Question time on oral care

With one in three customer queries in pharmacy said to relate to oral health, it is clear the public is keen to brush up on their mouth care knowledge. Is your team prepared?

Learning objectives

After reading this feature you should be able to:

  • Support customers to practise a good oral hygiene routine
  • Recommend oral care products that suit individual needs
  • Manage common oral health complaints

While awareness regarding the factors that can affect the health of teeth and gums has increased, there is still much to do when it comes to changing the nation’s dental habits. “The fact is that when it comes to oral care we’re not brushing our teeth often enough, or for anywhere near long enough,” says Dr Nigel Carter, chief executive of the Oral Health Foundation.

In its latest annual YouGov survey, Simplyhealth Professionals1 found that around a third of British adults did not brush twice a day as recommended, with a further 37 per cent admitting they didn’t floss. More than a quarter said this was because they simply couldn’t be bothered or found it “boring”.

On average, people are brushing for only around half the two minutes-plus that experts recommend, Dr Carter continues, with a significant proportion only picking up a toothbrush once rather than twice in a day.

This tendency to skip brushing often takes place at the worst time, too – last thing at night – when the natural reduction in saliva flow causes changes to the bacteria in plaque. “Sales of toothbrushes tell us that people don’t change them as often as recommended,” he adds. “The advice to use a new one every three or four months actually translates into an annual average usage of just 1.3 units per head of population.”

“Sales of toothbrushes tell us that people don’t change them as often as recommended”

Bridging the gap

Experts say there are a number of reasons for the questions pharmacy teams are asked regarding oral care – convenience, fear of going to the dentist, the financial barrier involved and a deeprooted resentment at having to pay for treatment.

“As the first point of call when people have dental pain, pharmacists and their assistants are naturally well-placed to underline key oral health messages that aim to help with prevention, but also direct people to a dentist when necessary,” Dr Carter says.

National programmes such as Smile Month present community pharmacists and local dental practices with an ideal opportunity to liaise, says Professor Nairn Wilson of the British Dental Association. “An excellent goal would be joined-up working between pharmacists and dentists to reduce inappropriate antibiotic prescribing for conditions such as toothache,” he says, “or in persuading pharmaceutical companies to provide sugar-free medication, particularly liquid-based products.”

Other joint initiatives could include displaying information and web links, as well as holding best practice workshops in pharmacy targeting specific groups within the community (e.g. pregnant women, carers, children and older people) and covering oral health tips and techniques, and offering essential advice.

Mouth cancer awareness

The most important role pharmacy teams can play is in highlighting the risk of mouth cancer, which has seen a 49 per cent increase in the number of cases across the UK in the past decade, says the Oral Health Foundation.2

“While most people have heard of mouth cancer, our research shows that awareness of some of the actual symptoms and risk factors remains low,” Dr Nigel Carter says, “so we’d really like to see pharmacy teams helping to boost education in this area.”

According to Dr Carter, surveys indicate that around a third of questions in pharmacy also centre around mouth ulcers, which can be a symptom. “It is hugely important that pharmacy assistants know to ask how long an ulcer has been causing a problem,” he continues. “If it has been there for two to three weeks, then it needs to be looked at by a dentist or GP to rule out mouth cancer.”

Product knowledge

The market for oral health products is extensive – estimated to be over £1bn – but with such a vast range of lines to choose from, customers can find the oral hygiene fixture difficult to navigate.

Toothpaste

Since its introduction during the early 1970s, fluoride remains the key ingredient for good oral health. Fluoride is a natural mineral found in teeth, which combines with enamel during growth to help form the hard surface of the tooth. Fluoride helps to reduce acid levels in the mouth by interrupting the growth of bacteria, making it an essential weapon for combatting tooth decay.

When combined with calcium, fluoride also helps to remineralise and plug any holes that have appeared in teeth due to acid erosion. It should be noted that when used in excess, it can lead to a mottling of the teeth.

Recommended fluoride levels for adults and children over the age of three years is 1350ppm (adult strength), with 1000ppm the norm in products for children up to three years. However, a dental team may advise individual patients according to their risk.

“The vast majority of toothpastes have fluoride in them at the recommended levels, so it is then a question of how you interpret the advice from a mass of different products,” says Dr Carter. “This is really about looking at individual conditions – so in the case of gum health problems, for example, customers should be looking at products that reduce plaque.”

With a third of people estimated to suffer from dental sensitivity, a large number of formulations have been developed to target this specifically. Complete or total care products, meanwhile, aim to perform a number of functions, including that of an antibacterial for reducing gum disease as well as better stain removal.

In recent years, whitening toothpastes have also become popular. However, Dr Carter points out that EU regulations governing the level of peroxide contained in whitening products means that these formulations are more about meeting a consumer demand. “These toothpastes are better at removing stains and restoring natural whiteness without bleaching the teeth,” he explains, “but they don’t contain enough peroxide to be effective in whitening teeth from their natural colour.”

For his part, Professor Wilson would like to see pharmacy teams help limit the sale of oral hygiene products marketed as environmentally-friendly (e.g. additive-free/no fluoride) or those offering other benefits such as whitening, but with no real evidence of efficacy (e.g. charcoal toothpastes).

Toothbrushes

Both manual and power toothbrushes come in a range of designs that aim to cater for various issues. Customers should be advised to choose a toothbrush with a small head and medium-textured bristles, which may be either manual or electric. When used correctly, both will brush teeth effectively.

“Power toothbrushes are certainly a good recommendation for pharmacy staff to be giving customers,” Dr Carter says, “as these products have been found by a number of studies to be more efficient at removing plaque and help ensure people are brushing for the correct length of time. They are also useful when manual dexterity starts to go in older customers, offering them a nice chunky handle to hold and good cleaning.”

Interdental cleaning

Decay and gum disease both start in between the teeth, so dentists recommend that any oral care regimen includes the use of interdental brushes or flossing at least once a day to ensure that food debris or any extra plaque that normal toothbrushing may have left behind is removed. In the case of flossing, customers should apply eight to 10 strokes up and down per tooth.3

“Children consume around three times as much sugar as they should”

Mouthwashes

Mouthwashes are designed to help remove any additional residual food or plaque and freshen breath, as well as offer teeth added fluoride or other protection. Experts recommend using a mouthwash outside of brushing times in order to avoid washing away the protective layer of fluoride left by toothpaste. Instead, mouthwash should be used after a meal, when sugar levels tend to be high. Alcohol-free formulations are usually available and will help prevent the mouth becoming too dry.

Common oral ailments

Mouth ulcers

Typically seen on the inside of the cheeks, lips or tongue, mouth ulcers are very common and can have different causes – including illness, diet or biting the cheek.4 Although painful, they are usually harmless and tend to clear up on their own within a week or so. However, any customer with a mouth ulcer lasting longer than two weeks (or in the case of ulcers being a regular issue) should be referred to a GP or dentist.

An antimicrobial mouthwash, pain-relieving mouthwash, gel or spray, or corticosteroid lozenges may be recommended. Customers should also be advised to avoid crunchy or spicy/salty/acidic foods, as well as toothpaste containing sodium lauryl sulphate.

Teething

Teething typically starts when a baby is around six months, but can be earlier or later. The symptoms and level of distress will vary, but may include sore, swollen, red and inflamed gums, fretful or clingy behaviour, a flushed cheek, drooling and the rubbing of an ear. Children under 16 years of age should not be given aspirin, but a sugar-free painkiller containing ibuprofen or paracetamol may be used.

Gently rubbing or massaging the gums is recommended, with teething rings are also a good option. Some may be suitable for cooling in the fridge, but should never be put in the freezer. Sugar-free teething gels may also be considered as an option in some cases.

Bad breath (halitosis)

Poor oral hygiene, alcohol, smoking and particular foods can all cause increased levels of bacteria and consequently, bad breath. Brushing teeth correctly, using a mouthwash, drinking some water after meals and chewing sugar-free gum can help. In appropriate cases, pharmacy teams should also explore the potential for dry mouth and recommend the appropriate product. In the case of persistent bad breath, customers should be referred to a dentist.

Toothache

Any customer complaining of dental pain should be advised to visit a dentist. Although clove tinctures and oils have traditionally been used to relieve dental pain, Dr Carter of the Oral Health Foundation says there is no real dental benefit and that the incorrect application of clove oil to gums can result in mouth ulcers. The use of normal analgesics and a recommendation to visit the dentist is the best advice, he says.

Denture pain

Sore spots are common with dentures, when food can typically become stuck under a plate and rub against the gums. A simple analgesic can be used to relieve pain in the short-term, while a denture adhesive may be recommended to improve comfort levels. If the problem persists, a visit to the dentist is advised.

Oral health in children

In spite of substantial improvements in children’s oral health since the 1970s, the removal of decayed teeth via general anaesthetic remains the number one reason for children aged between five and nine years being admitted to hospital – a situation the British Dental Association describes as “outrageous”.

In 2016/17 nearly 43,000 operations were carried out to remove children’s teeth. In England alone, the BDA says, 5 million children have not visited a NHS dentist in the past year while, on average, children are estimated to be consuming three times as much sugar as they should.5 “We are particularly concerned about the persistent and unacceptable inequalities,” Professor Wilson explains, “whereby children from deprived backgrounds are more likely to suffer from tooth decay than their peers.”

Evidence for this is apparent in Public Health England’s latest Child Oral Health Survey,6 which showed 49.4 per cent of fiveyear- olds in Pendle, Lancashire, had tooth decay – compared with just 5.1 per cent of their counterparts in Waverley, Surrey.

According to Dr Carter, pharmacy teams can play an important role in children’s oral health by helping parents understand that the fight against tooth decay begins from the moment their child’s first tooth appears.

“It is fair to say there can be an element of complacency when it comes to young children, in terms of parents perhaps thinking that their children can afford to lose their primary teeth,” he says. “However, keeping primary teeth is essential as they keep the space open for the secondary teeth to come in. What is more, these early years are crucial to shaping healthier oral habits that will last a lifetime.”

Toothbrushing should begin with the first tooth and a baby’s first dental appointment is recommended during their first year. Supervised brushing should continue until the age of seven years, using the following tips7:

  • For children under three years old: a smear of toothpaste containing no less than 1000ppm fluoride
  • For children between three and six years of age: a pea-sized amount of toothpaste containing more than 1000ppm fluoride
  • Children should spit out the toothpaste after brushing and avoid rinsing with water (as this will wash away the fluoride and reduce the efficacy of the product).

Older children (aged 12 to 17 years) should also be using interdental brushes, with flossing an alternative option for those with tighter spaces between the teeth. Any children with orthodontic braces should follow their specialist’s instructions for cleaning.

While there is no real need for children to have a separate toothpaste to the rest of the family, the market does contain a number of anti-erosion formulations geared towards sugary and acidic drinks. “Erosion attacks the smooth surface of children’s teeth, so these products are designed to be low abrasive so as to not make the problem worse, as well as help with remineralisation,” says Dr Carter.

Gum health and diabetes

While studies have linked dental issues with numerous conditions, the biggest connection made to date is with diabetes. People with diabetes are estimated to be three times more at risk of gum disease.9 “Diabetes and gum disease is a two-way process,” explains Dr Carter.

“If you have poor oral health, you are less likely to have well-controlled sugar levels in your mouth – and in turn, you are more likely to develop type 2 diabetes if you have gum disease. We’ve always known that diabetic patients are more prone to getting gum disease, so there is a clear role for pharmacy teams to give some good preventative advice here.”

Older people’s oral care

Increased longevity is having its own impact on oral health, with older people naturally keeping their own teeth for longer. However, the ageing process poses its own challenges – mainly through a tendency for the saliva flow to reduce, which can lead to dry mouth (xerostomia) and cause a change in the composition of bacterial flora, which can lead to rapid decay.

Polypharmacy can also lead to this condition, so pharmacists and their teams should be on hand to advise. A number of products, including artificial saliva formulations and chewable tablets, have been developed to combat this problem.

Customers with dental implants face the same risk of inflammation and gum disease as those with natural teeth, so standard oral care measures still apply. In the case of dentures, experts recommend that a dedicated denture cleaner is used to remove plaque and residual food particles before soaking to preserve both the appearance of the plate and reduce the risk of a candida infection. Wherever possible, dentures should be removed from the mouth overnight.

While denture adhesives were typically viewed as a sign of an ill-fitting denture, Dr Carter says this glue, which is often formulated to be antibacterial, will help enhance comfort levels and increase a person’s confidence.

Pregnancy and oral care

Hormonal changes during pregnancy can make the gums more vulnerable to plaque, leading to inflammation and bleeding – a problem that can be exacerbated by smoking and any increased levels of acid caused by morning sickness.8 Customers should be advised to stop smoking and pursue a healthy diet.

In the case of vomiting, the recommendation should be to rinse the mouth with plain water following each episode, then wait an hour before brushing as stomach acid will soften the coating on teeth. Women are entitled to free NHS dental treatment during pregnancy and any treatment up to one year after their due date.

Additional learning & materials

  • The BDA recently endorsed a new free e-learning programme on children’s oral health aimed at parents, expectant mothers, early years healthcare workers, teachers, nurses, GPs and the public, but which is also suitable for pharmacy teams. Developed by Health Education England e-Learning for Healthcare (HEE e-LfH) with the Faculty of Dentistry, Royal College of Surgeons and UCL Eastman Dental Institute and Hospital, it covers the main causes of tooth decay and simple actions that can be taken to prevent the problem. Visit: e-lfh.org.uk/programmes/childrens-oral-health
  • UK Government guidelines on Delivering Better Oral Health
  • The Oral Health Foundation offers a wide range of patient education materials that pharmacies can download or purchase

References

1. Survey shows millions fail on basic oral health care. Dental Review 22 May 2018

2. State of Mouth Cancer UK Report 2018-2019. Oral Health Foundation

3. How to keep your teeth clean. NHS
4. Mouth ulcers. NHS
5. Change4Life – Sugar. NHS
6. National Dental Epidemiology Programme for England: oral health survey of five-year-old children 2017. Public Health England
7. A quick guide to a healthy mouth in children. Public Health England

8. Teeth and gums in pregnancy. NHS: nhs.uk/conditions/pregnancy-and-baby/teeth-and-gums-pregnant
9. Diabetes and gum disease. Diabetes UK

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