Easing the burden

toothbrush oral hygiene

Pharmacists are the medication experts, but can they also become advocates to help improve poor oral health?

Despite advancements in oral health knowledge and treatments, many Australians continue to suffer from poor oral and dental health. What’s more, poor oral health extends beyond the mouth and can greatly impact a person’s general well-being.

Issues with oral and dental health can have large consequences for the individuals affected, in the form of pain, discomfort, low self-esteem and even social isolation.

Dr Meng-Wong Taing, a lecturer at the School of Pharmacy, University of Queensland, is particularly interested in further developing evidence for pharmacists working in collaborative oral healthcare models in Australia.

He has witnessed first hand the social and psychological impact of poor dental health. He explains, “At the age of 30, my mum had just four natural teeth, the rest were implants. I’ve seen how this affects her quality of life. She’s embarrassed about her teeth, so she smiles with her mouth closed for any photo opportunity.

“Her implants affect how she eats and what she chooses to eat. When you see these things it makes you realise the larger impact of poor oral health.

“Globally, people who are socially disadvantaged generally have poorer oral hygiene and more oral problems compared to middle class populations. This affects their self-esteem and how they are portrayed, for example when they attend job interviews.

“There are also the systemic issues associated with poor oral health such heart disease, cancer and diabetes.”

How do Aussies fair when it comes to oral health?

According to The Oral Health Tracker 2020, a progress report that provides an update on how Australian adults’ oral health is tracking, the results for gum disease and tooth decay aren’t looking good.

“These conditions are largely preventable, yet they’ve increased in prevalence and we continue to get further away from our goal of improving Australia’s overall oral health,” says Dr Mikaela Chinotti, oral health advisor for the Australian Dental Association.

While Australian adults are keeping their natural teeth for longer, there’s been an increase in dental disease, she explains.

“We need to be targeting the causes of tooth decay and gum disease, such as poor oral hygiene and high sugar consumption.”

Other findings from the Oral Health Tracker 2020 report include:

  • the number of adults with untreated and potentially painful tooth decay has increased substantially from a quarter of adults to around a third of adults (25.5% to 32.1%);
  • adults with periodontal pockets (≥ 4mm), which can lead to tooth loss, shot up from 19.8% to 28.8%;
    adults reporting toothache in the past 12 months went up by one quarter, from 16.2% in 2018 to 20.2% in 2020;
  • 48.8% of adults surveyed had visited a dentist for a checkup within the past 12 months, a drop of 6.7% since the first Tracker;
  • only 53% of us are brushing twice a day, a minor 2% improvement on 2018;
  • Australians are keeping their teeth for longer, with the number of adults with fewer than 21 teeth dropping from 15.5% to 10.2%; and
  • rates of adult oral cancers have remained almost static at 10.3 people per 100,000.

“What really strikes me is how many oral health problems, such as cavities, gingivitis and periodontal problems, can be prevented. The messages just don’t get relayed to the public.

“In my view we need to take more of a proactive approach to dental health in Australia; there’s not a big focus on prevention,” says Dr Taing.

The pharmacist’s role in dental health

Dr Peter Alldritt, member of the Australian Dental Association’s oral health committee, says, “Not every person will make an appointment with the dentist when they have a dental problem. In many cases people will experience pain, so they will present to their local pharmacy for analgesics.

“Other reasons why the dentist might not be the first port of call include: they might not have a dentist or perhaps they fear the dentist (i.e. dental phobia). There are also barriers such as cost or availability of dental appointments.

“On the other hand, there are many reasons for a person to present to the pharmacy with a dental issue. They might have a mouth ulcer, bad breath, a sore wisdom tooth or denture pain, and pharmacists are in a key position to provide emergency oral health information.”

Dr Taing says, “Our studies show that pharmacists do see themselves having a greater role in dental health. In fact, we found that more than 80% of pharmacists and assistants are consulted for oral healthcare advice five or more times each week. This shows that people are receptive to receiving oral advice and education from pharmacists.”

Dr Alldritt agrees that pharmacists are well placed with the community to advise on oral health. He says not only can pharmacists educate parents on baby bottle tooth decay, which affects thousands of babies and young children in Australia every year, but they can also inform people of the negative impact of smoking on oral health.

“If a custom comes into pharmacy for Nicabate or Nicorette or some other quit smoking aid, this is an ideal entry point for a conversation. Everyone knows smoking causes cancer, heart disease, lung diseases and a whole host of other health concerns but people often aren’t aware of the negative oral effects of smoking.

“Aside from yellow teeth and nasty breath, there are more serious oral health issues to consider. Smoking is one of the main causes of periodontal disease. It restricts blood flow around the gum tissues and the bone, making those tissues more vulnerable to bacterial infection (periodontitis).

“The gums start pulling and shrinking away from the teeth. In addition, the bone underneath the gums is getting eaten away by infection too. The teeth become loose and eventually they’ll be lost.

“Smoking is also a major cause of oral cancer, which isn’t as common as some other causes of cancer in terms of the number of cases diagnosed per year, however, it has a bad prognosis. Once it’s diagnosed it’s usually so advanced that the outcome is very poor.

“These are all good reasons why we should encourage people to stop smoking. From a pharmacy point, pharmacists and their staff are in a great position to be having these conversations and sharing this information with the customers.”

The scope of pharmacy practice in oral health was laid out in a position statement, released in 2015 as a joint initiative between the ADA Victoria, Dental Health Services Victoria and the PSA. It states that pharmacists can play an integral role in the improvement of oral health in the community by incorporating the following:

  • advise on preventive measures, good oral hygiene and minor oral health problems;
  • recommend patients see their dentist regularly for tailored oral health advice;
    reinforce advice provided by the patient’s dentist on common oral health problems;
  • supply of oral health products and provision of evidence based advice;
  • address common risk factors in chronic diseases
  • advice for medications, which may affect oral health;
  • assessment and referral pathways; and
  • oral health promotion 

The need to upskill and collaborate

In 2016, researchers from the School of Pharmacy and Pharmaceutical Sciences, University of Sunderland, conducted a pilot oral health promotion intervention, involving five pharmacies in North East England and 1089 members of the public. Participating pharmacists and staff attended a training course that took place over one evening and covered the basics of oral hygiene. Following this, selected patients received a five-minute oral health intervention as they waited for prescriptions or when they presented to pharmacy for advice and medications.

The participants were advised on how to brush their teeth properly, checks were made to ensure they were using the right oral health products and key information was provided on how to properly care for teeth and gums.

Project leader Mr Andrew Sturrock explains, “We already know there are lots of people who don’t have a dentist, have phobias about dental treatment or avoid regular check-ups, especially in deprived areas.

The pharmacy is certainly not taking over the dentists’ role; this is just about giving some really basic healthcare advice and signposting patients in the right direction.

“It’s also about trying to prevent people from needing dental treatment later on.”

Following the intervention, 72% of participants perceived their knowledge of oral health as much better, 66% intended to change their oral health habits and 64% believed the pharmacy was an appropriate place to receive advice about oral health.

While it’s apparent that pharmacists are in a good position to offer basic oral health advice, the question is do they have the knowledge and assurance to do so.

Dr Taing tells the AJP, “A few years ago we looked at pharmacists’ self-confidence in dealing with common oral health issues. The majority of pharmacists reported that they were confident in managing oral presentations such as mouth ulcers and gum disease, for example.

“However, further research into ‘actual’ pharmacy practices involving mystery shoppers showed that a large proportion of pharmacists and pharmacy staff weren’t dealing with oral presentations, in particular non-healing mouth ulcers, in line with standard guidelines.

“They were presented with a case involving a non-healing mouth ulcer and the appropriate course of action was to refer to the doctor, but only 10% of the participants actually referred.

“As pharmacists, we are really in a position to implement interventions or screen patients. Yet, one of the barriers is the fact that, at this stage, pharmacists just don’t have the level of knowledge or training to really position themselves to put into practice a formal model of oral healthcare in the community.”

Dr Taing adds, “Along with further training in the area of oral health, we need more pharmacists to reach out and get to know the dentists in their local area.

“I have dentists who call me for medicine-related advice and that’s the beginning of a trusted and professional relationship. It opens the lines to build a partnership. We can then start to stock the products they need, initiate a referral pathway, or call them to ask advice. Pharmacists often work in silo, so we need to let our guard down.”

Dr Alldritt says Dental Health Week (held annually during the 1st week of August) is an ideal opportunity for pharmacists to team up with dentists in their area to offer oral health advice to the local community.

“One year I was invited into a nearby pharmacy as part of an in-store oral health promotion. I hovered around the oral health section and when people came to look at the toothbrushes or mouth rinses I introduced myself and made a joke out of the fact it’s not all that common to be offered free advice from a dentist!

“It was a great opportunity to talk to people and answer those oral-health related questions they’ve never bothered to ask anyone about.

“The upside for the dentist is that they get to promote their own dental practice through word of mouth. The benefit for the pharmacist is that it may draw more people into the pharmacy. They might offer specials on various oral health items or tie it in with some other in-store promotion.

“I would love to be able to pick up the phone and call a local pharmacist to ask about the drugs a patient is taking; or I might want to prescribe an antibiotic but could do with some advice on the dosage.

“We need to initiate that first conversation. This sort of alliance would benefit the dentist and the pharmacist, but also their clients or patients. It could certainly work well where there’s a pharmacist and dentist in a strip of shops or in a small shopping centre.”

Medicines and oral health

Many medicines can affect oral health due to their high sugar levels or because they can cause dry mouth as a side effect.
Without adequate flow of saliva in the mouth, food and bacteria remain on the teeth, increasing the risk of tooth decay. Medicines that can cause dry mouth include:

  • antihistamines;
  • decongestants;
  • analgesics;
  • beta-blockers and antihypertensives;
  • muscle relaxants;
  • anticholinergics; and
  • anti-depressants.

Liquid medicines, such as cough syrups, along with lozenges, vitamins, antacid tablets and anti-fungal agents contain sugar that can lead to tooth decay.

Pharmacists can check labels and suggest sugar-free medications when appropriate or request an alternative to sugar-based prescription medicines.

For patients using a sugar-based medication, recommend they rinse their mouth with water directly after taking the medication.

Again, pharmacists are well placed to advise on medicines and the related oral health issues. A UK study by Clare Appleby and Iain Mackie looked into whether parents would give their children a sugar-free medicine if recommended by their pharmacist.

Of the 45 parents with children below two years of age that were interviewed, 96% said they would try a sugar-free medicine if recommended by their pharmacist.

Information sources
22Taing MW, Ford PJ, Gartner CE, Freeman CR. Describing the role of Australian community pharmacists in oral healthcare. Int J Pharm Pract. 2016 Aug; 24(4): 237-46.
ADAVB, DHSV and PSA (Vic). Joint position statement on oral health. March 2015. Available at: dhsv.org.au.
Sturrock, A, Cussons, H, Jones, C. et al. Oral health promotion in the community pharmacy: an evaluation of a pilot oral health promotion intervention. Br Dent J. 2017;223:521-5.
Appleby C, Mackie IC. Parents’ acceptance of sugar-free medicines. Int J Health Promot Educ. 1993;31(2):60-3.

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