The Dental Den

Hygienist Kellie O’Shaughnessy describes her award-wining oral health programme aimed at reducing childhood caries

A major issue for our dental services is childhood caries, currently the most chronic childhood disease 1.

As a parent of two young children and being a dental hygienist working in private practice, I realised the stark reality of how hard the task of prevention comes to parents.

In this day and age where children snack between meals, with hidden sugars, variations of brushing advice and fluoride use, the difficulty of reading labels and the power of advertising by food companies, there was a need for new techniques of prevention delivered in a simple fun way.

And so, the Dental Den was developed.

The Dental Den aimed to improve the oral health and advice on non-milk extrinsic sugars of children under the age of sixteen. The programme initially ran over a two-year period within private practice where data was collected and evaluated using a combination of caries risk assessment and parent questionnaires.

Caries risk assessment
Guidelines for strategies to prevent dental caries in children and adolescents (2009)2, an evidence based document, highlighted caries risk assessment. The strategies guidelines recommended children should be offered dental assessments in their first year of primary school in order to identify high risk caries children in line with first permanent molars erupting.

The North South Survey (2002)3 identified 55 per cent of five year olds in non-fluoridated areas and 37 per cent of five year olds in fluoridated areas in the Republic of Ireland have experienced decay. Currently there is no national data on pre-school children’s oral health, however some regional surveys have identified decay in three year olds, with levels higher among the more disadvantaged4.

The Dental Den aimed to encourage members of the community to attend from age one with their children, the dentist to take a risk assessment and prevention advice tailored to individual and families need. In the particular area where the Dental Den was run, the first school assessments were being carried out when children were nearly eight years of age, and some parents were not aware of the recommended age for dental visits and importance of regular recalls. The strategies guideline recommend recalls for children of high risk should not exceed 12 months. This is in accordance with the evidence base5.

The Dental Den programme used the Caries Risk Assessment Checklist at first appointment and each subsequent recall. The risk assessment is an essential process with The Dental Den and established a baseline for the programme and assessed individual and local need.

The use of health impact or risk assessment is recommended by the World Health Organisation within their Health in All Policies document, nationally in the Healthy Ireland Framework and proposed for the new Oral Health Policy6,7,8.

The Dental Den’s objectives
An important aspect of the Dental Den was to embrace health in general, the ethos that the mouth is the gateway to the body and by improving our oral health we may improve general health. Health promotion is the process of enabling a person to increase control over and improve their own health and wellbeing (WHO, 1986)9.

The objectives included to create practice policy and deliver messages on oral health; fluoride advice, plaque control and advice on non-milk extrinsic sugars. Non-milk extrinsic sugars (NMES) are the sugars most responsible for dental caries, these are sugars added to food and drink. The Dental Den incorporated label reading as a process to educate and empower children and their parents/grandparents/carers. This process was made fun and easy using real everyday food labels and enabled the process to be carried out at home, supported with written worksheet with visual images.

The frequency of NMES has been long confirmed as the most vital factor in dental caries. The Stephan Curve10 illustrates the process of demineralisation which occurs just minutes after the intake of NMES. Caries risk assessment highlighted that 83 per cent of children seen in the Dental Den were consuming sugars more than twice a day. The process of explaining frequency was perhaps the most challenging part to deliver. To enable this message, initially a visual image was used from a HSE designed resource which displayed the image of an acid attack along with food. An important process in the programme was evaluation. It was recognised that although the sugar frequency was a key message, children often became distracted which meant the adults also became distracted.

With this in mind a resource was developed known as the Dental Den sugar clock. The sugar clock involved interactive action that children became part of, and this visual demonstration had a powerful effect of understanding by adults present.

Testimonials for the sugar clock:
“The sugar clock is such an innovative idea and the kids love it, a great purchase. Very durable and practical.” Magee Dental Care, Lurgan

“I’m a dental nurse in a specialist dental clinic and work with a paediatric dentist and we see children and special needs patients all the time. We use the sugar clock every single day teaching about foods and drinks with hidden sugars. The clock is fantastic for this as it allows the patients to visually see and they really enjoy getting involved in the learning process. I find it brilliant to work with and it makes my job so much easier.” Chloe Sheehan, Citygate Dental, Cork

Plaque control demonstrations took place with the visual use of disclosing tablets, this process gave the oral health promoter the opportunity to assess levels of dexterity and tailor an oral hygiene routine that suited the individual and encouraged adults to participate and monitor plaque control. The first risk assessments highlighted that 62 per cent of children brushed twice a day and 38 per cent had fissure sealants. Fissure sealants were encouraged through the programme as a preventive measure, however financial constraints were highlighted. With this in mind the practice lowered the fee for fissure sealants and encouraged the dental hygienists to carry these out as this was more cost effective.

Topical fluorides were advised, the levels of fluoride on both toothpaste and mouthwash – if indicated by the dentist – were advised. It was evident that variations of fluoride levels did exist in children’s toothpastes and mouthwashes so this was an important message.

Evaluation
The Dental Den programme ran for two years and was evaluated using the caries risk assessment and patient feedback questionnaires. Data is currently being evaluated to clarify if risk levels reduced over the time frame, early indications show some success.

The Dental Den has become a public source of information via social media and website, www.thedentalden.com

I have recently relocated to the Galway area and my hope is to engage other private practices to run the Dental Den. The programme is FREE and embraces a team approach, with dental nurses showing skills that would enable oral health promotion to grow within the team. Working together nationally and locally within our communities we can deliver a stronger oral health message that is clear for our patients to understand.

For more information, call Kellie on 08 7922 4347, email thedentalden@gmail.com or visit www.thedentalden.com


References

1. Health, N. I. of. (n.d.). Oral Health in America: A Report of the Surgeon General (Executive Summary). Retrieved from http://www.nidcr.nih.gov/datastatistics/surgeongeneral/report/executivesummary.htm
2. Irish Oral Health Services Guideline Initiative. Strategies to prevent dental caries in children and adolescents: Evidence-based guidance on identifying high caries risk children and developing preventive strategies for high caries risk children in Ireland (Summary guideline). 2009
3. North South Survey of Children’s Oral Health 2002. (n.d.). Retrieved from http://www.dohc.ie/publications/coral.html
4. Tuohy M. A study of dental caries levels among three-year-old children in South Tipperary – a comparison of medical card holders and non-medical card holders. Thesis submitted in part fulfilment of the requirements for the degree of Master of Dental Public Health. Cork: University College Cork, 2000.
5. NICE. (n.d.). Dental recall. NICE. Retrieved from http://www.nice.org.uk/guidance/CG19
6. WHO | Health in All Policies: Framework for Country Action. (n.d.). Retrieved from http://www.who.int/healthpromotion/frameworkforcountryaction/en/
7. Healthy Ireland – A Framework for Improved Health and Wellbeing. (n.d.). Retrieved from http://www.dohc.ie/issues/healthy_ireland/
8. A new National Oral Health Policy. (n.d.). Retrieved from http://www.dohc.ie/issues/Oral_Health_Policy/
9. WHO The Ottawa Charter for Health Promotion. (n.d.). Retrieved from http://www.who.int/healthpromotion/conferences/previous/ottawa/en/
10. Stephan Curve. (n.d.). Retrieved May 25, 2014, from http://oxfordindex.oup.com/view/10.1093/oi/authority.20110803100531178