cleaning.
Many toothbrushing techniques are based on the Bass technique. Important points to convey to the patient are:
Brush at least twice a day, last thing at night and at one other time during the day. 5
The toothbrush should be held at a 45-degree angle to the tooth, with the bristles reaching the gingival margins.
For manual brushes, small circular or horizontal motions should be used with gentle pressure, reinforcing that there is no need to scrub. A medium bristle brush should be recommended.
An electric toothbrush simply requires placement of the toothbrush head at a 45-degree angle against the gingival margin of each tooth. Electric toothbrushes, especially those with rotating oscillating heads have proven to be more effective in controlling plaque in some patient groups. 6
Whether using a manual or electric brush, it is important to have a systematic approach to brushing to cover all surfaces of the teeth: buccal, occlusal and palatal/lingual.
Toothbrushes or toothbrush heads should be replaced every 3 months to maintain efficacy.
Plaque is not effectively removed in between teeth by toothbrushing alone. Interdental cleaning is important to ensure interproximal plaque is also addressed:
For larger interdental spaces, such as in periodontal patients, interdental brushes are recommended.
The colour of the interdental brush corresponds to a different sized gap: dental care professionals should provide tailored advice on the appropriate colours required for the patient’s dentition.
Smaller interdental spaces can be reached with dental floss; demonstrating the correct technique to patients is important to avoid soft tissue trauma.
Short-term chlorhexidine mouthwash is clinically proven to reduce plaque levels and is recommended when more severe gingival inflammation is present.7 However, prolonged use of chlorhexidine mouthwash (for more than 4 weeks) can cause taste disturbances, brown staining of teeth and irritate the oral mucosa. 8
Fluoride protects teeth by making enamel more resistant to demineralisation, allowing remineralisation to occur instead. This protective action of fluoride is important in the prevention of caries and tooth wear.
Fluoride can be administered at home using fluoride toothpaste and mouthwashes or in the dental surgery as high strength topical fluoride varnish.
Key recommendations regarding fluoride:
For both children and adults, it is important to brush twice daily (last thing at night and on one other occasion) with a fluoridated toothpaste, for 2 minutes at least. This should commence from as soon as the first tooth erupts. 5
Parents should supervise brushing until the child is approximately 8-years-old or once the child has sufficient manual dexterity.
Following brushing, excess toothpaste should be spat out, not rinsed away with water or mouthwash. This maintains fluoride levels in the mouth for as long as possible.
Mouthwash may be used daily (0.05% Sodium Fluoride), at a different timeto brushing, for added protection.
Table 1. The recommended concentrations and quantities of fluoride toothpaste.
7 years and above
Dental care professionals can also apply varnishes (5% Sodium Fluoride) up to 4 times yearly or prescribe high fluoride toothpaste (0.619% or 1.1% Sodium Fluoride) depending on the patient’s caries risk. Alternatively, fluoride can be provided on a mass scale through water fluoridation, inclusion in foods, or prescription of supplements, although this is currently very limited in the UK.
Diet control is another means of preventing caries and tooth wear. Frequent consumption of high sugar foods and drinks increases caries risk by providing a regular substrate for plaque bacteria to metabolise, accelerating the demineralisation process. Regular intake of acidic foodstuff also results in erosive tooth wear. The consumption of sugary and/or acidic food and drinks should therefore be limited to mealtimes, when the salivary flow rate is at its highest to help clear and neutralise plaque acids, rather than as inter-meal snacks. Occasional treats are acceptable, but it is encouraged to limit these to mealtimes.
Dentists may give patients a 3-day diet diary to monitor dietary habits, highlight key changes needed and advise accordingly.
‘Safer’ alternatives include:
Consumption of plain water or milk throughout the day.
It is recommended that good dietary practices are adopted early in line with the Eatwell Guide to promote a healthy, balanced diet. ⁵
Fissure sealants may be placed by dental care professionals to fill in the grooves on the surfaces of teeth, where food debris and plaque collect. These are particularly important in young children, to protect high-risk sites, such as the occlusal surfaces of first permanent molars. They can be resin or glass ionomer based, depending upon the patient’s cooperation and level of moisture control achieved. It is a quick, easy, effective process that has been shown to reduce caries between 11-51%. 9 Sealants can last for many years but will gradually wear over time.
Regular recall and screening
Recall intervals are individually tailored based on the risk of developing dental disease, in accordance with NICE guidance.10 For anyone below the age of 18, intervals are set between 3 to 12 months as caries progresses more rapidly in children and to monitor the developing dentition. In adults, recall intervals are set between 3 to 24 months. Considerations in determining recall periods include assessing diet, lifestyle, previous dental disease and general health condition. It is important that patients are reviewed at these intervals to help maintain oral health, monitor changes over time without adding unnecessary visits.
Screening oral cancer risk
A regular, comprehensive hard and soft tissue examination of the mouth and oropharynx is required illustrating, documenting, and monitoring any abnormalities identified. 10Every patient should be asked about their smoking status- past or current smoking, cigarettes per day, pack-years and response to smoking cessation advice. Likewise, for alcohol consumption, the number of units per week should be recorded.
Basic periodontal examination
The basic periodontal examination (BPE) is a screening tool completed for all patients above 12 years old at regular recall intervals, with a modified version available for children above 6 years old.5 11 It allows identification of patients whose periodontal health requires further assessment and treatment. Local causative factors can be identified and removed such as sites of supragingival calculus or overhanging restorations. Once there are signs of periodontitis, a full periodontal examination and treatment plan is necessitated. Patients with periodontitis will usually be placed on 3-monthly recall intervals for monitoring of inflammation, bone levels and to prevent further disease progression.
Smoking cessation and alcohol advice
Smoking and alcohol consumption work synergistically in raising the risk of developing a malignancy by up to 30 times. Smoking or chewing tobacco in the form of paan or betel nut increases the risk of developing cancer by 7-10 times. Smokers are also 6 times more likely to develop periodontal disease and have impaired wound healing, making them more susceptible to infections and dry socket. Stopping or reducing smoking at any stage has a beneficial effect on both health and quality of life. Healthcare professionals should therefore follow the 5As approach (ask, assess, advise, assist, arrange) to promote smoking cessation at every available opportunity. This could involve signposting or referring to local support services. Alcohol consumption should be advised in line with the national guidance of 14 units per week, spread out over a 3 day period.5
Other preventative measures
Other preventative measures which should be encouraged include:
Effective UV light protection: discouraging the use of tanning beds, applying high SPF sun creams and educating those at highest risk.
HPV vaccines for school-aged children and practising safe sex to reduce the future incidence of HPV-associated oropharyngeal cancers. 3
Prevention focuses on the early detection and intervention of dental disease.
Good oral hygiene underpins many aspects of prevention in dentistry: it is important to encourage effective toothbrushing techniques and interdental cleaning, tailored to each individual.
Fluoride delivery promotes the remineralisation of enamel making teeth more resistant to decay. This is primarily through the use of toothpaste but can also be provided in mouthwashes (at a different time to brushing) and professionally applied varnishes.
The frequency of acidic or high sugar food intake should be reduced and restricted to mealtimes where possible.
Oral cancer risk can be reduced by quitting smoking, safe alcohol consumption, a healthy diet and attending regular dental recalls for screening.
World Dental Federation. ‘FDI’s Definition of Oral Health’. Published in 2016. Available from: [LINK]
National Institution for Health and Care Excellence. ‘Head and neck cancers- recognition and referral’. Published in 2016. Available from: [LINK]
Oral Health Foundation. ‘Mouth Cancer risk factors’. Published in 2019. Available from: [LINK]
Brocklehurst, P., Kujan, O., O’Malley, LA., Ogden, G., Shepherd, S. & Glenny, AM. ‘Screening Programmes for the early detection and prevention of oral cancer’. Published in 2013. Available from: [LINK]
Public Health England. ‘Delivering Better Oral Health: an evidence-based toolkit for prevention’. 3rd edition published in 2017. Available from: [LINK]
Yacoob, M., Worthington, HV., Deacon, SA., Deery, C., Walmsley, AD., Robinson, PG. & Glenny, AM. ‘Powered versus manual toothbrushing for oral health’. Published in 2014. Available from: [LINK]
Riley, P. & Lamont, T. ‘Triclosan/copolymer containing toothpastes for oral health’. Published in 2013. Available from: [LINK]
James, P., Worthington, HV., Parnell, C., Harding, M., Lamont, T., Cheung, A., Whelton, H. & Riley, P. ‘Chlorhexidine mouthrinse as an adjunctive treatment for gingival health’. Published in 2017. Available from: [LINK]
Ahovua-Saloranta, A., Forss, H., Walsh, T., Nordblad, A., Makela, M. & Worthington, HV. ‘Sealants for preventing tooth decay in permanent teeth’. Published in 2017. Available from: [LINK]
National Institution for Health and Care Excellence. ‘Dental checks: intervals between oral health reviews’. Published in 2004. Available from: [LINK]
British Society of Periodontology. ‘Basic Periodontal Examination’. Published in 2019. Available from: [LINK]
Dr Louise Griffith
General Dental Practitioner and Honorary Research Associate