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2013 How to Guide A Manual for delivering Designed to Smile Issue date March 2014 Revision date April 2015 Foreword David Thomas, Chief Dental Officer for Wales Having an unhealthy mouth can have a real impact on health and wellbeing. There is a strong correlation between deprivation and poor oral health, and this is of particular importance in Wales where oral health is now the worst in Britain. However, there is much we can do to tackle this important public health problem, as oral diseases are almost entirely preventable. Welsh Government has the key aims and actions for improvement in its programme for government which includes Designed to Smile. We also know that children who develop tooth decay in their baby teeth are far more likely to have serious dental problems in later life. All the evidence, from clinical research to expert opinion, tells us that we can prevent tooth decay by brushing twice daily with fluoride toothpaste. The Welsh Government`s Designed to Smile programme is continuing to help ensure that children brush their teeth every day with a fluoride toothpaste. Healthy teeth mean healthy smiles and better lives. For these reasons, Designed to Smile has developed a tooth brushing programme for nurseries and primary schools throughout Wales to help our children establish good habits early on. The tooth brushing programme is supported by oral health promotion work in all settings, and with parents as well as children and teaching staff. In addition there is a fluoride varnish application programme and fissure sealant programme – both designed to reduce risk of tooth decay in children. This How to Guide provides an update on the programme for all Designed to Smile team members, dental and other health professional staff and those working in settings where the programme is being delivered. I trust you find this guide helpful in your continued efforts to improve the dental health of children in Wales. David Thomas Chief Dental Officer for Wales 1 Contents Introduction ...................................................................................................................................................... 3 Part 1: An Overview of Designed to Smile and its Key Components ................................................................. 4 1.1 An overview of Designed to Smile ..................................................................................................... 4 1.2 Overview of the Tooth brushing Programme .................................................................................... 5 1.3 Overview of the Fluoride Varnish Application Programme ............................................................... 6 1.4 Overview of the Fissure Sealant Application Programme ................................................................. 7 1.5 Overview of the Oral health Education (OHE) Programme ............................................................... 8 Part 2: Stage by stage guide to delivering Designed to Smile ......................................................................... 10 2.1 Contacting the school or setting ........................................................................................................... 10 2.2 Tooth brushing Programme Protocol .................................................................................................... 13 2.3 Fluoride Varnish Application Programme Protocol ............................................................................... 24 2.4 Fissure Sealant Application Programme Protocol ................................................................................. 36 2.5 Oral Health Education and Promotion .................................................................................................. 37 Part 3 MONITORING AND EVALUATION ......................................................................................................... 39 Part 4 Quality Framework ............................................................................................................................... 41 Part 5 Evidence Base ....................................................................................................................................... 42 APPENDICES .................................................................................................................................................... 43 Appendix 1 Evidence -‐ Based Advice on Tooth Brushing ............................................................................ 43 Appendix 2 Evidence for the effectiveness and use of fluoride varnish .................................................... 50 Appendix 3 Evidence for the effectiveness of Fissure Sealants .................................................................. 58 Appendix 4 Evidence of relevance to Behaviour Change (oral health education) .......................................... 65 Appendix 5 Screening Protocol ....................................................................................................................... 67 2 Introduction • This How to Guide is a resource for everyone involved in managing and delivering Designed to Smile (D2S), but particularly dentists and Dental Care Professionals (DCPs) who have a “hands on” role in D2S. • It will also be useful for other Community Dental Service (CDS) personnel, teachers and teaching assistants, General Dental Service teams and other health professionals. These groups may like to contact their local D2S team for further information. D2S teams contact details are on the website: http://www.designedtosmile.co.uk/home.html • Delivering Better Oral Health also supports dental teams to deliver evidence based preventive advice to patients and service users of all ages. Version 3 is available on the D2S website. • This Guide is designed to be user friendly and a resource to refer to frequently – not read as a “textbook”. It is supported by resources which can either be downloaded from the website or purchased as printed • D2S is a Welsh Government commitment in the Programme for Government and is publicly funded. It is a key component of Together for Health -‐ a National Oral Health Plan for Wales http://wales.gov.uk/topics/health/cmo/professionals/dental/publication/information/plan/?lang=en • The principles of D2S are outlined in a Welsh Health Circular and Ministerial Letter. http://www.designedtosmile.co.uk/fluoride_varnish_new3.html • D2S is consistent with other Welsh Government Policies and Guidance, particularly those which relate to infant and early years feeding and nutrition. Welsh Government is revising these key publications which will be put on the D2S website under “Information for Professionals” when published. • D2S is delivered by teams working within the CDS. The CDS Clinical Directors are ultimately accountable for the delivery of D2S in their Health Board area but everyone who works with in D2S has a duty to ensure they deliver the programme efficiently and effectively. • D2S must be delivered to the highest quality. This Guide includes the Welsh Government D2S Quality Framework which outlines the programmes quality principles (page 39). The Framework is underpinned by detailed Quality Standards which are part of every activity in D2S. Acknowledgements: Much advice and support has been provided by the Childsmile programme in Scotland, and we thank NHS Scotland for giving permission to use Childsmile resources as a basis for developing this How to Guide. This version of the How to Guide has been developed with the support and expertise of D2S and Community Dental Services personnel in Wales and Cardiff University. We welcome your feedback – please contact [email protected] if you would like to comment. 3 Part 1: An Overview of Designed to Smile and its Key Components 1.1 An overview of Designed to Smile In their Eradicating Child Poverty in Wales’s strategy1, Welsh Government set a target that by 2020 the dental health of 5 and 12 year olds in the most deprived fifth of the Welsh population will improve to that presently found in the middle fifth. In March 2008, the Welsh Government laid out plans for the commissioning and implementation of a school-‐based fluoride supplementation programme called Designed to Smile, aimed at meeting these targets. The programme is one of the principle initiatives of the National Oral Health Plan for Wales (NOHP)2. The original core programme incorporated three elements: (i) supervised tooth brushing in school or nursery for 3-‐5 year olds; (ii) oral health promotion for key groups of children, their parents and health and teaching professionals ; and (iii) promoting oral health from birth (0-‐3 year olds) .As the programme has become embedded the tooth brushing element has been extended to include younger children, and now children in nurseries and schools can participate from 6 months to 7 years old inclusive. The programme also incorporates the original Welsh Government Fissure Sealant programme, and a fluoride varnish application programme. Much of the early work has focussed on the first of these elements: the supervised tooth-‐brushing programme aimed at schools and nurseries. The CDS (CDS) has been responsible for organising, coordinating and delivering the programme, including the production and translation of resources, the sourcing of materials and recruitment of new staff members to the project. The scheme was originally piloted in two areas: in South Wales, in Cardiff, the Vale of Glamorgan, Bridgend, Rhondda Cynon Taff and Merthyr Tydfil; and also in the North Wales region. As well as providing a mixture of urban and rural localities, the pilot areas also cover almost a third of the Welsh population. In October 2009, the Welsh Government made the decision to expand and enhance the programme, including the involvement of CDS teams in Aneurin Bevan, Abertawe Bro Morgannwg, Hywel Dda and Powys Health Board areas. 1. Eradicating Child Poverty in Wales – Measuring Success, Welsh Assembly Government, October 2006. Web address: http://wales.gov.uk/topics/childrenyoungpeople/publications/eradicating/;jsessionid=310PLHyfQfQJdfCwt2C9 pGy2NZv05f1tBT1yzP2ZvKvXbyJhrNtW!200562741?lang=en 2 . Welsh Government. Together for Health: A National Oral Health Plan for Wales 2013-‐18 . http://wales.gov.uk/topics/health/cmo/professionals/dental/publication/information/plan/?lang=en 4 1.2 Overview of the Tooth brushing Programme Why carry out supervised tooth brushing? There is strong scientific evidence that the daily application of fluoride toothpaste to teeth reduces the incidence and severity of dental decay in children. It has also been shown that a supervised tooth brushing programme is more effective than an unsupervised programme at reducing decay (see The Evidence Base). Nursery and early school life can provide the perfect environment for children to take part in a supervised tooth brushing programme, teaching them to brush their teeth effectively from a young age What is involved? The tooth brushing programme is a targeted programme aimed at children in the most disadvantaged communities. Target settings have been identified by WOHIU. Children between the ages of 3 and 5 years in these settings are offered free daily supervised tooth brushing with fluoride toothpaste. In nurseries children from 6 months are included but the programme is carefully tailored to ensure safe participation in age groups 6-‐18 months, 18 months to 2 years and 2 to 3 years. The children (and their parents) are accessed through schools and local authority, voluntary and private nurseries and organisations such as Flying Start. Oral health education is given to these children and the programme has a focus on healthy living in line with other national initiatives such as the healthy schools scheme. In addition tooth brushes and toothpaste are provided to those taking part, for use at home to compliment the programme. Who is involved? The daily tooth brushing programme is carried out and supervised by nursery/school staff, who are trained and supported by their local D2S team. Each school or nursery is allocated its own D2S team from the local CDS consisting of a Dental Health Educator or Oral Health Improvement Practitioner and a Dental Health Support Worker. These teams will visit the nursery and school classes regularly to support the staff and teach the children how to brush their teeth. They will be local points of contact for teachers, parents and school nurses, facilitating the smooth running of the programme and providing advice. Quality and Safety Appropriate training is provided to all nursery/school personnel involved in the programme, with an effective support system in place from the D2S teams. Protocols must be adhered to by those taking part. The D2S teams will supervise how the tooth brushes are stored and replaced, and ensure that the necessary checks are carried out to meet the set hygiene standards. Formal Quality Assurance assessments will be carried out by the D2S teams on a regular basis and any necessary remedial action taken immediately. 5 1.3 Overview of the Fluoride Varnish Application Programme Why apply fluoride varnish to teeth? In the absence of water fluoridation fluoride varnish is an effective option for the application of topical fluoride to teeth. High quality evidence of the decay-‐preventive effectiveness of fluoride varnish is available (see The Evidence Base), and a number of systematic reviews conclude that twice-‐yearly applications of the varnish (strength: 22,600 ppm) is safe and can reduce decay rates by up to 33% in primary teeth, and 46% in permanent teeth. Fluoride varnish is well accepted by patients and its application is simple. Application of fluoride varnish should begin when the child starts nursery or school and should be carried out at approximately 6 monthly intervals, although it can be applied 4 times a year. How is it applied? The application is carried out within the school or nursery setting. Parents are notified about the procedure and written consent obtained. An area is then set up in the school or nursery by the dental team where the children can be seen individually. Fluoride varnish is painted onto each child’s teeth with a small brush after they have been dried with cotton wool. The whole procedure takes just a few minutes. Who applies the varnish? The varnish is applied by a member of the D2S team. The team consists of a hygienist, dental therapist or other DCP qualified with extended duty to apply fluoride varnish and a dental nurse or support worker. School or nursery staff are not involved in its application. Quality and Safety The D2S protocol for fluoride varnish application must be adhered to by the D2S Team. Risk assessments are carried out as part of this protocol and cross-‐infection procedures are observed in line with national guidelines WHTM 01-‐05 (Welsh Health Technical Memorandum on Decontamination in Primary Dental Care and Community Dental Services). 6 1.4 Overview of the Fissure Sealant Application Programme Why apply fissure sealants to teeth? Fissure sealant is a resin based material which is applied to the occlusal (biting) surface of posterior (back) teeth to prevent dental caries in this area. The material “smoothes” the fissure to prevent food and plaque collecting and to make it easier to clean. Fissure sealants can last for many years, but should be checked at intervals to ensure they are intact. (See evidence base Appendix 3.) How is it applied? Fissure sealant can be applied in a range of settings including school or mobile or fixed dental surgery. Children are screened for suitability and written consent sought from parent / person with parental responsibility prior to placement. Fissure sealant is applied in simple steps. If necessary the tooth is cleaned and then etched, dried and the sealant applied. The whole process takes a few minutes and the majority of children find the process acceptable. Who applies the fissure sealants? The fissure sealant is applied by a member of the dental team usually a dental therapist or dental hygienist using recognised techniques and materials. The dental clinician is supported by a trained dental nurse. School or nursery staff are not involved in fissure sealant application Quality and Safety All D2S programmes follow a specific protocol. Risk assessments are an integral part of this protocol and national cross infection guidelines are followed (WHTM 01-‐05). 7 1.5 Overview of the Oral health Education (OHE) Programme Why provide OHE lessons/sessions? There are many ways to provide meaningful learning experiences about oral health that can encourage children to develop good attitudes and habits. Learning about good oral health care at an early age can benefit children throughout their lives. Dental disease can be prevented and healthy teeth can last a lifetime. Oral Health Education is also offered to adults, particularly parents and teaching staff. Structure of the lessons • Aims and objectives – education begins with a goal (an aim), and the means of achieving that goal (objectives) • A lesson plan – detailed step by step • Evaluation – to gauge how successful elements of the lesson were Aims – should be: • • • • Brief Clear Simple Comprehensive (covering all the material to be taught in a session) For example: ‘I aim to teach this group how to brush effectively’ Objectives – should be: • • • • • Specific (state exactly what the learner will achieve) Measurable (there will be a means of testing new skills, knowledge or attitude) Attainable (the learning ability of the group must be considered) Relevant (relating to what you want the learner to achieve) Time – related (what is achievable in the time available) For example -‐ know which toothbrush to use, how to brush their teeth properly and understand “spit don’t rinse” Remember! SMART When setting objectives, the educator must first consider: • • • • • The age, sex and social class of the group/learners Previous knowledge and attitudes Resources available Time allocated for the session What the learner should realistically be able to achieve after the session Lesson Plan – all lessons no matter how short need a plan. A plan enables the educator to: • Keep to the topic • Refer to the objectives • Keep to the teaching method 8 • Asses how well the patient learned • Evaluate the lessons As educators gain experience, they will refer to plans less and less. However, it is still a good idea to have a plan to double-‐check that nothing has been forgotten. Effective evaluation will tell you, whether objectives have been achieved and if the educator’s efforts were worthwhile. Content of the lessons There are four key messages to promote good oral health 1. Diet 2. Tooth brushing 3. Fluoride 4. Dental attendance In older age groups additional topics may be covered. Examples include smoking, alcohol, use of mouth guards and breastfeeding. 9 Part 2: Stage by stage guide to delivering Designed to Smile Resources to support programme delivery are described on the D2S website. Many can be downloaded from the website, while others are available in hard copy format. 2.1 Contacting the school or setting Stage 1: Initial Contact A D2S team member makes initial contact with head teacher/manager of the school/nursery. 1. Talk through the main issues with regard to the D2S programme on the phone: • Welsh Government funded programme • Describe elements of the programme • Supported and Supervised by school staff • Supported by D2S team 2. Arrange an appointment to meet the head teacher. When arranging to visit a new school, it may be necessary to confirm the school postcode and to enquire if there are any special arrangements for parking on site and entering the school. 3. Explain that you will confirm the meeting by letter or e-‐mail if required, and provide your full contact details Notes* Throughout this document all references to “parent” mean parent or person with parental responsibility. All references to “head teacher” should be regarded as head teacher or nursery manager. 10 Stage 2: First visit to school or nursery setting Ensure that you arrive in good time and allow at least 5 minutes to be prepared. • Introduce yourself and sign in at the school. Ensure you are wearing your personal ID badge, as it is essential you have proof of identity to comply with school security policy. • Give the head teacher a copy of your contact details and those of the D2S Team, if appropriate. Describe D2S: (see Overview of D2S) Provide an overview of the D2S Team, the role of each team member and the key components of the programme. D2S Introductory pack – ensure the head teacher has a copy of relevant ‘D2S documents, which may include: • Contact details • Overview of D2S • Information for parents • Programme component protocols • Initial enquiry and assessment form • Classroom assessment • Risk assessment sheet • Criteria for award 11 Stage 3: Follow up action from meeting: 1) Head teacher not interested at present time If head teacher is not interested in participating in the programme, identify their main concerns and record them. Send a follow-‐up letter confirming this decision has been made. 2) Head teacher interested but not able to commit immediately If head teacher is committed but has no time to complete information sheets and assessment -‐ leave paperwork at the school and arrange a date for another visit to meet head teacher/other staff members as appropriate and complete paperwork together. 3) Head teacher committed Head teacher is committed to joining the programme and has time to complete initial paperwork. Schools may elect to take part in some or all parts of D2S. Class Lists – Ask the Head teacher/school secretary for the class list(s) for all classes to be included in the programme. Class teachers/Classroom assistants – Ask to meet and introduce yourself to these individuals although this may need to be arranged at the follow up visit. Stress the importance of daily tooth brushing. The programme is of maximum value if this is achieved. Complete the assessment paperwork and arrange a further visit to confirm details and meet with other staff members, preferably to include school nurse. Send a letter confirming date and time of this follow up meeting. Advise that if school leaves programme after parents have given consent the head teacher is responsible for informing parents of decision to withdraw, and for informing school governors 12 2.2 Tooth brushing Programme Protocol See evidence base section for evidence underpinning tooth brushing programme (Appendix 1) Stage 1: Setting up – initial visit The school / nursery will be given D2S pack at this time. This includes: - Contact details of the D2S Team Copy of Initial Enquiry and Assessment Form Risk assessment sheet Samples of consent letters Sample brush bus/rack and brushes Register for those attending training QA monitoring paperwork Sample Register for children, brushing record Copies of individual protocols for tooth brushing programme Equipment list Class list (to be obtained from school staff) 1. Complete on-‐site schools information sheet in consultation with head teacher and/or other staff members to confirm how the programme will work in school. 2. Agree which school staff member will supervise and oversee the programme and act as main contact for D2S team. 3. Complete on-‐site risk assessment for each classroom, to include details re storage and cleaning. 4. Agree target start date and date for consent meeting. 5. Arrange for consent letters to go out at least 2 weeks prior to target tooth-‐brushing start date. 6. If you have not yet met with all class teachers or support workers, arrange a separate visit. 7. Arrange further school visit on target start date to deliver resources and assist implementation. 8. Explain that you are likely to be on site every day for the first few days, to give assistance with implementing the tooth brushing, and will be providing support at agreed intervals to ensure the safe delivery of the programme. Ensure a D2S team member can be contacted by phone if any queries arise. 9. Obtain / develop class list if not yet received. Details of all participating classes required. 10. It may be useful in some nurseries/crèches to have details of day(s) when children attend. 13 Stage 2: The positive consent process Seek advice from the head teacher/nursery manager as to the best way to obtain valid consent from parents. Model A Information and consent forms are sent out to parents via the school system. OR Model B The D2S team meet with the parents to explain the details of the programme, and then consent is obtained. This may be done at reception intake meetings. Model A: Consent forms are sent out via the school system: • The D2S team member takes consent packs to the school for the teacher to give out. The pack includes - • • • Envelope with child’s name on it Tooth brushing consent form Tooth brushing information leaflet Blank consent packs are left in case of non-‐returns/mislaid consents. For forms not returned after a week, D2S team send out an additional consent pack to relevant child/children. Allow no more than 2 weeks before collecting completed consent forms. For any forms still not returned, liaise with teacher over most appropriate local action to take to encourage a reply. All children who return positive consent forms are entered onto the tooth brushing register. • Model B: Where a parents meeting takes place • D2S team introduce themselves. • Explain why D2S and the tooth brushing programme is available at the school, and use of home packs • Discuss key messages of oral health, remembering the holistic approach to health promotion. • Ensure that the parents understand the consent documentation. • Advise the parent where they can get more information at a later date, if appropriate. • After explaining the tooth brushing programme to the parent, he/she should be asked if they want their child to participate in the programme. If yes: • Ask the parent to fill in the details for the child on the consent form. • Provide support in completing the form if required. • If asked, offer advice on where the child can access dental care. • Ask the parent to sign and date the consent form. 14 If no: • Ask if they want to have more time to think about it or discuss it with somebody else. • Ensure it is clearly noted where parents have refused to allow their child to join the D2S programme. • For those children who were not represented at the consent meeting, ensure consent form is placed in an envelope and given to teacher/assistant for distribution. Stage 3: Post consent process administration • Ensure that the completed consent forms are kept safely either in school/nursery or CDS premises • Collate equipment needed for each class Requirements for set up of school based tooth brushing File containing: • Class lists and signed consent forms. (The signed consent forms may be kept at the D2S office – a list of consenting children will be left at the school). • Instructions for teacher – daily and weekly programme routines. • Record tick sheet for daily tooth brushing. • Spare consent forms. Equipment: Blue clinical roll. Box of disposable gloves. Storage trolley. Rack/brush bus (labelled). Tooth brushes (labelled). Tooth paste (with appropriate F content). Timer. Mouth model/brush • • • • • • • • • Ensure the buses / racks and brushes are labelled appropriately. • Ensure that teacher and assistant understand the tooth brushing protocol, the risk assessment form, and the other aspects of Quality Assurance Form and that all relevant staff sign the documents. Place in the class file. • Ensure that tooth brush buses/racks are all stored as per the risk assessment. • Discuss tooth brushing record sheet with appropriate member of staff – to be completed daily, and kept in class file. • Obtain signature of the member of staff responsible for acknowledging the receipt of equipment (Return to central office as agreed with line manager.) 15 Stage 4: Start of tooth brushing programme When meeting the classes for the first time members of the D2S team should: • Provide teacher with the list of children whose parents have consented. • Ask teacher if any additional consents received or withdrawn. • Introduce themselves to children and school staff. • Discuss key messages with children utilising D2S stories/resources at a level appropriate to the age group. • Demonstrate tooth brushing to the class and teacher/assistant. • Daily tooth brushing commences. • Home packs may be issued at this stage. NB Some or all steps in Stage 4 may be done prior to start of tooth brushing programme depending on local CDS systems Stage 5: Review and monitoring of the tooth brushing programme • D2S team member to attend each participating class during the first week as required, ensuring that the programme is smoothly and safely implemented. Revisit the following week and then as required. • When programme effectively established a formal Quality Assurance must be completed once a term. • Ensure that any new staff have appropriate training. • Ensure that for any new children to the class that consent forms have been obtained and that they have been instructed in the correct tooth brushing technique. • Ensure that all consumables are signed for by a named member of staff and form returned to the administration office. • The D2S tooth brushing home packs will be given out at least twice a year or 3 times if resources permit. This should be recorded on the class sheet. Quality Standards for Tooth brushing 1) Children use an appropriate and effective quantity of toothpaste whilst minimising cross contamination. Rationale Regular daily brushing with appropriate fluoride toothpaste is highly effective in preventing dental decay. Good oral hygiene practice should be established at an early stage in a child’s life and become an integral part of normal daily hygiene. Criteria: 1.1 Toothpaste from a pump dispenser or tube containing 1000 parts per million fluorides (+/-‐ 10%) is used (see Appendix) for children under the age of 3. Toothpaste from a pump dispenser or tube containing a minimum of 1350 parts per million fluoride is used for children aged 3 years and over. 1.2 A smear (0-‐2 year olds) or small pea-‐sized amount (3-‐6 years) of toothpaste is used. 1.3 A supervisor or the individual child dispenses the toothpaste. Children dispensing toothpaste must be supervised. 1.4 Where toothpaste is shared, it is dispensed directly onto a clean surface such as a plate or paper towel. 1.5 There is sufficient spacing between the quantities of dispensed toothpaste to allow collection without cross contamination. 16 1.6 Toothpaste will be applied to a clean dry tooth brush. 2) Tooth brushes and brushing techniques are appropriate and are able to be used effectively by each child. Rationale Tooth brush size and shape influences the effectiveness of brushing. Brushing programmes should work towards establishing effective tooth brushing techniques for the developing child. Criteria 2.1 Tooth brushes and brushing techniques are appropriate to the age and ability of the child, with help provided if needed. 2.2 Tooth brushes are replaced at least once a term or earlier if required. 2.3 Tooth brushes are individually identifiable for each child either with child’s name or a symbol to avoid confusion and cross contamination. 3) Tooth brushing is organised in a safe and effective way which is integrated with nursery and school routines. Rationale Children up to the age of 7 should be supervised whilst tooth brushing. Tooth brushing programmes should be integrated into normal nursery and school routines to ensure maximum compliance. Criteria 3.1 Each child brushes once a day in the tooth brushing programme. 3.2 Children are closely supervised when brushing. 3.3 Tooth brushing takes place at a time which is most suitable for each establishment. 3.4 Tooth brushing takes place in groups or individually with children seated or standing at a sink area. 3.5 Children are discouraged from swallowing toothpaste during or after brushing. They should spit out excess but not rinse. Reinforce the “spit don’t rinse” message and ensure this is done in all settings 3.6 After tooth brushing, brushes are rinsed thoroughly and replaced in the storage system with bristles upright. 3.7 The tooth brushing programme uses one of two models (see later) 4) Toothpaste storage systems comply with best practice in the prevention of cross contamination. Rationale Tooth brushes are a potential source of infection. Criteria 4.1 Tooth brushes are stored in appropriate storage systems or individual holders. 4.2 Storage systems enable brushes to stand upright when positioned. 17 4.3 Storage systems allow sufficient distance between tooth brushes to avoid cross contamination. 4.4 Storage systems display symbols corresponding with those on the tooth brushes to allow individual identification. 4.5 Storage systems which do not have covers are stored within a designated trolley or in a clean dry cupboard. 4.6 Opened brushes that are in use must never be stored in toilet areas. It may be possible to store sealed boxes of unopened toothbrushes in toilet areas but only if there is no other storage area and after a risk assessment. 4.7 Tooth paste must be stored safely where children cannot access it. 5) Appropriate cleaning procedures are in place to ensure that cross infection risks are minimised. Rationale Tooth brushes are a potential source of infection. Good cleaning practice should be an integral part of childcare in the nursery and school setting. Criteria 5.1 Manufacturers’ guidelines are followed when cleaning and maintaining storage systems. 5.2 Dedicated household gloves are worn when cleaning storage systems and sinks; and all cuts, abrasions and breaks in the skin are covered with a waterproof dressing before cleaning is carried out. 5.3 Storage systems, trolleys and storage areas are cleaned, rinsed and dried with neutral detergent. 5.4 Care is taken to ensure that tooth brushes do not cross-‐contaminate when being removed or replaced in storage systems. 5.5 Storage systems are not positioned adjacent to the sink area whilst tooth brushing takes place in order to prevent contamination via aerosol spread. 5.6 Storage systems are replaced if cracks, scratches or rough surfaces develop 5.7 Any tooth brushes dropped on to the floor are discarded. 5.8 Tooth brushes are not soaked in Milton or other cleaner/ Disinfectant. 6) Supporting Information for Tooth brushing Children suffering from toothpaste allergies or those who do not use toothpaste containing animal derivatives should have appropriate alternative toothpaste provided. The standards on fluoride concentration should be followed. 1.1 Whilst it is usually recommended that tooth brushing should not directly follow the consumption of acidic foods or beverages, it is acceptable for establishments providing tooth brushing programmes to opt to brush at any time throughout the day. In these circumstances it is considered that the benefits of decay prevention outweigh concerns about dental erosion. 1.2 It is recommended that children are discouraged from actively rinsing after tooth brushing. Rinsing after brushing significantly decreases the benefits of fluoride. Settings must be advised on how best to ensure children can comply with “spit don’t rinse” policy 1.3 Baby and antiseptic wipes are suitable for skin but are unsuitable for plastic. 18 surfaces. Disinfectant wipes are not recommended for storage systems. Household detergent is recommended since it kills the vast majority of relevant micro-‐organisms and is the first stage in any decontamination process. 1.4 Rough surfaces on storage or dispensing systems can encourage the growth of harmful micro-‐ organisms. Damaged racks therefore need replacing. 19 1.5 Individual tooth brush holders can be used for storing brushes, although most establishments involved in tooth brushing programmes elect to use a rack system. If individual holders are used, ensure that excess water is removed from the brushes before returning them to the holder. The standards apply equally to individual holders as to rack systems. 1.6 Whilst some tap water supplies in nursery and school settings are not technically of drinking water quality, it is considered suitable for rinsing tooth brushes as the water is not ingested. 1.7 Ideally, nurseries and schools participating in the tooth brushing programme should have sinks available that are designated for tooth brushing and personal hygiene. Where only one sink is available, nurseries should be encouraged to work towards the provision of a second, dedicated sink for tooth brushing and personal hygiene as best practice. 1.8 Nurseries and schools should have a condensed format of the ‘Standards’ that can be used for reference purposes within establishments involved in nursery tooth brushing programmes. 1.9 Once a tooth brushing programme is well established, local monitoring should take place at least once every term : more frequently if the programme is just starting or if the D2S team or school staff have concerns (Standard 1). Monitoring should include observation of the tooth brushing session; discussion of the Standards with the key nursery or school lead; feedback to the overall programme lead; arrangement of a follow-‐up visit. Nursery Tooth Brushing Models Model 1 – Tooth brushing at a sink 1. The supervisor or child is responsible for collecting the tooth brush from the storage system. 2. Toothpaste is dispensed following the appropriate methods (see Standard 1). 3. Tooth brushing takes place at the identified sink area. 4. Ideally, no more than two children are permitted at each available sink. They should be closely supervised. 5. Tissues/paper towels must be disposed of immediately after use in a refuse bag. 6. Tooth brushes can either be: - Returned to the rack by each child and taken to an identified sink area by the supervisor who is responsible for rinsing each tooth brush individually under running water; or - Rinsed at a designated sink area where each child is responsible for rinsing their own tooth brush under running water. The supervisor or the child can be responsible for the control of the running tap. 7. After rinsing of the tooth brushes is complete, the child or the supervisor is responsible for shaking off excess water into the sink. 8. Each child or supervisor can return the tooth brush to the storage system to air dry. 9. Paper towels should be used to mop up any drips visible on the storage system. 10. Supervision must be present at all times. Supervisors are responsible for rinsing sinks after tooth brushing is complete. 20 Model 2 – Tooth brushing in a dry area 1. The supervisor or child is responsible for collecting the tooth brush from the storage system. 2. Toothpaste is dispensed following the appropriate methods (see Standard 1). 3. Children may be seated or standing whilst tooth brushing takes place. 4. After tooth brushing is completed, children can spit excess toothpaste into either a disposable tissue or a disposable paper towel. 5. Tissues/paper towels must be disposed of immediately after use in a refuse bag. 6. Tooth brushes can either be: - Returned to the rack by each child and taken to an identified sink area by the supervisor who is responsible for rinsing each tooth brush individually under running water; or Rinsed at a designated sink area where each child is responsible for rinsing their own tooth brush under running water. The supervisor or the child can be responsible for the control of the running tap. 7. After rinsing of the tooth brushes is complete, the child or the supervisor is responsible for shaking off excess water into the sink. 8. Tooth brushes are returned to the storage system by the supervisor or child and allowed to air dry. 9. Disposable paper towels should be used to mop up any drips visible on the storage system. 10. Supervision must be present at all times. Supervisors are responsible for rinsing. Tooth brushing for age groups 6 months to 3 years The programme is carefully tailored to ensure safe participation in age groups 6 to 18 months, 18 months to 2 years and 2 to 3 years. Nursery staff are trained and parental consent obtained as per the system used in school. -‐ -‐ -‐ Babies 6 months to 18 months : usually in a high chair and the tooth brush is given with a VERY THIN smear of 1000ppm fluoride tooth paste, the baby holds the brush in the mouth for approximately 10 seconds (with guidance from the staff). 18 months to 2 year old, tooth brush for 1 min with a thin smear of 1000ppm toothpaste (1 min egg timers given to this group). 2 to 3 years old, tooth brushing for 2 minutes with a thin smear of 1000ppm tooth paste (2 min egg timers are given). 21 QUALITY ASSURANCE The Quality Assurance assessment must be completed using the recognised QA form (see below). Formal QA should be carried out within each setting at least termly, but this may be more frequent if the setting is just beginning the programme or there is reason for concern. • The D2S QA check list is completed at each QA session. • If there are any areas of concern, these are addressed immediately. • If there are areas of concern which cannot be addressed in the setting immediately, the programme is suspended pending additional training for the staff concerned. • The D2S manager is informed. • An appointment is made for additional training, with an emphasis placed on the importance of adhering to the D2S protocols and guidelines. • Following re commencement of the programme, the guidelines for the initial setup are followed. 22 Home packs for School/Nursery Children Rationale: There is strong evidence that the daily application of fluoride toothpaste to teeth reduces the incidence and severity of dental decay in children. The provision of home packs will allow the continuation of this daily application throughout the year, including weekends and holiday periods. Home packs consist of a suitable sized tooth brush and appropriate strength fluoride toothpaste Home packs will be distributed to children actively participating in tooth brushing, Fluoride Varnish or Fissure Sealant Programme. As a general rule they will not be distributed to non-‐participating children. However in exceptional circumstances a small number of packs can be provided for non-‐participating children as a one off PR exercise. They are delivered to participating schools and nurseries by the D2S team, and are distributed to the classes by school staff. Children should receive at least 2 home packs per year, or 3 where resources allow. Oral Hygiene Packs for Flying Start Where resources allow D2S teams may provide oral hygiene packs to Health Visitors for children attending Flying Start. As with home packs for schools and nurseries, they are for children participating in tooth brushing programme. Settings who decide to leave the tooth brushing programme Head teachers may decide to leave the programme in full or in part. In the first instance the D2S clinical lead and / or the CDS Clinical Director should discuss this with the head teacher to deal with any issues / concerns. It may be possible to alleviate these. If the head teacher still decides to withdraw from the programme he / she must be sent an Exit Questionnaire (see Information for Professionals section on D2S website) which must be copied to the Chair of Governors. The Chief Dental Officer must be advised of any settings leaving the programme in full or in part 23 The next sections deals with Fluoride Varnish and Fissure Sealant protocols. See Appendix 5 for the all Wales screening protocol and all Wales consent process which describes screening to identify children for fluoride varnish or fissure sealant 2.3 Fluoride Varnish Application Programme Protocol For use in a nursery or school setting The D2S Programme uses a Colgate fluoride varnish called Duraphat * which contains 22,600ppm or 5% sodium fluoride. Many scientific studies from around the world have shown that fluoride varnish is effective in reducing the dental decay rate in children when used in addition to brushing teeth regularly with fluoride toothpaste. A Cochrane Systematic Review (Marinho et al. 2002) reported the statistically significant caries-‐ inhibiting effect of fluoride varnish. The CDS Clinical Director is the overall clinical lead for the fluoride varnish programme as outlined in a letter (November 2015) to CDS CDs from the Welsh Government Chief Dental Officer Fluoride varnish works in two ways: • It slows down the development of decay by stopping demineralisation. • It makes the enamel more resistant to acid attack (from plaque bacteria), and speeds up remineralisation (remineralising the tooth with fluoride ions, making the tooth surface stronger and less soluble). Fluoride varnish is a very safe material to use. However, if children ingest too much fluoride over a prolonged period of time, during the period when their teeth are developing, they can develop fluorosis in these teeth. In most cases, dental fluorosis appears as barely visible pearly white flecks or lines on the surface of the affected tooth and is only detectable by a trained examiner. (There are more severe and unsightly forms of dental fluorosis but these are uncommon in the UK.) The D2S Programme supports the use of fluoride toothpaste from the time that the first teeth erupt and the professional application of fluoride varnish from the age of three. The programme has been carefully designed to ensure that the possibility of a child developing fluorosis as a result of the D2S Programme is highly unlikely and is balanced against the benefits of the prevention of decay. Duraphat is the only fluoride varnish that is licenced in the UK for caries prevention The fluoride varnish applications in the D2S Programme are offered in targeted nurseries and schools twice a year. If the nursery or school children also receive fluoride varnish from their own dental practice, they will receive an additional benefit and their teeth will become stronger and healthier. Children involved in the nursery and school aspect of the programme receive an aftercare leaflet that they should take to their dentist informing them of when they had the fluoride varnish applied. Children who take fluoride tablets or drops, or those who use high fluoride toothpaste, must not have fluoride varnish applied as part of D2S. Duraphat can be safely used in children who have not eaten recently. The controlled quantity of Duraphat will not irritate an empty stomach 24 Stage 1 : Contacting the Head Teacher to Introduce the Programme The programme must be introduced initially to the head teacher or nursery manager. An appointment should be arranged for a member of the D2S team to meet with them. Preferably this person should be the individual who will be applying the varnish. In some D2S services children are screened prior to fluoride varnish application. See all Wales screening protocol (Appendix 5). At this visit points covered should include: • An explanation of the D2S and fluoride varnish programme. A pack should be given to the head teacher including a written brief, copies of the consent form, information leaflet and an aftercare card. • An explanation of the importance of gaining valid consent. • Identification of a suitable area for the session and a risk assessment form completed. This area should be quiet and safe. • Determine whether tooth brushing is undertaken at the school/nursery. If so, request that it is carried out pre-‐application if possible. When it is not possible to brush pre-‐application, tooth brushing should not be undertaken for that day post-‐application. Tooth brushing can resume the following day as normal. • Record the times of school breaks on the risk assessment form. Application of fluoride varnish should ideally cease 30 minutes prior to eating. • Request an up-‐to-‐date class list. For nursery classes determine children that only attend AM/PM. • Agree on a date for the application which suits both the school and the D2S team. Ensure that enough time is allowed to collect the consents and obtain any prescription from the dentist. . Some nursery or pre-‐school groups may request a discussion with parents or resources that could be used to prepare the children. These should be arranged prior to application date. Administrative tasks needed at this stage: • Complete consent forms with children’s names and class, put them in envelopes and distribute to the school. A date for collection should also be given. • Complete a proforma with children’s names in alphabetical order. • A file will need to be assembled for each school containing class list, risk assessment form, proformas used, etc. Stage 2: After collection of consents Consents need to be checked and prescriptions completed by the designated dentist if Patient Group Directives1 are not being used. Individual forms must be assessed to ensure each child’s suitability to participate. The child’s medical history should be checked. If a child has been hospitalised due to asthma or allergies then they are unable to 1 A PGD is a formal written document signed by a senior dentist and Health Board Medical Director/Lead Pharmacist as a minimum. It allows trained, qualified and indemnified dental therapists and dental hygienists to use products such as Duraphat fluoride varnish on groups of patients/service users which would otherwise need to be prescribed for every individual patient/service user. PGDs can not be used for dental nurses 25 participate in the programme. If the medical history is unclear, a phone call to the parent should be made to clarify the child’s health status. At this stage the parents must be notified in writing of the date of the visit. Fluoride Varnish should not be applied to any child who has known sensitivity to colophony or sticking plasters, or has been hospitalised due to asthma or allergies Administrative tasks needed at this stage: • Consents should be placed alphabetically in the file along with the amended class list proforma and risk assessment. • The proforma should also be completed to record children with valid consent, whether they can participate and, if they cannot participate, the reason why. • Distribute fluoride application reminder cards to all children who have consent. Stage 3: Preparation before the Application Session Prior to the application session, the equipment and stock must be collected and checked to ensure there is sufficient quantity for the number of children to be seen. Equipment List • File for school/nursery containing class list and proforma consents/record sheets and treatment prescription • Leaflets and aftercare information for parents and teachers • Motivator stickers • Seating for clinician and child • Daray lamp or appropriate light source • Sterilised, bagged and labelled metal mouth mirrors or disposable plastic mirrors • Cardboard trays for clinical materials • Blue roll/ clinical sheets • Gauze and cotton wool rolls • Duraphat fluoride varnish • Microbrushes or Bendabrushes • Dosage dispensing pad • Personal Protective Equipment for patient- safety glasses and bibs • Personal Protective Equipment for clinician – safety glasses, latex free gloves • Clinical waste bags and tags • Disinfectant wipes and alcohol hand gel • Emergency equipment (see page 31) • Duraphat removal pack • Trolley for storage and transportation 26 Equipment must be carried into premises by both members of the team, in line with manual handling and health and safety guidelines, and set up in the designated risk assessed area. Stage 4: Preparation at Application Session • Check attendance for that day, note absent children. Determine the order and number you would like to see at each visit. • Remind teacher of procedure and that tooth brushing should not be undertaken that day after application. • Set up equipment in designated area. A cardboard tray should be made for each child with cotton wool rolls or gauze, 0.25ml (primary dentition) or 0.40ml (mixed dentition) of Duraphat using dosage pads, sterile or disposable mouth mirror and a Microbrush or Bendabrush. • Dental team members must wash hands prior to the session. If this is not possible, alcohol hand gel should be used. The alcohol gel should also be used in between every patient. Duraphat should be kept in the lockable trolley box at all times and only dispensed when needed. Stage 5: Clinical Procedure • Welcome each child in turn to the clinical area. • Ask the child their full name to ensure correct child. • Explain the procedure in simple terms to the child and ask if they are happy to take part. If they are clearly unwilling do not do the procedure and inform the parent. • Bib and glasses should be placed on the child. • Operator and assistant, if qualified dental nurse, should both wear a fresh pair of gloves for each patient and a visor. A risk assessment should be carried out on every child before the Duraphat is applied: 1. The child should firstly be assessed extra-‐orally. Check the skin of the face and around the mouth for any swelling/abnormalities - Check lips for lesion or infections 2. The child should be assessed intra-‐orally. With the mouth mirror check the right and left buccal mucosa, dorsal surface of tongue and floor of mouth The teeth and gums should then be checked for dental caries and /or infection in a methodical order. Fluoride varnish is contraindicated in children with ulcerative gingivitis or stomatitis 27 If everything appears normal the fluoride varnish may be applied. If any abnormalities of the face, lips or soft tissues are found the child should be excluded from the varnish application process for that episode. This should also occur if the child is displaying obvious signs of systemic illness e.g. cold, flu, and chickenpox. If dental lesions, or a concern such as facial swelling which requires immediate attention, are observed the operator should document findings on the recording sheet and contact the D2S clinical lead or a community dentist for further advice. Further action advised may involve contacting the parent by letter or by phone. The varnish can be applied to carious teeth but any exposed pulps should be avoided as it could cause discomfort. Stage 6 : The application procedure Once the risk assessment has been carried out and the operator is happy that the child is suitable, the fluoride varnish can be applied. If the child becomes upset or protests during any part of the procedure, the procedure should be abandoned. Divide the mouth into sextants (6 sections), starting with the upper right posterior teeth: • Gently retract the right cheek with your finger or mirror and dry the canine and molars with a cotton wool roll. • Place the cotton wool roll in the upper right buccal sulcus. • Holding the roll in place, apply a small amount of fluoride varnish with a Microbrush/Bendabrush to the contact points of the canine and molars. Apply more varnish to the occlusal surfaces of the molars. • Repeat for the lower right, upper left and lower left sextants. For the anterior sextants: • Retract upper lip with finger and dry anterior teeth with cotton wool roll. • Apply varnish to the labial and contact surfaces. • Repeat for the lower anterior sextant. 28 After application, ensure that all equipment is removed from the mouth. Used gloves, brushes and disposable mirrors should be disposed of in a clinical waste bag, as should any clinical paper waste. If metal mirrors are used, these should be placed in a clear rigid marked dirty instrument container which contains a damp paper towel to prevent the mirrors drying before cleaning and sterilising. The light source, chair and glasses should be wiped/sprayed down between each child and at the end of screening. There should be no transportation of dirty instruments or clinical waste between schools. Used metal dental mirrors should be sterilised according to local procedure. Administrative tasks needed at this stage: • Proforma completed to record whether varnish was applied/ child refused or child was absent. Any problems with application should be noted. • Amount dispensed, batch number and expiry date of the Duraphat tube used should be recorded on the school/nursery paperwork. If more than one tube is used each batch number and expiry date should be recorded along with identification of which child was treated from each tube. • For children who have had the varnish applied an aftercare card with appropriate instructions should be issued. • Children who were absent or refused, issue appropriate card • Parent information letter given if appropriate • When possible the date for the next 6 monthly applications should be arranged. • A Quality Assurance assessment form for fluoride varnish application should be completed during and after the session. (see form below) Quality Assurance for fluoride varnish application A D2S team member will complete the fluoride varnish QA assessment form during every fluoride varnish application session. These assessments should be reviewed regularly and used as a quality assurance tool. Any areas of noncompliance must be assessed, rectified if necessary and used as learning for subsequent sessions. Health Board policy will dictate whether any noncompliance has to be reported as a safety incident. 29 Quality Assurance Assessment for Fluoride Varnish Application If answer to any question is “no” put a note of explanation alongside Requirements prior to session An up-‐to-‐date participation list is available: yes / no Consents and medical histories are readily available: yes / no Appropriate mechanisms are in place for sharing with staff details of children with/without consent and relevant medical histories: yes / no The risk assessment form has been completed: yes / no Appropriate paperwork has been distributed to school staff, children and parents: Demonstrating Effective Practice during the session yes / no The designated application area has been set up appropriately: yes / no Checks have been made to ensure correct child is seen: yes / no Appropriate assessment has been made of child pre-‐application: Duraphat has been dispensed appropriately and correct dose given: yes / no Duraphat has been applied in line with the national protocol: yes / no Application has been recorded on child’s form: yes / no Appropriate post-‐treatment advice has been given: yes / no yes / no Prevention of Cross Infection The designated application area was clean and new equipment was used for each child: Appropriate hand hygiene has been carried out and fresh gloves were used for each child: Equipment has been sprayed down between each child: Clinical waste has been disposed of appropriately: Transportation and sterilisation of dirty instruments/clinical waste has been in line with protocol/local procedure: yes / no yes / no yes / no yes / no yes / no Completed by (name)……….. Date….. Setting………… 30 Medical Emergencies – The collapsed child Thorough checking of individual medical history and eliminating children who should not receive fluoride varnish should reduce risk of medical emergencies. Emergency equipment will be taken to the school as per agreed Welsh protocol (below) and in line with GDC registration. The child’s medical history must be completed before use of FV, and updated before subsequent administrations D2S teams must liaise with schools and know - what emergency equipment the school has and where it is kept (NB -‐ schools and nurseries very seldom have equipment to deal with a medical emergency) - what their emergency procedure is - who is the first aider (on the day make sure the first aider knows dental team in school-‐ and the team knows where first aiders are) - they have immediate access to a phone to dial 999 (may be D2S mobile – check it has signal) • • This information must be checked again on the day Dentists and DCPs must be trained to deal with emergencies, including paediatric resuscitation and administration of adrenaline. The most severe problem will be a child having an anaphylactic shock. This is very rare, but all dentists and DCPs must be able to recognise and deal with this. D2S teams must take Emergency equipment with them. This will include the standard CDS emergency drug box and Oxygen. Adrenaline should be in a simple to use delivery system (E.G a child Epipen or monoject) or as advised by HB Resuscitation Lead. GDC regulations state all clinical areas should have immediate access to an automated external defibrillator. Schools and nurseries are not clinical settings -‐ It will be for individual services to decide whether to take a defibrillator. D2S teams are advised to use a simple checklist to ensure they have all emergency equipment prior to fluoride varnish sessions. • • • • The most likely cause of a collapsed child is syncope (faint) but a thorough assessment of the child should be undertaken to rule out other possible causes including anaphylaxis and underlying medical conditions, such as epilepsy, cardiac conditions or diabetes. In the rare event of a collapsed child this protocol should be followed: • Stop the procedure and summon help from staff/team • Call 999 • Remove all equipment from the vicinity of the child • Remove other children from the area • Assess child regarding Airway, Breathing, Circulation • Treat any known cause if possible • Start Basic Life Support if necessary and maintain until help arrives 31 • If ABC satisfactory, place the child in the recovery position Allergy and Anaphylaxis Duraphat varnish should not be used on patients with hypersensitivity to colophony (also found in sticking plasters) or any other constituents, those with ulcerative gingivitis or stomatitis, or anyone who has been hospitalised with asthma or allergies. Allergy to Duraphat is very rare (≤1/10,000) but symptoms may include: Urticaria (itching) Burning sensation Vomiting Dyspnoea, (shortness of breath) Conjunctivitis Swelling Skin rash Chest tightness Rhinorrhoea (sudden onset runny nose) More serious reactions may involve angioedema, asthmatic attack and anaphylaxis. 32 Emergency Treatment for Suspected Allergy • Fluoride varnish must be removed immediately from the teeth using the removal pack. The varnish can be rubbed off using a brush and gauze. More stubborn layers can be removed with the excavator. • The child should be encouraged to rinse their mouth with copious amounts of water. • Close monitoring of the child should occur post-‐treatment for a minimum of 30 minutes to confirm no further deterioration, and until all symptoms have resolved. • Consideration should be given to the provision of antihistamines from a Community Dentist, the child’s GP or from a pharmacist. • Advice should be sought from a Community Dentist regarding aftercare. • Thorough notes should be made regarding the incident and the D2S Clinical Lead should be informed as soon as possible. Emergency Treatment for Asthmatic Attack Most attacks will respond to 2 puffs from the salbutamol inhaler. Further puffs are required if the patient does not respond rapidly. If the response remains unsatisfactory, or if further deterioration occurs, then the patient should be transferred urgently to hospital. Whilst awaiting transfer, oxygen should be given with 4-‐10 puffs of salbutamol every 10 – 20 minutes as necessary. Emergency Treatment for Anaphylaxis Symptoms and Signs: Paraesthesia, flushing and swelling of face Generalised itching, especially of hands and feet Bronchospasm and laryngospasm (with wheezing and difficulty in breathing) Rapid weak pulse together with fall in blood pressure and pallor, finally cardiac arrest. Management: • Stop the procedure and summon help from staff/team • Call 999 • Secure the airway • Restore blood pressure (laying the child flat and raising the feet, or in the recovery position if unconscious or nauseous and at risk of vomiting) • Administer adrenaline • Administer oxygen • Arrange to transfer child to hospital urgently 33 Administration of Adrenaline: This is done intramuscularly in the appropriate doses below. The dose is repeated if necessary at 5-‐minute intervals according to blood pressure, pulse and respiratory function. Dosage: Adult and child 12-‐18 years Child 6-‐12 years Child under 6 years 500 micrograms 300 micrograms 150 micrograms 0.5ml adrenaline injection 1 in 1000 0.3ml 0.15ml Fluoride Varnish Doses and Toxicity Recommended doses: • 0-‐5 yrs =0.25ml Duraphat for the full mouth • 5-‐12yrs =0.40ml Duraphat for the full mouth • 12+ =0.75ml Duraphat for the full mouth The toxic dose of fluoride ingestion is estimated at 5mg of fluoride per kg of child body weight. The average three year old weighs 11-‐20kg, so a 15kg child would need to ingest 75mg to cause acute fluoride toxicity. The dose of 0.25ml of Duraphat contains 5.6mg of fluoride – well within safe limits. Acute fluoride toxicity causes nausea and vomiting. If an individual is suspected of ingesting excess fluoride they should be given milk to drink, the local A&E department telephoned and the situation explained. Reporting Adverse Reactions If there are any adverse reactions to the fluoride varnish (e.g.mucositis, allergy etc.) then these must be reported using local reporting process. A yellow British National Formulary (BNF) card should be completed and submitted as per local procedure. Questions and Answers on the Fluoride Varnish Programme How frequently can Duraphat be applied? Duraphat can very safely be applied 4 times a year. In fact, this number of applications is recommended for high caries-‐risk individuals within the ‘Delivering Better Oral Health’ document. These applications should be approximately 3 months apart but Duraphat is also recommended for the treatment of sensitivity when it should be applied 2 or 3 times in a few days, so showing that applications close together are also safe. There is research into the timing of applications, with some studies showing greater effectiveness when the applications are close together. D2S teams are trained to use the correct amount of Duraphat. As we are only applying twice a year, further application of Duraphat by any GDP will not be a problem and shouldn’t be discouraged. 34 Could Duraphat cause mottling? It is the abuse, rather than the use, of fluoride that leads to dental fluorosis, caused by frequent high doses of fluoride. If a child is swallowing large amounts of fluoride toothpaste regularly, or has a habit of eating toothpaste, there is a slight increased risk of fluorosis. It is therefore important that tooth brushing is always supervised by an adult until the child is around 7 years of age. Drinking water in Wales is not fluoridated and therefore using appropriate strength daily fluoride toothpaste and having planned Duraphat applications is extremely unlikely to cause any form of mottling. The anterior teeth are most susceptible to fluorosis at the age of 2, an age at which Duraphat is not applied, and the ingestion of fluoride after 6 years of age will not cause fluorosis. If a parent or teacher would like more information/explanation refer them to an appropriate dentist. Is there a potential risk to a child who has received two fluoride varnish applications at a dental practice followed by a further two applications as part of the targeted D2S programme? No. D2S aims to apply fluoride varnish twice a year to children at increased risk of developing dental caries, but a child can safely have four applications a year. This dose is well within the safe limits for acute toxicity levels or chronic ingestion resulting in fluorosis, even if two applications were on the same day. Furthermore, most of the teeth and certainly the six anterior teeth will have calcified by the age of 3.5 years. The optimum benefit would be four doses equally spaced throughout the year What strength toothpaste should a child use? We should follow the evidence based guidance in ‘Delivering Better Oral Health’ (DBOH). Version 2 of DBOH is available on the D2S website. Children under 3 should use a smear of toothpaste containing no less than 1,000 ppm fluoride Children aged 3 years and over should use a pea-‐sized amount of toothpaste containing 1,350 – 1,550 ppm fluoride. A list of toothpastes and their fluoride content can be found in DBOH Why are there medical concerns with fluoride varnish application? Asthma: If ‘asthma’ is stated on the medical history with no further information, the parent/person with parental responsibility needs to be contacted to find out if the child has ever been hospitalised because of their asthma. Admission because of a chest infection is not a concern. If a child has been hospitalised due to asthma, this gives us an indication of the asthma severity and the very small chance that they may be more reactive to Duraphat. In extremely rare instances attacks of dyspnoea have occurred in asthmatic children. Sticking Plaster Allergy: Though there are many brands of plaster available, a history of allergy to sticking plasters raises concern because some contain ‘colophony’, a known allergen, which is also present in Duraphat. Though the risk of an 35 allergic reaction is minimal, we would rather be over-‐cautious and therefore, if any child is allergic to sticking plasters, we will not apply Duraphat. 2.4 Fissure Sealant Application Programme Protocol All clinicians applying fissure sealant will be suitably trained and qualified Cross infection control will be in line with WHTM 01-‐05 and any additional local policies Children will be screened prior to being offered fissure sealant and positive consent sought from parent. See all Wales screening protocol. The British Society of Paediatric Dentistry (BSPD) fissure sealant guidelines underpin the process. However all children attending D2S schools are considered eligible for fissure sealant assessment (and application if first permanent molars are erupted and sound) as D2S is a targeted programme. Quality Assurance Rationale: it is important to ensure that fissure sealants are intact after placement. Timeframe for checking the sealants is open to local decision. Criteria: an audit should be conducted to check the integrity of fissure sealants placed as part of D2S programme. The audit frequency, standards, criteria and data collection can be developed locally 36 2.5 Oral Health Education and Promotion Oral Health Education and Promotion are an integral part of D2S. However they can place considerable demands on D2S team time and resources. This section outlines the OHE/P that must be delivered or offered to schools and settings which are eligible for D2S and which take up all or part of the D2S programme. It also notes other elements that are optional and can be delivered if capacity and resources allow. In all cases it is essential to take account of the evidence base (page 65 on) which notes Systematic reviews of the research evidence show that traditional classroom based oral health education is ineffective in improving oral health (Sprod et al. 1996; Kay and Locker, 1998). These reviews concluded that interventions which do not include the provision of fluoride do nothing to prevent dental caries and in fact have the potential to widen oral health inequalities. Occasionally D2S teams will be asked to provide OHE/P to schools / settings which are not eligible for D2S. These requests have to be declined, although teams may refer the school to the D2S website or resources which teachers can use to support their own lessons OHE / P input that must be delivered or offered At least one lesson for every child who is participating in tooth brushing, Fluoride Varnish application or fissure sealant programme. Lessons are not appropriate for children under 3 – in this case OHE/P will be delivered to health and teaching professionals who oversee the tooth brushing / FV programme. OHE/P for parents is noted below. . OHE/P may be delivered to each class group, or in larger groups if more practical. Lesson and presentation should be age appropriate and cover at least-‐ • • • • Diet Tooth brushing Fluoride Dental attendance Teaching staff All staff involved in tooth brushing programme. Include OHE/P and specific training on tooth brushing protocol and process -‐ Additional training may be required if QA identifies concerns Flying Start teaching / supervisory staff Health Professionals Health Visitors (especially working with Flying start) School nurses Health, teaching and supervisory staff working in Nurseries and Flying Start in Community First areas. 37 Offer to deliver OHE / P to • • • parents and carers on school premises. Experience shows that parents can be a “hard to reach” group and schools will be able to advise D2S teams how best to deliver this, for example at school intake meetings. parents and carers of children in Nurseries in Community First areas. parents and carers of children in Flying Start settings in Community First areas. The offer may be declined, E.g. school declines because parents so seldom attend events like this, but it is important to make the offer. Liaise with Welsh Network of Healthy Schools Schemes on work done in schools. This may be via the D2S Steering Group or other structured meetings. OHE / P input that is optional where capacity and resources allow. Examples include: • Offer resources and support to teaching staff to enable them to deliver OHE/P lessons. This primarily applies to classes in settings participating in D2S but where the children are no longer tooth brushing or participating in FV or fissure sealant programmes. It may also apply to teachers in settings which are not participating at all in D2S • Child-‐minders, other settings in high need areas • Agencies providing supply teachers • Flying start in non Community First areas • Student Health and Teaching Professionals • Looked after children teams Delivering key messages Key messages include:-‐ • • • • Teeth must be brushed morning and evening. Avoid overly prescriptive advice such as “brush teeth after breakfast”. It is sufficient to advice teeth are brushed in the morning. “Spit don’t rinse” after tooth brushing Use appropriate quantity of toothpaste. Evidence shows that parents don’t always understand the difference between a “smear” of paste and a “pea sized amount”. D2S printed resources illustrate this clearly, but it is helpful to demonstrate this to parents and other adults. Evidence shows that knowing the social norm is helpful. Advice parents that “most parents ensure their child brushes morning and evening” 38 Part 3 MONITORING AND EVALUATION THE MONITORING PROCESS The Welsh Oral Health Information Unit (WOHIU) based at Cardiff University is responsible for the process monitoring of D2S. The aim is to review the activity generated by D2S (e.g. supervised tooth-‐brushing, fluoride varnish application and cross sector working) in relation to the resources used. Objectives 1. To determine consent rates for settings and individual children taking part; 2. To ensure that those children taking part are from the prioritised areas; 3. To assess how frequently participating children are brushing their teeth within this supervised scheme; 4. To quantify the numbers of parents, school, nursery and primary health care personnel taking part in oral health education sessions; 5. To quantify the number of dental packs distributed for home use; 6. To provide a crude estimate of the cost effectiveness of the programme, incorporating total costs allocated and resources utilised (capital items, staff costs and consumables). Evaluation reports should be sent to the WOHIU on an annual basis, i.e. for the reporting periods April 1st – March 31st by the 1st of May each reporting year. DATA COLLECTION This involves the completion of the Wales D2S monitoring tool which consists of an Excel workbook with sixteen work sheets: 1. Guidance to users1: provides information on how to complete the monitoring form together with guidance on how to password protect the file. 2. How to guide: which explains how to use the drop down menus which have been incorporated into the most recent edition of the monitoring tool. 3. Guidance to users2: requests some additional information on high costs items and a short written report on health promotion activity or unforeseen issues, both positive and negative. 4. Targeting settings: requests address details of settings scheduled to take part in the initiative during the period, with an indication of whether the schools consented to take part. 5. Activity data TB-‐Nursery-‐Yr2: requests information on the number of children eligible for inclusion broken down by Nursery, Reception and Years 1 and 2; followed by the number of parents who consent and the number who actually start the scheme. Also, details of the number of times per week the programme was run in each year group are requested. CDS personnel are also asked to provide details of the number of dental packs distributed for home use. 6. Activity data Yrs3-‐6: requests similar information to 4 above but for the older children. 7. Home packs FS and FV: collates data specifically relating to home packs for the Fissure Sealant and Fluoride Varnish elements of D2S. 8. OHP -‐ Parents and Staff: the number of parents taking part in group and one to one oral health education sessions need to be recorded for each reporting period. Similarly the number of school and primary health care personnel taking part in oral health education sessions should be recorded on this worksheet. 39 9. OHP (Pre-‐school-‐Yr2): this worksheet requests information on the numbers of pre-‐school – Year 2 children in each school year who take part in wider oral health education sessions. 10. OHP (Yrs3-‐6): this worksheet requests similar information to point 7 above but for those in school years 3-‐6 11. Fluoride varnish: collects the activity relating to the fluoride varnish element of the programme highlighting the number of children receiving one or two applications during the year. 12. Fissure Sealant Programme: collects the activity relating to the fissure sealant element of the programme highlighting the number of children being assessed and treated. 13. Quality Assurance: this sheet records the number of QAs undertaken together with any remedial action taken. 14. Staffing data: details are requested on members of staff taking part in the scheme broken down by unitary authority; this includes details of the grade of staff members, the number of days spent working on the initiative, whether these personnel were new staff or constituted increased session for existing staff. 15. Staff development: details of any courses attended by those working on D2S. 16. Cost data: costs (by unitary authority) of tooth brushes, pastes, buses, packs, programme administration, travel and staff training are requested on this worksheet. If there are any queries regarding the monitoring process, these should be forwarded to Maria Morgan at the WOHIU ([email protected]). 40 Part 4 Quality Framework The Chief Dental Officer for Wales requires all D2S teams and CDSs to comply with the Quality Framework which underpins delivery of D2S. The CDO will seek assurance on compliance with the standards at the D2S National Forum, and during annual review meetings with Health Boards. D2S Health Board Steering Groups will be expected to monitor day to day compliance with the standards Rationale Safe, effective and evidence based procedures are a key priority in the D2S programme. Partnership working across health, education and Local Authorities is integral to promoting good oral health. The Quality Framework Standards • The Health Board has a D2S programme in place which meets national recommendations and has clear reporting and accountability arrangements. • A multi-‐disciplinary, multi professional steering group is in place which has an overview of the HB D2S programme. • The CDS Clinical Director has overall accountability for delivery of D2S. • The HB has a designated lead clinician with responsibility for overseeing the D2S programme. • All targeted settings are encouraged to participate fully in the programme, or to participate in parts of the programme as they see appropriate. • The D2S team offer and provide on-‐going support and guidance to all participating settings. • All staff involved in delivering D2S have received appropriate induction, training and on-‐going updates. • Staff induction, training and updates are recorded and monitored. • Valid consent is in place for all children participating in D2S and records maintained. • Appropriate records are kept for participating settings. • Appropriate records are kept for participating children. • Patient safety incidents / concerns / complaints are handled using Health Board reporting systems, and appropriately shared at National D2S Forum to ensure learning is disseminated. • All data for monitoring and evaluation is submitted to WOHIU in prescribed timeframe, and is accurate and up to date. • There is a nominated person with responsibility for quality assuring the monitoring and evaluation data before it is submitted to WOHIU • D2S can be offered to additional settings (other than target settings) when local D2S team resources and capacity allow. These additional settings will serve children in social deprivation and be identified using local knowledge and Public Health Wales advice. • An Exit Questionnaire is required from all settings which choose to leave the programme in full or in part. 41 Part 5 Evidence Base All components of D2S are informed by and underpinned with an evidence base. These have been researched by Cardiff University Dental Public Health Unit and are included in the Appendices. Appendix 1 – evidence base for tooth brushing Appendix 2 – evidence base for fluoride varnish Appendix 3 – evidence base for fissure sealant Appendix 4 – evidence base for behaviour change (oral health education) Appendix 5 – screen protocol 42 APPENDICES Appendix 1 Evidence -‐ Based Advice on Tooth Brushing This document reviews the evidence for the use of a fluoride toothpaste/tooth brushing programme in nurseries and schools in Wales. The classification of the evidence and grades of recommendation assigned are based on those used by the journal for Evidence Based Dentistry (Appendix A). The evidence contained in this document while directed at supervised tooth brushing programmes in schools applies equally to children brushing their teeth at home and can be used by all members of the dental team in providing advice to parents and the carer of children on tooth brushing. Recommendations The results of these studies provide clear evidence in support of a supervised tooth brushing scheme for Wales. The recommendations based on the studies reviewed with the grade of evidence to support them are: Toothpaste containing 1350-‐1500 ppm fluoride is used for all children aged 3 and over. For children aged 3-‐6 years it is recommended Grade A that the amount of toothpaste dispensed be restricted to a pea-‐size amount, For children aged less than 3 years, toothpaste containing no less than 1000 ppm fluoride should be used – the amount dispensed o the tooth brush being kept to a smear Children are given toothpaste and tooth brush for home use and advised to have their teeth brushed twice a day, preferable after breakfast and last thing at night Grade A Children are encouraged not to rinse their mouth after brushing. Grade A Until age 7, children should be supervised / helped when brushing their teeth. Children should not be allowed to lick or eat toothpaste from Grade C the tube. Like all medicines, toothpaste should be stored out of the reach of small children. The papers included in this review have been divided into four principle subject areas namely: use of fluoride toothpaste to prevent caries, the concentration of fluoride in toothpaste, the role of supervised brushing and the frequency of brushing and post-‐brushing rinsing. For each subject area relevant papers have been identified and the results analysed. 43 Subject area Evidence Source In a systematic review of fluoride toothpaste, 70 studies contributed data for a meta-‐analysis (involving 42,300 children). The results demonstrated that 24% of decay experience can be prevented by brushing with fluoride toothpaste. The effect of fluoride toothpaste increased with higher baseline levels of decay experience but was not influenced by exposure to water fluoridation. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2003, Issue 1. 54 studies contributed to a further systematic review of the caries preventive effect of fluoride toothpaste. The results revealed strong evidence for the effect of daily use of fluoride toothpaste in the young permanent dentition. The preventive fraction was 24.9%, with on average 0.58 fewer decayed, missing or filled tooth surfaces per year for children using fluoride toothpaste compared to placebo. Twetman S, Axelsson S, Dahlgren H, Holm A-‐K, Källestål C, Lagerlöf F, Lingström P, Mejàre Supervised brushing A systematic review which included 12 studies demonstrated that children who participated in supervised tooth brushing programmes displayed a higher preventive fraction than those with unsupervised interventions both when compared to placebo (31.0% vs. 23.3%) and other fluoride containing controls (12.0% vs. 3.9%). There was strong evidence for the fact that supervised brushing with fluoride-‐containing toothpaste had a superior caries preventive effect over non-‐ supervised brushing. Twetman S, Axelsson S, Dahlgren H, Holm A-‐K, Källestål C, Lagerlöf F, Lingström P, Mejàre I, Nordenram G, Norlund A, Petersson LG and Söder B (2003) Caries-‐preventive effect of fluoride toothpaste: a systematic review, Acta Odontologica Scandinavica, 61:6, 347-‐355. Ia Four years after the end of a 30 month randomised controlled trial of supervised tooth brushing with 1000ppm fluoride toothpaste at school, the intervention group still had significantly less caries than the non-‐intervention group, demonstrating the prolonged benefit of the intervention. Pine CM, Curnow MM, Burnside G, Nicholson JA, Roberts AJ (2007) Caries prevalence four years after the end of a randomised controlled trial. Caries Res., 41(6):431 -‐6. Ib Provision of fluoride toothpaste Level of evidence Ia Ia I, Nordenram G, Norlund A, Petersson LG and Söder B (2003) Caries-‐preventive effect of fluoride toothpaste: a systematic review, Acta Odontologica Scandinavica, 61:6, 347-‐355. 44 A randomised controlled trial of daily supervised tooth brushing in school with 1450ppm fluoride containing toothpaste demonstrated a reduction of 10.9% in caries for the intervention group compared to the control group Jackson RJ, Newman HN, Smart GJ, Stokes E, Hogan JI, Ib Brown C, Seres J. (2005) The effects of a supervised toothbrushing programme on the caries increment of primary school children, initially aged 5-‐6 years. Caries Res.,39(2):108-‐15. A two year clinical trial of an oral health programme involving health education and supervised daily tooth brushing with 1100ppm fluoride toothpaste for 3 year old children showed a reduction in caries increment of 30.6% for the children in the intervention group. Rong WS, Bian JY, Wang WJ, Wang JD. (2003) Effectiveness of an oral health education and caries prevention program in kindergartens in China. Community Dent Oral Epidemiol.,31(6):412-‐6. Ib In a randomised controlled trial of daily supervised brushing in school for children aged 5 at the start of the study, the 2-‐year caries increment on first permanent molars was 56% lower for caries into dentine for children in the intervention arm of the study than children in the control group. Curnow MM, Pine CM, Burnside G, Nicholson JA, Chesters RK, Huntington E. (2002) A randomised controlled trial of the efficacy of supervised toothbrushing in high-‐caries-‐risk children. Caries Res., 36(4): 294-‐300. Ib Concentration of fluoride in toothpaste A study of supervised toothbrushing with 1200ppm fluoride toothpaste in nursery aged children demonstrated 10% fewer children with caries in the test group compared to a matched retrospective control group. Holtta P, Alaluusua S. (1992) Effect of supervised use of IIa a fluoride toothpaste on caries incidence in pre-‐school children. Int. J. Paediatr. Dent., 2(3): 145-‐9. A systematic review found a non-‐significant difference (p=0.051) between caries levels and fluoride concentration in toothpaste, with an 8% increase in prevented fraction per 1000ppm fluoride. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2003, Issue 1. Ia 45 Four studies included in a review of low fluoride (<600ppm F) compared to standard fluoride toothpastes provided limited evidence for an anti-‐caries difference between the fluoride concentrations. Twetman S, Axelsson S, Dahlgren H, Holm A-‐K, Källestål Ia C, Lagerlöf F, Lingström P, Mejàre I, Nordenram G, Norlund A, Petersson LG and Söder B (2003) Caries-‐preventive effect of fluoride toothpaste: a systematic review, Acta Odontologica Scandinavica, 61:6, 347-‐355. Nine papers included in the evaluation of toothpastes with higher fluoride content found a significant higher caries reduction with a 1500ppm toothpaste compared to a standard formulation (1000ppm) with an average difference in prevented fraction of 9.7% (0-‐22%). Six of the studies were high quality randomised controlled trials, which provided strong evidence that toothpastes containing 1500ppm had a superior preventive effect. Twetman S, Axelsson S, Dahlgren H, Holm A-‐K, Källestål Ia C, Lagerlöf F, Lingström P, Mejàre I, Nordenram G, Norlund A, Petersson LG and Söder B (2003) Caries-‐preventive effect of fluoride toothpaste: a systematic review, Acta Odontologica Scandinavica, 61:6, 347-‐355. A systematic review included seven randomised controlled trials concluded that 250ppm fluoride toothpaste was not as effective in caries prevention in permanent teeth as those containing 1000ppm fluoride or more. Frequency of brushing and rinsing after brushing Ia Ammari AB, Bloch-‐Zupan A, Ashley PF. (2003) Systematic review of studies comparing the anti-‐caries efficacy of children’s toothpaste containing 600ppm of fluoride or less with high fluoride toothpastes of 1,000ppm or above. Caries Res., 37: 85-‐92. In a systematic review of fluoride toothpaste the effect of fluoride toothpaste increased higher frequency of use such that there was a 14% increase in prevented fraction with twice daily brushing as opposed to once daily. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2003, Issue 1. Ia 46 Reported frequency of tooth brushing was strongly related to caries experience in a three year clinical trial of 12 year old children. Caries increment was 20% lower in participants who reported brushing more than once a day compared to those who reported brushing less than once per day. Overall frequency of brushing and rinsing method accounted for over 50% of the explained variance in caries increment. Chestnutt IG, Schafer F, Jacobsen APM, Stephen KW (1998) The influence of tooth brushing frequency and post-‐brushing rinsing on caries experience in a caries clinical trial. Community Dent Oral Epidemiol, 26: 406-‐ 11. Ib A cross-‐sectional study of 7 year old Flemish children found that children who brushed their teeth less than once a day were more likely to have decay than those who cleaned their teeth at least once a day (odds ratio 1.24, p=0.05). Vanobbergen J, Martens L, Lesaffre E, Bogaerts K, Declerck D. (2001) Assessing risk indicators for dental caries in the primary dentition. Community Dent Oral Epidemiol, 29: 424-‐34. A cross-‐sectional survey of pre-‐school children in the UK found that in children from non-‐manual backgrounds, 13% had decay if they brushed their teeth once a day or less compared to 8% of those who brushed more than once a day. For children from manual backgrounds the difference was not significant with 24% of children with decay for less frequent brushing and 21% for those who brushed twice daily. Gibson S, Williams S (1999) Dental caries in pre-‐school children: associations with social class, tooth brushing habit and consumption of sugars and sugar-‐containing foods. Caries Res, 33: 101-‐13. III III 47 Results from the studies described provide clear evidence that: 1. 2. 3. 4. 5. Fluoride toothpaste reduces the incidence and severity of dental decay in children, The higher the concentration of fluoride in the toothpaste the greater its preventive effect, A supervised tooth brushing programme is more effective than an unsupervised programme, Twice daily use of a fluoride based toothpaste is more effective than less frequent use in reducing caries, Rinsing after tooth brushing reduces the effectiveness of the fluoride toothpaste. For young children the risk of dental fluorosis (a potentially unsightly discolouration of the teeth) from the ingestion of toothpaste has led to concerns about the concentration of fluoride in toothpaste. The critical period for the calcification of the upper incisors (front teeth) and therefore the risk of developing fluorosis is 22 -‐25 months.1 Up to three years of age it is sensible to restrict the concentration of fluoride in toothpaste to 1000ppm and to use a smear on the brush to limit the risk of fluorosis to the upper front teeth whilst maximising the protective effect of fluoride. For children aged 3-‐6 years, a pea-‐sized amount of family fluoride toothpaste (1,350-‐1,500 ppm fluoride) is indicated as the risk of fluorosis of cosmetic significance is small. 2 Commissioned by the Welsh Assembly Government and Produced by: Dental Public Health Unit Cardiff University Dental School June 2008 1 SIGN 83: Prevention and management of dental decay in the pre-‐school child. November 2005 2 Delivering better oral health. An evidence based toolkit for prevention. Department of Health, England 2007 48 Classification of evidence levels and grades of recommendations Evidence Level Required Standard Ia Ib IIa Evidence obtained from meta-‐analysis of RCT Evidence obtained from at least one RCT Evidence obtained from at least one well-‐designed controlled study without randomisation IIb Evidence obtained from at least one other type of well-‐designed quasi-‐ experimental study* III Evidence obtained from well-‐designed nonexperimental descriptive studies, e.g., comparative studies, correlation studies and case studies Evidence obtained from expert committee reports or opinions and/ or clinical experiences of respected authorities IV Grades of Recommendations A Requires at least one RCT as part of a body of literature of overall good quality and consistency addressing specific recommendation (evidence levels Ia, Ib) B Requires availability of well-‐conducted clinical studies but no RCT on topic of recommendation (evidence levels IIa, IIb, III) C Requires evidence obtained from expert committee reports or opinions and/ or clinical experiences of respected authorities. Indicates an absence of directly applicable clinical studies of good quality (evidence level IV) *A situation in which implementation of an intervention is beyond the control of the investigators, but an opportunity exists to evaluate its effect. RCT, Randomised controlled trial. 49 Appendix 2 – Evidence for the effectiveness and use of fluoride varnish Evidence based technical document for fluoride varnish application Designed to Smile, as announced by the Minister for Health and Social Services in April 2008, forms a key element of the oral health improvement agenda in Wales. The core programme comprises two parts, the supervised tooth brushing scheme for 3-5 year olds and a promotional programme for 6-11 year olds. The core programme also includes the clinically appropriate use of other fluoride supplements. This document reviews the evidence for the use of fluoride varnishes as a supplement to the toothpaste/tooth brushing programme in Wales. The classification of evidence and grades of recommendation are based on those used by the journal for Evidence Based Dentistry (Appendix A). Recommendations Children between the ages of 3 of 16 should be eligible for fluoride varnish Grade A Children from the ages of 6 months to 3 years who have a high risk of caries should be considered for fluoride varnish applications Grade A* Children at high risk of dental caries or from high risk areas are advised to have topical fluoride varnish applications 2-4 times per year at regular intervals of 6 months or less Grade A Fluoride varnish needs to be delivered through a programme that encourages the participation of children from high caries risk groups Grade B 50 The papers have been divided into areas of; fluoride varnish, fluoride varnish as a supplement to fluoride toothpaste, the concentration and dose of fluoride varnish preparations, frequency of application, fluoride varnish in high and low risk populations and programmes for the delivery of fluoride varnishes. Results from the studies reviewed provide evidence that: 1. Fluoride varnishes are effective in inhibiting caries. 2. Fluoride varnishes are effective in children from the ages of 3 to 16 years. 3. There is a small but inconclusive amount of evidence suggesting that children aged from 6 months in high risk groups would benefit from fluoride varnish applications. 4. Fluoride varnish techniques are quick and acceptable to young patients. 5. Application of fluoride varnish for high risk populations at regular 6 monthly intervals would help to prevent caries in the population. 6. Application of fluoride varnishes for high risk populations at regular intervals of 4-6 months would prevent approximately 37-43% of carious surfaces. 7. The most effective and tested concentration of fluoride varnish preparation is 22,600 ppm F-(2.2%F-). For young children below the age of 3, there was only a small amount of evidence to support the use of fluoride varnishes.1 The lack of evidence in this area does not demonstrate fluoride varnishes are not potentially appropriate or effective in the prevention of caries. There are different definitions in studies for the risk of dental caries, with some studies using a child’s individual caries history as the indicator of risk and other studies using area based measures, area DMFT and economic deprivation. Few studies compared the effects on fluoride varnish on children with differing levels of risk. However there is a trend towards an increased preventative effect in high risk populations. Studies have most frequently measured the mean number of carious surfaces in first permanent molar teeth. The overall effects of fluoride varnish application on the other teeth in the dentition have been subject to less research. 51 There is limited evidence comparing community based programmes to deliver fluoride varnish. Non responses, lack of consent and drop out rates have affected most studies of fluoride varnishes. Analysis of non-responders has shown that this population is the most likely to have untreated dental caries2, therefore prevention programmes should aim to encourage participation from these groups. Fluoride varnishes are not suitable for all children as they are contraindicated in children with ulcerative gingivitis and stomatitis.3 Children with a history of hospital admissions for allergic episodes should not have varnish application as the preparation Duraphat contains colophony (roisin), which can cause allergy in a small number of children.3 1 SIGN 83: Prevention and management of dental decay in the pre-school child. November 2005. 2 Splieth, C. H. et al. 2005. Responder and non-responder analysis for a caries prevention program. Caries Research 39(4), pp. 269-272. 3 Delivering better oral health. An evidence based toolkit for prevention. Department of Health, England 2007. 52 Subject area Fluoride varnish Evidence Source In a systematic review of fluoride varnishes 9 studies were included (involving 2709 children) of which 7 studies contributed to a meta analysis. A mean of 33% fewer surfaces with caries in the primary dentition and 46% fewer carious surfaces in the adult dentition was seen in the population of children treated with fluoride varnishes compared to those with no treatment. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No.: CD 002279. DOI: 10.1002/14651858.CD002279. Twenty four trials including over 12,000 children were included in a systematic review of the use of fluoride varnishes in children. Children receiving fluoride varnish had a mean of 30% fewer carious surfaces in permanent molars compared to a placebo or no treatment. Children treated with fluoride varnish had 17.8% fewer carious surfaces than active controls treated with other fluoride treatments. In addition three trials compared the effects of fluoride varnish on the deciduous dentition of young children. One of the three studies found a mean of 44% fewer surfaces with caries in the population treated with fluoride varnish, while the other 2 studies did not have significant results. Petersson LG, Twetman S, Dahlgren H, Norlund A, Holm AK, Nordenram G, et al. Professional fluoride varnish treatment for caries control: a systematic review of clinical trials. Acta Odontol Scand. 2004 Jun;62(3):170-6. A systematic review of Duraphat fluoride varnish for the prevention of caries included a meta analysis including 8 studies involving 927 children. The population treated with fluoride varnish had a mean of 38% fewer carious tooth surfaces than untreated controls. Helfenstein U, Steiner M.1994. Fluoride varnishes (Duraphat): a meta-analysis. Community Dentistry & Oral Epidemiology 22(1), pp. 1-5. A systematic review of the literature identified 7 studies of fluoride varnish use in the deciduous dentition, of which only two were randomised controlled trials. The incidence of carious surfaces was lower in population treated with fluoride varnish in the studies, but the findings were statistically insignificant in 5 of the 7 studies. Rozier, R. G. and Rozier, R. G. 2001. Effectiveness of methods used by dental professionals for the primary prevention of dental caries. Journal of Dental Education 65(10), pp. 1063-1072. Level of evidence Ia Ib Ia Ib 53 Fluoride varnish to supplement fluoride toothpaste Concentration and dose of fluoride varnish A randomised controlled single blind trial including 376 children at enrolment tested the effect of applying fluoride varnish to children who were between the ages of 6 and 44 months at the start of the study. Despite errors in the allocation of fluoride varnishes, children who did not have fluoride varnish treatment had 50% more carious surfaces than the population treated with fluoride varnishes. The children treated more frequently, with up to 4 applications of with fluoride in a year had fewer new carious lesions. Weintraub, J. A. et al. 2006. Fluoride varnish efficacy in preventing early childhood caries. Journal of Dental Research 85(2), pp. 172-176. One systematic review identified two studies comparing the combination of fluoride varnish and fluoridated toothpaste with toothpaste alone. One of the trials included compared the effects of combined therapy (toothpaste and fluoride varnish) on the percentage of new carious surfaces in permanent teeth, with the population treated with varnish showing 48% fewer carious surfaces. The second study showed that combined therapy prevented 15% of carious surfaces in the deciduous dentition compared to toothpaste alone. Marinho VCC, Higgins JPT, Sheiham A, Logan S. Combinations of topical fluoride (toothpastes, mouthrinses, gels, varnishes) versus single topical fluoride for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.:CD002781. DOI: 10.1002/14651858. CD002781.pub2. A systematic review included a meta analysis of 4 studies involving a total of 924 children; these studies compared fluoride varnish and other fluoride delivery systems as controls. The results indicated that fluoride varnish had a positive effect on caries, with all but one of the studies demonstrating positive findings but the study findings were not statistically significant. Strohmenger L, Brambilla E. 2001. The use of fluoride varnishes in the prevention of dental caries: a short review.Oral Diseases. 7: 71–80. There was no conclusive evidence identifying the most effective concentration of fluoride varnish preparation. However one systematic review noted that the most frequently used concentration in studies used to demonstrate the effectiveness of fluoride varnish was 22,600 (2.2%F ). Azarpazhooh, A. Main, PA. 2008. Fluoride varnish in the prevention of dental caries in children and adolescents: a systematic review.[reprint in Tex Dent J. 2008 Apr;125(4):318-37; PMID: 18491761]. Journal (Canadian Dental Association) 74(1), pp. 73-79. A systematic review of fluoride varnishes included 3 studies that found single dose vials provided a more consistent dose of fluoride than multidose vials, though no optimum dose was specified. Azarpazhooh, A. Main, PA. 2008. Fluoride varnish in the prevention of dental caries in children and adolescents: a systematic review.[reprint in Tex Dent J. 2008 Apr;125(4):318-37; PMID: 18491761]. Journal (Canadian Dental Association) 74(1), pp. 73-79 Ib Ia Ia Ib Ib 54 Frequency of application A systematic review of fluoride varnishes detailed the findings of the 7 articles meeting the inclusion criteria. This concluded that regular fluoride varnish application 2-4 times per year in the deciduous and permanent dentition prevents caries in children. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No.: CD 002279. DOI: 10.1002/14651858.CD002279. One randomised controlled trial compared different regimes for the application for fluoride varnishes. Fluoride varnish applied monthly prevented 76% of caries, whilst the 6 monthly application of varnish prevented 57% of carious surfaces across all of the populations. Skold UM, Petersson LG, Lith A, Birkhead D. 2005. Effect of School-Based Fluoride Varnish Programmes on Approximal Caries in Adolescents from Different Caries Risk Areas. Caries Research 39, pp. 273-279. Fluoride varnish for prevention in high and low risk populations In one randomised controlled trial, there was a greater percentage of caries prevented in children living in areas with a high risk of caries. Children from high risk areas treated with fluoride varnish had 69% fewer carious surfaces, compared to no varnish treatment, whereas there was a 20% reduction in the caries in the population treated with fluoride varnish from a low risk area. Skold UM, Petersson LG, Lith A, Birkhead D. Effect of School-Based Fluoride Varnish Programmes on Approximal Caries in Adolescents from Different Caries Risk Areas. Caries Research 39, pp. 273-279. Acceptability of Fluoride varnish A controlled trial compared the acceptability of professionally applied fluoride delivery systems and concluded that fluoride varnish was a faster procedure than other methods and patients found this technique more acceptable. Hawkins R, Noble J, Locker D, Weibe D, Murray H, Weibe P, Frosina C, Clarke M. A comparison of the costs and patient acceptability of professionally applied topical fluoride foam and varnish. Journal of Public Health Dentistry 64(2), pp. 106-110. A randomised controlled trial applying fluoride varnish of very young children’s teeth, Starting with children aged 6-44 months, they reported little difficulty with co operation in this population. Weintraub, J. A. et al. 2006. Fluoride varnish efficacy in preventing early childhood caries. Journal of Dental Research 85(2), pp. 172-176 Cluster Randomised controlled trial of a fluoride varnish programme involved 334 children aged 6-7 in the test group and 330 in the control group in 32 schools. The study, which involved the application in fluoride varnish to children in school found significantly fewer enamel lesions in the treatment group but did not find a significant reduction in caries in the children receiving varnish. The lack of significance was attributed to the population with the greatest likelihood of decay and subsequent Hardman, MC. Davies, GM. Duxbury, JT .Davies, RM. 2007. A cluster randomised controlled trial to evaluate the effectiveness of fluoride varnish as a public health measure to reduce caries in children. Caries Research 41(5), pp. 371-376. Fluoride varnish programmes Ib Ia Ib IIa Ib Ib 55 potential for prevention not consenting to participate. A cross sectional study was used to evaluate the effectiveness of a caries prevention programme in Germany. Alongside tooth brushing and oral health education this programme included fluoride varnishes. Continual decreases in the population mean DMFT for school children of all ages was observed year on year. Dohnke-Hohrmann, S. Zimmer, S. et al. 2004. Change in caries prevalence after implementation of a fluoride varnish program. Journal of Public Health Dentistry 64(2), pp. 96100. III 56 Appendix A Classification of evidence levels and grades of recommendations Evidence level Required standard Ia Evidence obtained from meta-analysis of RCT Ib Evidence obtained from at least one RCT IIa Evidence obtained from at least one well-designed controlled study without randomisation IIb Evidence obtained from at least one other type of well-designed quasi-experimental study III Evidence obtained from well-designed non experimental descriptive studies, eg, comparative studies, correlation studies and case studies IV Evidence obtained from expert committee reports or opinions and/ or clinical experiences of respected authorities * Grades of recommendations A Requires at least one RCT as part of a body of literature of overall good quality and consistency addressing specific recommendation (evidence levels Ia, Ib) B Requires availability of well-conducted clinical studies but no RCT on topic of recommendation (evidence levels IIa, IIb, III) C Requires evidence obtained from expert committee reports or opinions and/ or clinical experiences of respected authorities. Indicates an absence of directly applicable clinical studies of good quality (evidence level IV) * A situation in which implementation of an intervention is beyond the control of the investigators, but an opportunity exists to evaluate its effect. RCT, Randomised controlled trial. October 2008 Mrs I.G. Johnson, Professor I.G. Chestnutt, Dental Public Health Unit, Applied Clinical Research and Public Health, Cardiff University School of Dentistry. 57 Appendix 3 Evidence for the effectiveness of Fissure Sealants Fissure sealants are a preventive dental technology that are designed to specifically reduce the caries susceptibility of the occlusal (biting) surface of posterior teeth. In the context of the D2S programme this applies particularly to the first permanent molar teeth which erupt around age 6 years. In the period immediately following eruption, the occlusal surface of these teeth are particularly at risk. At age 15, 80% of the caries burden is to be found on this single tooth surface and so steps to protect it and reduce vulnerability in “high-‐risk” 6-‐7 year olds is important. The most commonly used type of fissure sealant is Bis-‐GMA resin. This is a plastic material that is placed on the tooth surface and which forms a physical barrier between the tooth and the oral environment preventing the ingress of caries causing bacteria into the pit and fissures of the tooth surface. Recently published evidence suggests that an incipient carious lesions, confined to dental enamel do not progress when they are sealed and that cariogenic bacteria do not survive under sealants. For this reason, unless there is suspicion that dental caries has progressed into dentine (when operative intervention is then required), all first permanent molars should be sealed in children deemed at higher risk. This means it is appropriate to seal “stained fissures”. From the perspective of D2S, higher risk is on the basis of residence in an area of high caries prevalence. 58 Subject Area Evidence of caries prevention Evidence A 2013 Cochrane review examined the evidence for the caries preventive effect of fissure sealants. Thirty-‐four trials are included in the review. Twelve trials evaluated the effects of sealant compared with no sealant (2575 participants); 21 trials evaluated one type of sealant compared with another (3202 participants); and one trial evaluated two different types of sealant and no sealant (752 participants). Children were aged from 5 to 16 years. Trials rarely reported the background exposure to fluoride of the trial participants or the baseline caries prevalence. Source Level of Evidence Ahovuo-‐Saloranta A, Forss H, Walsh T, Hiiri A, Nordblad A, Mäkelä M, Worthington HV. Sealants for preventing dental decay in the permanent teeth. Cochrane Database of Systematic Reviews 2013, Issue 3. Art. No.: CD001830. DOI: 10.1002/14651858.CD001830.pub4. http://onlinelibrary.wiley.com/doi/10.1002/146 51858.CD001830.pub4/pdf Resin-‐based sealant compared with no sealant: Compared to control without sealant, second or third or fourth generation resin based sealants prevented caries in first permanent molars in children aged 5 to 10 years (at 2 years of follow-‐up odds ratio (OR) 0.12, 95% confidence interval (CI) 0.07 to 0.19, six trials (five published in the 1970s and one in 2012), at low risk of bias, 1259 children randomised, 1066 children evaluated, moderate quality evidence). If we were to assume that 40% of the control tooth surfaces were decayed during 2 years of follow-‐up (400 carious teeth per 1000), then applying a resin-‐based sealant will reduce the proportion of the carious surfaces to 6.25% (95% CI 3.84% to 9.63%); similarly if we were to assume that 70% of the control tooth surfaces were decayed (700 carious teeth per 1000), then applying a resin-‐based sealant will reduce the proportion of the carious surfaces to 18.92% (95% CI 12.28% to 27.18%). This caries preventive effect was maintained at longer follow-‐up but both the quality and quantity of the evidence was reduced (e.g. at 48 to 54 months of follow-‐up OR 0.21, 95% CI 0.16 to 0.28, four trials (two studies at low risk of bias and two studies at high risk of bias), 59 482 children evaluated; risk ratio (RR) 0.24, 95% CI 0.12 to 0.45, one study at unclear risk of bias, 203 children evaluated). The application of sealants is a recommended procedure to prevent or control caries. Sealing the occlusal surfaces of permanent molars in children and adolescents reduces caries up to 48 months when compared to no sealant, after longer follow-‐up the quantity and quality of the evidence is reduced. The review revealed that sealants are effective in high risk children but information on the magnitude of the benefit of sealing in other conditions is scarce. The relative effectiveness of different types of sealants has yet to be established. Evidence of relevance to the placement of fissure sealants in a school based programme In relation to each of the aims, the review came to the following Gooch BF, Griffin SO, Gray SK et al. Preventing conclusions: dental caries through school based sealant programs: updated recommendations and 1 Sound pit and fissure surfaces. What is the effectiveness reviews of evidence. Journal of the American of sealants in preventing the development of caries on sound Dental Association. 2009;140(11):1356-‐65. pit and fissure surfaces? Summary of evidence. Systematic http://www.ncbi.nlm.nih.gov/pubmed/?term= reviews have found that sealants are effective in preventing the Gooch+BF%2C+Griffin+SO%2C+Gray+SK+et+al.+ development of caries on sound pit and fissure surfaces in Preventing+dental+caries+through+school+base children and adolescents. d+sealant+programs%3A+Journal+of+the+Amer 2 Noncavitated or incipient lesions. What is the ican+Dental+Association.+2009%3B140(11)%3A effectiveness of sealants in preventing the progression of 1356-‐65. noncavitated or incipient carious lesions to cavitation? Summary of evidence. A systematic review found that pit-‐and-‐ fissure sealants are effective in reducing the percentage of noncavitated carious lesions that progressed to cavitation in children, adolescents and young adults. 3 Bacteria levels. What is the effectiveness of sealants in reducing bacteria levels in cavitated carious lesions? Summary of evidence. A systematic review found that pit-‐and-‐fissure sealants are effective in reducing bacteria levels in cavitated 60 carious lesions in children, adolescents and young adults. 4 Assessment of caries on surfaces to be sealed. Which caries assessment methods should be used in SBSPs to differentiate pit and fissure surfaces that are sound or noncavitated from those that are cavitated or have signs of dentinal caries? Summary of evidence. A systematic review found that visual assessment alone is sufficient to detect the presence of surface cavitation and/or signs of dentinal caries. 5 Surface preparation. What surface cleaning methods or techniques are recommended by manufacturers for unfilled resin-‐based sealants (self-‐curing and light-‐cured) commonly used in SBSPs? Summary of evidence. A review of manufacturers’ instructions for use for unfilled resin-‐based sealants found that they do not specify a particular method of cleaning the tooth surface. 6 Effect of clinical procedures. What is the effect of clinical procedures—specifically, surface cleaning or mechanical preparation methods with use of a bur before acid etching—on sealant retention? Summary of evidence. The effect of specific surface cleaning or enamel preparation techniques on sealant retention cannot be determined because of the small number of clinical studies comparing specific techniques and, for mechanical preparation with a bur, inconsistent findings. Bivariate and multivariate analyses of retention data across existing studies suggest that supervised tooth brushing or use of a hand piece prophylaxis may result in similar sealant retention rates over time. 7 Four-‐handed technique for applying dental sealant. Does use of a four-‐handed technique in comparison with a two-‐handed technique improve sealant retention? Summary of evidence. In the absence of direct comparative studies, the results of a 61 multivariate study of available data19 suggest that use of the four-‐handed placement technique is associated with a 9 percentage point increase in sealant retention. 8 Caries risk associated with lost sealants. Are teeth in which sealants are lost at a higher risk of developing caries than are teeth that were never sealed? Summary of evidence. Findings from a meta-‐analysis indicate that the caries risk for sealed teeth that have lost some or all sealant does not exceed the caries risk for never-‐sealed teeth. Thus, the potential risk associated with loss to follow-‐up for children in school-‐based programs does not outweigh the potential benefit of dental sealants. Evidence of relevance to the placement of fissure sealants in a school based programme In relation to each of the aims, the review came to the following Gooch BF, Griffin SO, Gray SK et al. Preventing conclusions: dental caries through school based sealant programs: updated recommendations and 1 Sound pit and fissure surfaces. What is the effectiveness reviews of evidence. Journal of the American of sealants in preventing the development of caries on sound Dental Association. 2009;140(11):1356-‐65. pit and fissure surfaces? Summary of evidence. Systematic http://www.ncbi.nlm.nih.gov/pubmed/?term= reviews have found that sealants are effective in preventing the Gooch+BF%2C+Griffin+SO%2C+Gray+SK+et+al.+ development of caries on sound pit and fissure surfaces in Preventing+dental+caries+through+school+base children and adolescents. d+sealant+programs%3A+Journal+of+the+Amer 2 Noncavitated or incipient lesions. What is the ican+Dental+Association.+2009%3B140(11)%3A effectiveness of sealants in preventing the progression of 1356-‐65. noncavitated or incipient carious lesions to cavitation? Summary of evidence. A systematic review found that pit-‐and-‐ fissure sealants are effective in reducing the percentage of noncavitated carious lesions that progressed to cavitation in children, adolescents and young adults. 3 Bacteria levels. What is the effectiveness of sealants in reducing bacteria levels in cavitated carious lesions? Summary of evidence. A systematic review found that pit-‐and-‐fissure 62 sealants are effective in reducing bacteria levels in cavitated carious lesions in children, adolescents and young adults. 4 Assessment of caries on surfaces to be sealed. Which caries assessment methods should be used in SBSPs to differentiate pit and fissure surfaces that are sound or noncavitated from those that are cavitated or have signs of dentinal caries? Summary of evidence. A systematic review found that visual assessment alone is sufficient to detect the presence of surface cavitation and/or signs of dentinal caries. 5 Surface preparation. What surface cleaning methods or techniques are recommended by manufacturers for unfilled resin-‐based sealants (self-‐curing and light-‐cured) commonly used in SBSPs? Summary of evidence. A review of manufacturers’ instructions for use for unfilled resin-‐based sealants found that they do not specify a particular method of cleaning the tooth surface. 6 Effect of clinical procedures. What is the effect of clinical procedures—specifically, surface cleaning or mechanical preparation methods with use of a bur before acid etching—on sealant retention? Summary of evidence. The effect of specific surface cleaning or enamel preparation techniques on sealant retention cannot be determined because of the small number of clinical studies comparing specific techniques and, for mechanical preparation with a bur, inconsistent findings. Bivariate and multivariate analyses of retention data across existing studies suggest that supervised tooth brushing or use of a hand piece prophylaxis may result in similar sealant retention rates over time. 7 Four-‐handed technique for applying dental sealant. Does use of a four-‐handed technique in comparison with a two-‐handed technique improve sealant retention? Summary of evidence. In 63 the absence of direct comparative studies, the results of a multivariate study of available data19 suggest that use of the four-‐handed placement technique is associated with a 9 percentage point increase in sealant retention. 8 Caries risk associated with lost sealants. Are teeth in which sealants are lost at a higher risk of developing caries than are teeth that were never sealed? Summary of evidence. Findings from a meta-‐analysis indicate that the caries risk for sealed teeth that have lost some or all sealant does not exceed the caries risk for never-‐sealed teeth. Thus, the potential risk associated with loss to follow-‐up for children in school-‐based programs does not outweigh the potential benefit of dental sealants. 64 Appendix 4 Evidence of relevance to Behaviour Change (oral health education) The role of traditional classroom based oral health education. Systematic reviews of the research evidence show that traditional classroom based oral health education is ineffective in improving oral health (Sprod et al. 1996; Kay and Locker, 1998). These reviews concluded that interventions which do not include the provision of fluoride do nothing to prevent dental caries and in fact have the potential to widen oral health inequalities. One to one health education in a clinical context, at the chair-‐side with parent and child is useful as tailored one-‐to one advice on diet and fluoride use can be provided. However, the current evidence shows that there is no place for traditional class-‐room teaching in groups, and especially not with young children. While this may play some part in providing knowledge, it does nothing to change behaviour, particularly in those children at greatest risk (Davies and Bridgeman, 2011). It is for these reasons that the Designed to Smile programme does not provide traditional stand-‐alone class teaching by oral health education teams – it is not an effective use of resources. The provision of oral health education is to support and enhance the implementation of daily brushing and fluoride varnish programmes which are more likely to bring about clinical change and address oral health inequalities (Shaw et al. 2009; Macpherson et al. 2013). References Davies, G. and C. Bridgman (2011). "Improving oral health among schoolchildren -‐ which approach is best?" British Dental Journal 210(2): 59-‐61. Kay, E. and D. Locker (1998). "A systematic review of the effectiveness of health promotion aimed at improving oral health." Community Dental Health 15(3): 132-‐144. Macpherson, L. M., Y. Anopa, D. I. Conway and A. D. McMahon (2013). "National supervised tooth brushing program and dental decay in Scotland." Journal of Dental Research 92(2): 109-‐113. 65 Shaw, D., L. Macpherson and D. Conway (2009). "Tackling socially determined dental inequalities: ethical aspects of Childsmile, the national child oral health demonstration programme in Scotland." Bioethics 23(2): 131-‐139. Sprod A.J., Anderson, R. and Treasure, E,T. (1996) Effective oral health promotion : literature reviewUniversity of Wales. College of Medicine. Dental Public Health Unit.; Health Promotion Wales.Cardiff : Dental Public Health Unit, UWCM : Health Promotion Wales. 66 Appendix 5 Screening Protocol All Wales CDS school dental screening / inspection protocol This protocol has been developed as part of the Welsh Government’s National Oral Health Plan commitment to work with PHW to consider evidence regarding dental screening, review the current school screening programme in Wales, and update advice to CDS. It is informed by Public Health Wales review of school screening (Hyperlink Screening Protocol literature overview). It is to be used by all CDS in Wales. This document and the Ministerial Letter on the Role of the CDS (EH/ML/014/08) refer to school dental screening, but it is important to note the legal framework refers to “inspection”. See Appendix 2 Published January 2014 To be reviewed January 2017 The purpose of screening There is no evidence to show that traditional school screening per se encouraged children with dental need to attend a dentist. This all Wales protocol focuses on links with Designed to Smile which has the potential to offer appropriate follow up in defined circumstances. Thus The primary purpose of screening is to • identify children with erupted first permanent molars (FPMs) which can be fissure sealed or have fluoride varnish applied, and • identify children who may benefit from fluoride varnish application where local policy includes screening for this. 67 Screening may also 1. Identify children with dental and oral disease / conditions requiring active treatment and inform their parents / people with parental responsibility (e.g where there is acute or spreading dental infection) 2. Facilitate those children to obtain appropriate treatment 3. Foster effective working relationships with schools and nurseries Children to be screened No children in secondary schools will be screened – unless identified as school for children with special needs In Wales the only children who will be screened are those in relevant year-groups in schools participating in D2S programme. That is primary school years 2 and 3 and 4 CDS may offer screening to the following groups as capacity and resources allow • • • Special schools/units Children in D2S eligible schools who have refused to participate in D2S, or who have withdrawn from the programme (in part or wholly). These children attend schools in areas of multiple deprivation and should be offered screening Other children in D2S participant schools, particularly where local decision is to pre-screen before applying fluoride varnish to teeth other than FPMs • School where Mobile Dental unit visits to provide treatment • Primary Schools in area with high Welsh Index Multiple Deprivation (WIMD) super output area, but not already in D2S or eligible for D2S. That is schools where recent epidemiological data shows significantly higher rates of caries as identified by Welsh Oral Health Information Unit (If requested, WOHIU will help CDS to identify these schools) 68 Welsh Government expect that children in year groups 2, 3 and 4 of D2S eligible schools will be offered screening in at least one of these year groups Schools in areas of low need These schools (as defined by WIMD) will not be offered screening, but CDS may offer to provide parents with written reminders of the importance of dental attendance. Consent to screening • • • • Consistent with D2S, and including medical history as appropriate In D2S year groups everyone is eligible for tooth brushing whether or not they consent to screening Children can only be offered Fissure Sealants if they have been screened Screening of children for fluoride varnish is for Local Health Board and CDS decision. Where screening is not undertaken there will be clear written processes on identifying and providing fluoride varnish for these children. Clinical criteria for school screening The main criteria relate to Designed to Smile • child for fissure sealant under D2S (as per local D2S provision) where first permanent molars are sufficiently erupted and good moisture control possible • child for fluoride varnish under D2S (as per local D2S provision) where first permanent molars are sufficiently erupted • caries in primary dentition (primarily as a marker for risk of caries in the permanent dentition) Screening may also identify children who could benefit from fluoride varnish on teeth other than first permanent molars. Screening of children for fluoride varnish alone is for Health Board and CDS decision Additional criteria which require standard letter to parent / person with parental responsibility are - • evidence of pathology including localised sepsis, generalised oral infection, mucosal lesion(s) • permanent incisors darkened / discoloured / fractured into dentine • caries in permanent dentition • child with either gross plaque, calculus or swollen gums 69 • dental developmental anomalies, E.g. Supernumary tooth, potential malocclusion Dental professionals will use their clinical judgement to note any other oral health issues or concerns about the child’s health and well-being (Adapted from Kearney-Mitchell et al, 2006 as noted in PHW review) Data collection Data will be collected in a standardised format which includes: General • Date of screening, • Name/ GDC number of dental professional • School name, Child specific • Child name and D.O.B, • Confirmation of positive consent • Year group and class. • Child absent for screening • Child refused screening • Child scores positive to any of the criteria -record the criteria and relevant clinical data. • Other Observations/comments e.g. safeguarding concern Screening Process and Documentation required The operational process for screening is described by the Community Dental Service Clinical Directors and standard documentation is included as part of the process. Every child will receive a feedback letter whether or not they require follow up as part of D2S programme or for other clinical reason. If requested the CDS must respond appropriately and promptly to facilitate access to dental care. 70 Consider providing a report letter to Head teacher giving information on number screened, number who require treatment, number who don’t require treatment etc. This information can be useful basis for discussion on Design to Smile where a school may be considering withdrawing from the programme. This protocol was developed with the support and expertise of Public Health Wales dental governance team and the CDS in Wales. 71
