Department of Oral Rehabilitation & Community Care

Preventive Dentistry Toolkit

How to advise and manage your patient

“All patients should be given the benefit of advice and support to change behaviour regarding
their general and dental health, not just those thought to be ‘at risk’ ”. -FDI

General advice for all patients

 Brush your teeth twice a day for two minutes (last thing at night and on one other
occasion) with FLUORIDE toothpaste. Fluoride should be constantly present in saliva in
recommended concentrations. In children, brushing should be done and/or supervised
by parents/carers up to age 8 and monitored from age 8 onwards.

 Small toothbrush head with medium texture or electric toothbrush (Oscillating, rotating
head).

 Brush the teeth and the gum line (modified bass technique) and use interdental cleaning
aids.

 Spit – do not rinse after brushing teeth.

 Use mouthwash at a different time during the day to tooth brushing.

 Reduce amount and episodes of sugar (<25g/day free sugars) and eat a healthy and well-
balanced diet. Avoid sugary drinks! Avoid sugar 2hrs before bedtime! Check food labels!
Drink WATER and PLAIN MILK.

 Regular visits to the dentist as often as needed (depending on risk category).

 Quit smoking and reduce alcohol consumption. (Ask, Advise, Act)

What are the risk factors for caries?

 Sugary diet
 History of caries ++
 Xerostomia
 Underlying medical conditions (Diabetes, HIV,
 Medications
 Special needs
 Low socio-economic status
 Low Fluoride availability

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Children 0-3 years

General

Use Sugar-free medications wherever possible

DO NOT add sugar to food/drinks
DO NOT share utensils/cups

0-6 months
 Exclusive breastfeeding for the first 6 months wherever possible.
 Cleaning of the oral mucosa with a moist gauze/ microfibre glove from birth and a
massaging brush/ finger brush from 3 months

From 6 months onwards:

 Start weaning onto food.
 Avoid rice cereals (very high sugar content).
 Continue using same source of milk as before.
 If drinking enough during the day try to reduce night time feeds by offering water.
 Introduce water in a cup not a bottle.
 When teeth erupt start brushing using a smear of at least 1000ppm fluoride toothpaste
and an age appropriate toothbrush (with bristles).

From 12 months:
 Discontinue formula milk, if being used, and shift to plain full fat fresh cow’s milk if there
are no intolerances and an appropriate unflavoured replacement if there are
intolerances.
 Most children can eat the same types of foods as consumed by the rest of the family –
importantly nutrient rich and cut into small pieces to avoid choking.
 Night time feeds should be tailed off.
 Establish a dental home. Child should start attending for regular check ups.

Children 3-6 years

Low risk

Fluoride
 Toothpaste Minimum 1000ppmF – pea size amount
 PI: application of fluoride varnish twice a year (22,600ppmF or 2.2% NaF)

Recall and BW radiographs

 Recall 6-12 months BWs 12-24 months

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Moderate to high risk

Fluoride
 Toothpaste containing 1350-1500ppmF – small pea-size amount
 PI: application of fluoride varnish more than twice (up to four times) a year (22,600ppmF
or 2.2% NaF)

Recall and BW radiographs

 Moderate risk: recall every 6 months, BWs every 6-12 months

 High risk: recall every 3 months, BWs every 6 months

 Diet –diet diary over 3 days, one weekend day and 2 weekdays (PHE)

Children 7+ and young adults

Low risk

Fluoride
 Toothpaste containing 1350-1500ppmF- pea size amount
 PI: application of fluoride varnish twice a year (22,600ppmF or 2.2% NaF)

Recall and BW radiographs

 Recall 6-12 months, BWs 24 months

Moderate to high risk

Fluoride

 Toothpaste containing 1500ppmF – pea-size amount

Prescription: 2,800 ppm F at age 10+ (high risk)
Up to 5,000ppmF at age 16+ (high risk)
 Prescribe daily fluoride mouth rinse (0.05% NaF) (not after brushing)

 PI: application of fluoride varnish more than twice (up to four times) a year (22,600ppmF
or 2.2% NaF)

 PI: Fissure seal permanent molars with a resin sealant (also other patients giving concern
e.g. Ortho patients)

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Recall and BW radiographs

 Moderate risk: recall every 6 months, BWs every 6-12 months

 High risk: recall every 3 months, BWs every 6 months

 Diet –diet diary over 3 days, one weekend day and 2 weekdays (PHE)

Adults

Low risk

Fluoride
 Toothpaste containing 1350-1500ppmF- pea size amount

Recall and BW radiographs

 Recall 6-12 months BWs: 24 months

Moderate to high risk

Fluoride
 Toothpaste containing 1500ppmF – pea-size amount
Prescription: 2,800 ppm F or 5,000ppm F (high risk)

 Prescribe daily fluoride mouth rinse (0.05% NaF) (not after brushing)

 PI: application of fluoride varnish twice a year (22,600ppmF or 2.2% NaF)

Periodontal Disease
Chlorhexidine containing toothpaste and mouthwash should be prescribed:

 0.05% Chlorhexidine – daily maintenance

 0.12% Chlorhexidine – short-term care 7-10 days
 0.20% Chlorhexidine – intensive short-term 7-10 days

Recall and BW radiographs

 Moderate risk: recall every 6 months, BWs every 12 months

 High risk: recall every 3-6 months, BWs every 6 months

 Diet –diet diary over 3 days, one weekend day and 2 weekdays (PHE)

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Older Adults

Consider
Increasing toothpaste dose, mouth rinsing when possible (both for caries and for perio), F
varnish on exposed root surfaces + demineralised lesions, salivary substitutes

Medications: xerostomia, gingival overgrowth (hyperplasia/hypertrophy)

Tooth wear: sensitivity ++, decreased OVD

Gingival recession: periodontal disease, root caries, toothbrush abrasion, sensitivity

Prosthodontic appliances: denture clasps, other plaque retention factors

Dependent older adults: involve their carers, decrease recall period

References
American Academy of Pediatric Dentistry. (2013). Guideline on caries-risk assessment and
management for infants, children, and adolescents. Pediatric Dentistry, 35(5), E157-64.

FDI. (2017). Caries prevention and management chairside guide. (Toolkit).World Dental
Federation. Retrieved from
https://www.fdiworlddental.org/sites/default/files/media/resources/2017-fdi_cpp-
chairside_guide.pdf

Public Health England. (2017). Delivering better oral health: An evidence-based toolkit for
prevention. Public Health England, Department of Health. Retrieved from
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data
/file/605266/Delivering_better_oral_health.pdf

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The Mediterranean Diet

 Eating primarily plant-based foods (mostly fresh and seasonal), such as fruits and
vegetables, whole grains, legumes and nuts
 Replacing butter with healthy fats such as olive oil and canola oil
 Using herbs and spices instead of salt to flavor foods
 Limiting red meat to no more than a few times a month
 Eating fish and poultry at least twice a week
 A moderate consumption of eggs and dairy products
 Limiting consumption of sugars
 Appropriate food portion sizes
 A moderate to vigorous level of physical activity
 Adequate rest and sleep as part of a balanced lifestyle

Evidence shows that the traditional Mediterranean diet reduces the risk of heart disease. The
diet has been associated with a lower level of oxidized low-density lipoprotein (LDL) cholesterol.
(Grosso et al 2015)
The Mediterranean diet is also associated with a reduced incidence of:
 Diabetes (Schwingshackl et al 2014, Koloverou et al 2014)
 Cancer (Dinu et al 2017, Schwingshackl and Hoffman),
 Alzheimer's disease and also slower cognitive decline (Peterssen and Philippou 2016,
Lourida et al 2013, Singh et al 2014).

The Healthy Plate

 Eat at least 5 portions of a variety of fruit and vegetables every day.

 Base your meals on starchy foods such as potatoes, bread, rice and pasta – choose
wholegrain versions where possible.
 Eat some beans or pulses, fish, eggs, meat and other proteins.
 Have some dairy or dairy alternatives (such as soya drinks) – choose lower-fat and lower-
sugar options.
 Choose unsaturated oils and spreads, and eat them in small amounts.
 Drink 6 to 8 glasses of fluid a day.
 If consuming foods and drinks that are high in fat, salt or sugar, have them less often and
in small amounts.

When giving diet advice, do not advise quitting sugar completely, since that advice is very
difficult to follow, especially for people on a high sugar diet who will be addicted to the
substance. Suggest the following:
 Reduce on snacks containing sugar.

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 Have smaller portions.

 Limit frequency.
 Identify hidden sugars on food labels.
 Avoid adding sugar to foods or drinks.
 Consider using sugar substitutes.
 Find Healthy alternatives.

Practical Healthy Alternatives to sugary snacks/lunches at work or school (easy to prepare):

 Chopped/segmented fruits (e.g. grapes, tomatoes, apples, oranges, peaches, melon,
watermelon, pear) or whole fruits (blueberries, raspberries)
 Vegetable cubes/sticks (carrot, cucumber, celery, peppers, beans, radishes)
 Unsalted Nuts that are lower in fat – Almonds (20), cashews (15), pistachios (30), walnuts
(18 halves) - for young children nuts need to be chopped to reduce choking hazards
 Homemade vegetable dips (hummus, guacamole, olive, bean, herbed yoghurt) with pita
triangles, water biscuits, breadsticks or crackers
 Unsalted unflavoured pop corn
 Plain yoghurt flavoured with fruits or nuts as above or spices such as cinnamon
 Oats, bran as cereals
 Low fat cheese cubes, cottage cheese, ricotta cheese
 Hard-boiled egg
 Homemade oven roasted chips – kale, potato, sweet potato, marrow/zucchini
 Olives
 Savoury muffins, quiches (low in fat and salt)
 Pasta/rice salads with vegetables, olives, cheese

Reading food labels

When giving dietary advice to patients, one should keep in mind other co-morbidities patients
might have and give recommendations that are beneficial for BOTH their oral and general health.
Below is the latest evidence on how to read food/drink labels:

Health Promotion and Disease Prevention Directorate, 2018.

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References

 American Academy of Paediatric Dentists. Guideline on Infant Oral Health Care. 2014.
 Dinu M; Pagliai G; Casini A; Sofi F . Mediterranean diet and multiple health outcomes: an umbrella
review of meta-analyses of observational studies and randomised trials. European journal of clinical
nutrition. 72: 30–43, 2017.
 Feldens CA, Giugliani ERJ, Vigo Á, Vítolo MR. Early feeding practices and severe early childhood
caries in four-year-old children from southern Brazil: A birth cohort study. Caries Res
2010;44(5):445-52.
 Grosso G, Marventano S, Yang J, Micek A, Pajak A, Luca Scalfi, Fabio Galvano & Kales SN(2015) A
comprehensive meta-analysis on evidence of Mediterranean diet and cardiovascular disease: Are
individual components equal?, Critical Reviews in Food Science and Nutrition, 57:15, 3218-3232,
 Health Promotion and Disease Prevention Directorate Malta. National breastfeeding policy and
action plan (2015-2020). 2015.
 Health Promotion and Disease Prevention Directorate Malta. Dietary Guidelines for Maltese Adults.
Healthy Eating the Mediterranean Way. 2015.
 Koloverou E; Esposito K; Giugliano D; Panagiotakos D . The effect of Mediterranean diet on the
development of type 2 diabetes mellitus: a meta-analysis of 10 prospective studies and 136,846
participants. Metabolism: clinical and experimental. 63 (7): 903–11, 2014.
 Lourida I, Soni M, Thompson-Coon J, Purandare N, Lang IA. Ukoumunne O C.; Llewellyn DJ.
Mediterranean Diet, Cognitive Function, and Dementia. Epidemiology. 24 (4): 479–489, 2013.
 Petersson SD; Philippou E . Mediterranean Diet, Cognitive Function, and Dementia: A Systematic
Review of the Evidence. Advances in Nutrition (Bethesda, Md.). 7 (5): 889–904., 2016
 Peres KG, Nascimento GG, Peres MA, Mittinty MN, Demarco FF, Santos IS, Matijasevic A, Barros
AJD. Impact of Prolonged Breastfeeding on Dental Caries: A Population-Based Birth Cohort Study.
Pediatrics 2017; 140.
 Petersson SD; Philippou E . Mediterranean Diet, Cognitive Function, and Dementia: A Systematic
Review of the Evidence. Advances in Nutrition (Bethesda, Md.). 7 (5): 889–904., 2016
 Rees K, Hartley L, Flowers N, Clarke A, Hooper, Thorogood M, Stranges S. Mediterranean dietary
pattern for the primary prevention of cardiovascular disease. The Cochrane Database of Systematic
Reviews. 2013 8: CD009825.
 Reisine S, Douglass JM. Psychosocial and behavioral issues in early childhood caries. Commun Dent
Oral Epidem 1998;26(suppl):32-44. 65.
 Schwingshackl L; Hoffmann, G. Adherence to Mediterranean diet and risk of cancer: a systematic
review and meta-analysis of observational studies. International Journal of Cancer. 135 (8): 1884–
97, 2014.
 Schwingshackl L; Missbach B; König J; Hoffmann G. Adherence to a Mediterranean diet and risk of
diabetes: a systematic review and meta-analysis. Public health nutrition. 18: 1–8. 2014
 Singh B,Parsaik AK, Mielke MM, Erwin PJ, Knopman DS, Petersen RC, Roberts RO. Association of
mediterranean diet with mild cognitive impairment and Alzheimer's disease: a systematic review
and meta-analysis. Journal of Alzheimer's disease: JAD. 39 (2): 271–82, 2014.
 Tham R, Bowatte G, Dharmage SC, Tan DJ, Lau M, Dai X, Allen KJ, Lodge CJ. Breastfeeding and the
risk of dental caries: a systematic review and meta-analysis. Acta Paediatr. 2015.
 World Health Organization. Guideline: Sugars Intake for Adults and Children. Geneva; 2015.
 Health Promotion and Disease Directorate, Malta, 2018.