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Pharmacy magazine – Oral health – March 2016 issue

 

 

New NICE guidelines on oral health give pharmacists and their teams more opportunities to give advice about oral health and hygiene.

By Sasa Jankovic

 

A trip to the dentist used to involve a quick poke about in your mouth followed by a scale and polish if you were lucky – or unlucky, if you are not a fan of hooked implements and tiny whirring brushes being scraped around your teeth.

 

That is no longer the end of the consultation, as new NICE guidelines on oral health aim to equip patients with the ability to make informed choices about their care by asking dental health professionals to also give them advice during examinations.

 

Based on the oral health messages in Public Health England's Delivering Better Oral Health, this includes advice on good oral hygiene practices and the use of fluoride, and it needs to be tailored to meet individual needs. To do this this, dental staff should ask and record whether the person uses alcohol, tobacco or smokeless tobacco and, if necessary, offer brief advice and a referral to their local stop smoking service.

 

All of this means that there is the potential for more people with oral care issues and questions to be heading for their local community pharmacy, so pharmacists and their teams need to be ready to communicate advice about oral health and hygiene – and products – to their customers.

 

So what might they be asking?

 

The 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 which is naturally found in teeth and 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 dental health.

 

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

 

“The toothpaste packaging will detail the amount of fluoride it contains, and current advice states:

  • Children under three years old should brush twice daily, with a smear of toothpaste containing no less than 1000ppm fluoride.
  • Children between three and six years old should brush at least twice daily with a pea-sized amount of toothpaste containing more than 1000ppm fluoride.
  • Adults should brush at least twice daily with a toothpaste containing 1350-1500ppm fluoride.”
     

If you want to drill down for more clinical advice, Steve Williams, clinical services director at {my}dentist, one of Europe's largest dental care providers recommends the Department for Health’s guide for practitioners and patients: Delivering Better Oral Health - Version 3.

 

He says: “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 to reduce dental cavities in children. Higher concentration fluoride toothpastes are also available as a POM and these are recommended for adults with a high risk of decay as the ageing population retain their teeth longer.”

 

Routines and products

Nowadays, a toothbrush and some toothpaste are not the top and tail of an oral healthcare kit. You should be able to give advice about brushing technique, as well as the types of product to manage specific oral health problems such as acid erosion, staining and gum disease.

 

Oral-B ambassador Dr Uchenna calls it “the ultimate beauty routine: brush twice daily for 2 minutes each time with an electric toothbrush and a good whitening toothpaste, and floss at least three times a week to prevent dark stains between teeth.”

 

Dr Uchenna, says using an electric toothbrush is “the most effective way of removing plaque bacteria, which 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, and 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 staff should be aware of the link and the need to remind customers to have regular dental check-ups.

 

Nonetheless, reinforcing the message about twice-daily brushing remains the most important thing, according to periodontist Soha Dattani, area medical director Northern Europe for GSK Consumer Healthcare. She says: “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 (1 in 3 men) don’t brush twice a day, and if you only brush once a day you are more than 33 per cent likely to get decay. It’s that reinforcement of the oral care message, and compliance, that pharmacy can do, particularly as it’s really important for children to get that behavioural message across at a young age.”

 

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

 

“Advice should be given on what medicines have that side effect, but even before that if three prescriptions are being given out to a patient this should be a sign to pharmacy staff to ask customers if they are suffering or their mouth is sore. If the dry mouth is very severe and they are unable to swallow they are at huge risk of decay, and you are a great referral service – back to their dentist.”

 

Lifestyle factors

Good oral hygiene is clearly the cornerstone of oral health, but there are other lifestyle factors that 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 professional oral healthcare range The Breath Company. He says most people don’t realise that their diet can have a significant impact on their oral health: “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 bacteria in the mouth that cause bad breath. He says hard sweets are a major culprit: “From bad breath to yellow teeth, these sugary treats should be avoided at all costs. Hard sweets – along with gummies and sweet gum – feed bacteria in your mouth that cause bad breath. Similarly, ice lollies are known to stain the teeth because of the amount of sugar they contain and the sticky substance that grips onto the teeth.”

 

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

 

Smoking is, unsurprisingly, another no-no for healthy mouths, according to Katz: “Smoking quickly dries out the mouth and introduces nicotine and tar, which contribute to making an even more complex unpleasant odour and also adhere to your teeth, causing discoloration.” 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, 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, and mouth ulcers can be the result, and 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 Katz, “as chromogens in red wine (also found in tea, coffee and tomato sauce) can stick to your dental enamel, causing deep stains. Coffee is another teeth staining culprit due to its acidity. When coffee is very hot, it can also cause tiny fractures on your teeth, making them more susceptible to stains, so rinse your mouth out with water after consuming these types of drinks.”

 

Fortunately, the pharmacy team in a really unique position to offer this kind of advice to customers, because Dattani says “there is no doubt that the oral care shelf is confusing. Even if customers get advice from their dental professional, by the time they go to the shelf they still get confused, so they’ll be seeking reassurance from pharmacy staff. Every mouth is unique so everyone has specific oral care needs, and if you talk to your customers you can tailor solutions to meet their requirements.”

 

With the new NICE guidelines likely to drive even more customers into pharmacy with questions about their oral health, you and your team have a great opportunity to consolidate your position in the community as healthcare experts, as well as to make the most of the increasing number of products available in this retail market. If you still don’t think this is your area of expertise, perhaps it’s time you got your teeth into it.

 

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Box: Common oral health problems, and what to recommend

 

Cold sores

Cold sores are the small blisters that develop on the lips or around the mouth, caused by the herpes simplex virus. The first symptom of a cold sore is usually a burning or stinging pain at the affected site, followed by pink bumps and small blisters which dry and crust over.

Cold sores usually clear up by themselves within 7-10 days without treatment, but a cool wet compress may help to soothe the irritation, as will applying a moisturising cream such as petroleum jelly to the skin. Washing the area gently with a salt bath or wash can also help. OTC antiviral creams can ease symptoms and speed up healing time, but to be effective they need to be applied as soon as the first signs of a cold sore appear.

Mouth ulcers

Mouth ulcers are painful round or oval sores affecting up to 20 per cent of people, particularly women and young people. They're usually white, red, yellow or grey in colour and are inflamed (red and swollen) around the edge.

 

Although mouth ulcers can be uncomfortable, especially when you eat, drink or brush your teeth, they are usually harmless. Most mouth ulcers will clear up by themselves within a week or two, but you can recommend that customers see their GP or dentist if the ulcer gets worse or lasts for longer than three weeks, or if they develop ulcers regularly.

 

Bad breath

Healthy mouths shouldn’t cause problems with bad breath, but it affects us all from time to time, either from smoking, what we eat or drink or because of an infection in the mouth.

 

Bacteria are responsible for bad breath so brushing teeth or chewing sugar-free gum can help and, surprisingly, so can avoiding dairy foods. Anaerobic sulphur-producing bacteria, the culprits behind bad breath production, use dense proteins as a fuel source to create strong offensive odours. This means diets high in dairy proteins (milk, cheese, ice cream) create an environment that leads to bad breath, but sipping some water after eating or drinking dairy products can help to stop the problem.

 

Toothache

According to the British Dental Association, 25 per cent of people are afraid of visiting the dentist, so the friendly face of community pharmacy means you will probably be the first port of call for many nervous customers suffering with toothache.

 

As well as advising your customer to steel themselves for a visit to their dentist, in the first instance you could recommend they try the traditional remedy of dabbing clove oil on the affected area to relieve the pain. Clove oil has been long used for the relief of pain caused by tooth decay and cavities as a result of its natural anaesthetic and antibacterial properties.

 

Teething

Teething can be a distressing time for both baby and parents alike and is an inevitable part of a baby’s early years. Each baby’s symptoms and level of distress will be individual to them and may include sore, swollen, red and inflamed gums, clingy behaviour, flushed cheeks, particularly on one side and a slight increase in temperature (but not over 39°C).

 

Teething rings give your baby something to safely chew on, which may ease their discomfort and provide a distraction from any pain. Some teething rings can be cooled first in the fridge, which may help to soothe your baby's gums. Babies over four months old can have sugar-free teething gel rubbed on their gums. These often contain a mild local anaesthetic, which helps to numb any pain or discomfort.

 

 

Denture pain

If dentures fit properly they should not cause any pain or move around, so customers shouldn't necessarily need to use denture fixative. However, if the jawbone has shrunk significantly since the dentures were made, adhesive may be the only way to help keep the dentures in place.

 

Even if someone has complete dentures they should continue to see their dentist regularly so they can check for any problems. If poorly fitting or worn dentures aren't replaced, they can cause great discomfort and lead to mouth sores, infections or problems eating and speaking.

 

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Box: The British Dental Health Foundation gives the following advice on good brushing technique:

• Place the head of the toothbrush against the teeth and tilt the bristles to a 45 degree angle against the gum line.

• Move the brush in small circular movements across each tooth covering the outside, inside and bite of the tooth ensuring the bristles are angled against the gum line.

• To brush the inside of the tooth angle the brush vertically and make circular movements with the front of the brush.

• Brush the tongue to remove bacteria and help keep the breath fresh.

• Change your toothbrush or attachment every three months.

• Never share toothbrushes as this can spread infections.

• Don’t rinse the mouth after brushing as this washes away the protective fluoride coating left by the toothpaste.

 

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-Ends-                                    Word count: 2500                                       24.02.16

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