Key Points
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Preventive dental care for young children should be based on best evidence and delivered in a consistent manner throughout the NHS.
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To help GDPs deliver preventive care in a consistent, evidence-based way, the current scientific evidence on fluoride use needs converting into clear, easy to follow recommendations for children of differing ages and caries risk.
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To help GDPs deliver preventive advice in a consistent way, an easy to follow, evidence-based hierarchy of specific diet and oral hygiene messages needs to be developed.
Abstract
Objective To increase understanding about the content of preventive advice and care offered by general dental practitioners to young children.
Design Qualitative study using semi-structured interviews.
Setting The North West of England. Interviews took place between March and September 2003.
Subjects and methods Ninety-three general dental practitioners practising within the general dental service were interviewed about the care they provide to young children. The interviews were recorded, transcribed and analysed using a constant comparative method.
Results Preventive advice given to parents of young children is usually about sugar consumption and tooth brushing behaviour but the emphasis and specific messages provided varies among general dental practitioners. Use of fluorides varied considerably, suggesting that some dentists either have reservations or are unclear about the appropriate use of fluorides. The study indicates important variation in the content of preventive care.
Conclusion There is important variation in the approach of general dental practitioners to the core activity of preventing caries in young children and some views expressed are not supported by the evidence base.
Main
Exploring the content of the advice provided by general dental practitioners to help prevent caries in young children A. G. Threlfall, K. M. Milsom, C. M. Hunt, M. Tickle and A. S. Blinkhorn British Dental Journal 2007; 202: E5
Editor's summary
The description of the way in which we have provided, and now provide, prevention advice gives a major clue to a shift in attitude by the profession. For many years it was known as dental health instruction. In today's terminology a very 'top down' attitude and process which reflected our notion of the dentist knowing best, telling the patient what they should do 'for their own good' and expecting them to follow our words explicitly and to the full. With changes in the way in which society views professionals and indeed with changes in the way we as professionals realistically view patients, the label moved to dental health education (now, arguably oral health education), denoting a subtle but important shift to a more benevolent stance in the dentist-patient relationship. While this is a significant development in itself, there is also a need to review exactly what type of education we are providing. How consistent are the messages? When are they delivered? Are they appropriate?
This paper takes some first steps in analysing this process by attempting to gather information on how oral health education is currently carried out in the busy atmosphere of general dental practice in the UK, specifically in relation to caries in young children. What emerges is a picture of somewhat haphazard content and delivery of 'messages' in many ways skewed by the subjective views of the individuals doing the 'educating'. This is somewhat perplexing given the current stampede for evidence-based practice and that a very adequate and continually updated evidence-base has been available for over 30 years in the form of the originally titled Scientific Basis of Dental Health (now Oral Health) Education. What steps do we need to take as a profession to rectify this situation? Is it a matter that should be tackled at the undergraduate level or does it require a completely different approach? Dentists have a highly technical, five year degree training followed invariably by a further year as a VDP. Is there a less expensive member of the dental team trained specifically in patient education methods who could do the job more consistently and thoroughly?
The full paper can be accessed from the BDJ website ( www.bdj.co.uk ), under 'Research' in the table of contents for Volume 202 issue 3.
Stephen Hancocks OBE, Editor-in-Chief
Author questions and answers
Why did you undertake this research?
Researchers based in Manchester have a long history of investigating the prevention of caries in young children. Recently, the new dental contract has been criticised for not supporting prevention in general dental practice. However, little is known about how general practitioners provide preventive care. The evidence base for prevention of caries in young children is strong, and recently published Cochrane systematic reviews clearly support the use of fluoride therapies. We specifically wanted to understand if the content of preventive care and advice provided by dentists followed evidence-based guidance. This is important, as if the new contract were to be changed to support prevention dentists, policy makers and NHS commissioners need to know that it is likely to be effective.
What would you like to do next in this area to follow on from this work?
This study provides cause for concern in that dentists seem not to be providing advice based on firm evidence, and that there is wide variation in the approach to providing preventive advice. To identify if there should be a policy shift to support prevention in practice, we need strong evidence from practice-based randomised trials that the fluoride therapies considered in recent Cochrane systematic reviews are cost effective when delivered in general practice. We also need to have a deeper understanding of how to ensure evidence changes practice and reduces variation in the approach to care.
Comment
Dietary advice to reduce the consumption and the frequency of intake of sugary food and drink and confectionery is a key message for dental health education.1 Disappointingly, there is little evidence for the effectiveness of this advice on caries, unless associated with the use of fluoride.2 Providing advice alone also consolidates existing social inequalities due to differential access to resources.3
Offering preventive advice in general dental practice remains the norm despite these problems, as this first of two papers describes. It aims to establish the content of preventive advice given to young children and their carers – the outcome of a rigorously conducted qualitative study in which 93 randomly selected GDPs were interviewed. The key findings were that while the participants reported providing preventive advice, there was little apparent consistency of approach, either between respondents or within any one respondent's advice-giving. Reservations or a lack of clarity about appropriate fluoride use were reported. An important predictor for providing more advice was the dentists' subjective judgements of levels of parental motivation.
The authors argue the need for guidelines to help dentists deliver consistent evidence-based advice. In other areas of prevention there is a substantial evidence base that supports the value and effectiveness of brief preventive advice. For example, the National Institute of Health and Clinical Excellence has recently published guidance on brief interventions for smoking cessation in primary care.4 Like smoking, diet is a common risk factor for oral and systemic disease. The value of dietary advice offered in general dental practice should not be seen in isolation from its possible contribution to other health messages. Its role in family-based programmes should be developed.5
References
Levine R S, Stillman-Lowe C R . The scientific basis of oral health education. London: BDJ Books, 2004.
Kay E J, Locker D . Is dental health education effective? A systematic review of current evidence. Community Dent Oral Epidemiol 1996; 24 231–235.
Schou L, Wight C . Does dental health education affect inequalities in dental health? Community Dent Health 1994; 11: 97–100.
Brief interventions and referral for smoking cessation in primary care and other settings. Public Health Intervention Guidance 1. London: National Institute for Health and Clinical Excellence, 2006.
University of York/NHS Centre for Reviews and Dissemination. The prevention and treatment of childhood obesity. Effective Health Care Bulletin 2002; 7(6).
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Croucher, R. GDPs' caries prevention advice for young children. Br Dent J 202, 148–149 (2007). https://doi.org/10.1038/bdj.2007.115
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DOI: https://doi.org/10.1038/bdj.2007.115
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