Brushing up on oral health

toothbrush oral hygiene

Tooth decay, oral cancer and gum disease are among the many oral health problems that can be prevented by pharmacists 

In 2018, the Australian Dental Association (ADA) and Australian Health Policy Collaboration (AHPC) at Victoria University released a world first—a national oral health report card, which revealed that more than 90% of Australian adults have experienced decay in their permanent teeth.

The report also revealed the following:

  • Tooth decay is the most common chronic disease in Australia.
  • Three out of four children and young people are consuming too much sugar.
  • Only 51% of Australian adults brush their teeth the recommended twice a day.
  • Risky drinking and smoking contribute to poor oral health.

Certainly, this highlighted the need for improvements in oral health but how have we faired since that inaugural report? Last year saw the release of the 2020 report, but it seems Australia’s oral health is getting worse.

Dr Mikaela Chinotti, the Australian Dental Association’s oral health promoter, says, “Largely preventable conditions, such as gum disease and tooth decay, have increased in prevalence and we continue to get further away from our goal of improving Australia’s oral health by 2025.

“Covid-19 is only making this worse. We’re anticipating a spike in the number of tooth decay and other oral health issues to emerge once the pandemic is over.”

The findings from the 2020 Oral Health Tracker include:

  • the number of adults with untreated and potentially painful tooth decay has increased considerably from a quarter of adults to around a third of adults (25.5% to 32.1%);
  • adults with periodontal pockets (≥4mm) which can cause tooth loss, went from 19.8% to 28.8%;
  • adults reporting toothache in the previous 12 months went up from 16.2% to 20.2%;
  • just under half (48.8%) of adults surveyed had visited a dentist for a check-up in the last 12 months, a drop of 6.7% since 2018;
  • only 53% of Australians brush their teeth twice a day.

Ms Chincotti says, “We’ve reached our set target for the number of adults with fewer than 21 teeth (this has dropped from 15.5% to 10.2%, which shows that Australians are keeping their teeth for longer.

“However, at the same time we’re seeing more disease. For tooth decay and gum disease we need to be targeting the causes—like poor oral hygiene and sugar consumption.”

Meaningful interventions

A recent survey, conducted by the University of Queensland and exploring the oral healthcare practices in Australian pharmacies, showed that both pharmacists (80.2%) and pharmacy assistants (83.6%) provide oral health advice to consumers up to five times per week on average.

The most frequent oral healthcare services offered were the provision of over-the-counter (OTC) treatments for oral health presentations, referral to a dentist or other medical practitioner, and identifying symptoms of oral health problems in patients.

Furthermore, just over half (54.3%) of the pharmacists involved in the study provided guidance and counseling for the treatment and prevention of oral health issues.

However, where there may be room for improvement is in being more proactive in discussing oral health, providing oral healthcare information to patients and following up on previous enquiries and consultations; less than half of pharmacists offered these services.

Dr Meng-Wong Taing, lecturer, School of Pharmacy at Queensland University and one of the authors of the study, tells the AJP, “While our studies show that around half of pharmacists do opportunistically discuss oral health with people, I think they need further education on the different types of risk factors that can predispose people to oral health issues.

“For example, reflux may increase the risk of dental problems, such as periodontitis and tooth enamel erosion. Likewise, smoking can be used as an in-road to talk about oral health, as smoking is a risk factor for periodontitis and oral cancer. There’s also methadone use, which can cause dry mouth, increasing the risk for cavities and gum disease.

“There are many reasons why people might come into the pharmacy for their dental health concerns; there’s dental anxiety, but also the fact they trust our advice.

“I often have patients using me as a sounding board. They might use the internet to learn about their oral health concern, but we tend to be the first health professional they turn to when making a decision on the most appropriate treatment. This is where we can step in and ask the patient questions to assess their risk factors.”

Budget 2015: closeup of mouth and dental mirror

Reminding patients

Dr Geraldine Moses, consultant pharmacist to the Australian Dental Association and consultant clinical pharmacist at the Mater Hospital in Brisbane, says, “At all stages of life, from infancy through to adulthood, there are many opportunities where pharmacists can advise on oral health. However, it’s important to recognise that the fundamental management of oral hygiene is still something people need to be reminded about and educated on.

“There’s a role for pharmacists to address very basic things like how to clean your teeth properly and the importance of flossing. This is very important in the elderly. It’s easily overlooked, as you might assume that older people know how to look after their oral health but as people get older they might lose their vision, manual dexterity or cognitive function—so they forget or are not able to clean their teeth well.

“In aged care this is a huge problem. Carers often don’t think it’s part of their job to clean their patients’ teeth, so oral care among aged care residents can be severely neglected.”

Dr Moses adds, “With regards to oral health products, there seems to be a fad at the moment for the use of non-fluoride based treatments such as herbal or charcoal toothpaste and ones based on calcium rather than fluoride.

“These toothpastes are not going to do the job of fluoride and I think we, as registered health professionals, should not be suggesting they are as good as fluoride toothpaste; that’s misleading and false information. We must recognise the damage we may cause in the community from these sorts of promotions. Fluoride-based toothpastes are essential in maintaining oral health.

“It’s the same with fluoride-based mouth rinses; we now know that topically applied fluoride works much better and more effectively than when swallowed. By using it topically and spiting out what you don’t need you’re not going to get that systemic toxicity. Pharmacists can explain this to patients and doing a bit of study in this area will make certain they have the right information.

“Unfortunately, in the area of oral health we have a few products that probably don’t offer all that much benefit, but could potentially pose a risk. The classic ones would be teething gels, which are typically formulated with salicylate and local anaesthetic. While they probably don’t pose too big of a danger to adults, teenagers have used these gels on their erupting wisdom teeth.

“However, because of the salicylate exposure, these gels have been linked to Reye’s syndrome. Pharmacists need to know there are risks and that teething gels shouldn’t be recommended for children and adolescents younger than 16.

“Possibly the most effective and safest intervention is to give a dose of paracetamol or ibuprofen, which will relieve pain without causing any toxicity.”

toothbrush and pills

Awareness of medicine-induced adverse oral effects

“Pharmacists can play a key role in oral care, but particularly in regards to drug-induced oral health disorders,” Dr Moses says.

“The classic, and most frequent, would be dry mouth, because there are so many medicines for which this is a common side effect.

“People hear dry mouth and think it’s something benign, but it has very significant consequences relating to recession of the gums and loss of teeth. We need to address it. Often the dentists won’t—partly because they seldom take a very detailed medication history, but also because they are not terribly familiar with what drugs are more likely to cause dry mouth. This leaves them feeling very disempowered about intervening.

“This is where the pharmacist must be the advocate for both the dentist and the patient, and talk about reducing the dose or de-prescribing that medication.

“Oral side effects of medication is not dentistry really, it’s pharmacology; it’s what we already know so it should be something we can do quickly and efficiently. However, what the pharmacist might not realise is that the dentist won’t be intervening, so it is up to us to take that step forward.

“Pharmacists should know that throughout Australia dentists are legally permitted to prescribe schedule 2, 3, 4 and some schedule 8 medicines, so long as they are for the ‘dental treatment’ of persons in their care. Yet, this can include prescribing a benzodiazepine to relax the patient for their dental appointment; so the definition of ‘dental treatment’ is very broad.

“Yet, understanding the common side effects of drugs and the risk of drug interactions is not something dentists are trained in, so if they want to prescribe a certain drug we can give advice on the potential side effects.

“Even if pharmacists focus solely on medication management, there is so much we can do in the area of oral health. For example, toothache is a very common presentation in pharmacy and the management of dental-related pain is something we can really help with. 

“There’s a lack of understanding that most dental pain is caused by inflammation. It could be an infection from caries, periodontal pain, a cracked tooth that’s become infected and developed an abscess, or post‑operative—all of which are linked to inflammation.

“However, dentists tend to fall back on opioids very easily whereas we are trying to move away from the use of codeine. This is because we know that neither paracetamol nor codeine has any anti-inflammatory effect, so they are not going to work well. Pharmacists are in a position to step in and advise that the drug of choice is an anti‑inflammatory.

“Even when there are old-fashioned beliefs about the safety of NSAIDs, or the patients says it upsets their stomach, the pharmacist can negotiate to find a solution.

“There are so many drugs in the NSAID class; there are also the COX-2 inhibitors, which have been found to be safer on the gut and also carry little or no risk for perforation, alterations and bleeding, so, we can update the dentists on these.

“The fact, the increase in dental prescriptions for oxycodone highlights the need to educate dentists on more appropriate use of opioids, as well as minimising use by only prescribing a two-day supply and keeping the doses down.”

An important role

Despite studies showing that pharmacists lack training in the field of oral healthcare, Dr Moses says pharmacists’ current level of knowledge means they have an important role.

“Dentists are not trained to know every drug, how to take a medication history, or even how the PBS works— but pharmacists are, so we can advise dentists. In the future, I would love to see pharmacists employed in the big dental practices, particularly the public health clinics, to document the patients’ medication history.

“Pharmacists can do so much to help the dental profession and support the oral health of the community by sticking to what they already know.”

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