Preventive and clinical care provided to adolescents attending public oral health services New South Wales, Australia: a retrospective study

The NSW fluoride policy pertaining to professionally applied fluoride products for individuals above 10 years of age recommends that fluoride varnish and/or high concentrated fluoride gels should be used for patients who have an elevated risk of developing caries [25]. Topical fluoride use has been scientifically proven to be effective in the prevention and control of dental caries and their use for caries stabilisation [9, 33, 34].

The majority of adolescents being treated came from deprived (low socio-economic) and rural and remote areas where caries rates are high [14]. For example the high levels of restorative and extraction activities recorded for Northern NSW (Table 2) which is an unfluoridated area should signpost the importance of providing fluoride treatments for these at risk patients. However, the Therapists recorded an actual level of only 5.4 percent topical fluoride treatments for these patients. Adolescents living in Northern NSW have high levels of dental caries and Therapists from this area did spend time on oral hygiene instruction (17.2%) and the use of fluoride tooth paste, which aligns with the fluoride policy [25]. Therapists in two other LHDs spent similar proportion of time on oral hygiene instruction, one metropolitan and one rural. The reasons other LHDs spent less time is not clear, and further research using qualitative approaches is warranted.

Skinner et al. [14] reported a mean DMFT of 2.4 for NSW rural and remote regions, with a mean DMFT for Mid North Coast of 3.0 therefore provision of topical fluoride treatments for adolescents residing in these areas is especially important in conjunction with oral hygiene education and promotion of tooth brushing with fluoride toothpaste, according to government policy [14, 25]. This study illustrated fluoride applications for rural and remote areas varied between 5.4 percent (Northern NSW) to 23.4 percent for Far West LHD, compared to metropolitan LHDs ranging from 8.1 percent (Sydney) to 32.3 percent in Nepean Blue Mountains.

Considering the Australian Government Teen Dental Program aimed at low socio-economic families had an emphasis on preventive care [23], it is disappointing to note the low levels of topical fluoride use and oral hygiene instruction across LHDs, as these are relatively simple and quick procedures that assist in dental caries prevention [9]. Previous studies have identified factors influencing clinician’s adherence to preventive guidelines for example lack of time, variances in practitioners awareness of protocols, guidelines and individual habitual clinical behaviours [35‐37].

Placement of fissure sealants in the occlusal surfaces of permanent molars, the sites most susceptible to dental caries is a proven clinical preventive intervention, especially for those individuals classed as being at high risk of developing dental caries [26, 38].

This study recorded the percentages of fissure sealants provided by Therapists for adolescents accessing the NSW Public Oral Health system; although levels of fissure sealants across LHDs were fairly low, the findings illustrated that Therapists placed fissure sealants aligned with permanent tooth eruption age timeframes. According to Skinner et al. [14] in their State-wide dental survey, South Eastern Sydney LHD 14–15 year olds had the most fissure sealants in their permanent teeth across NSW. However, in our study fissure sealant percentages provided to adolescents by Therapists in this LHD were particularly low. This suggests the focus on fissure sealants as a preventive modality for 14–15 year olds may well have occurred in the private sector. A study undertaken by Clarkson et al. [39] in Scotland offered incentives of remuneration and training for the underutilised practice of placement of fissure sealants by dentists. Following the intervention the authors reported a 9.8% increase in the provision of fissure sealants, with no significant difference noted in the type of education provided [39]. Little is known of the impact the Australian Government Teen Dental Program vouchers had on Therapists fissure sealant preventive practice as separate treatment items were not reported as there was a flat fee per voucher.

The use of bitewing radiographs by Therapists as a diagnostic and caries management tool was clearly not a standard procedure. This is clearly insufficient as they provide relevant clinical information prior to the placement of fissure sealants and planning a preventive strategy [26, 32, 40]. Despite the evidence of the value of fissure sealants as a preventive treatment, most NSW LHDs with high restorative and dental extraction activities reported low fissure sealant placement activity.

Bonetti et al’s [35] study used psychological models to understand and predict general dental practitioner’s clinical behaviour to placement of fissure sealants. The authors suggested that evidence-based behaviour of clinicians can be enhanced by influencing beliefs of the positive outcomes of fissure sealant placements and creating a clinical habit of performing them as an integral part of patient management.

Overall, the provision of fissure sealants as a preventive modality was inadequate in comparison with the time devoted to restorative care across the State for adolescents. Satur et al’s [41] study reported that due to greater demand in rural areas for urgent treatment including emergencies, less preventive care was being offered to patients, and this may explain why some Therapists were not placing fissure sealants.

According to the Cancer Council Australia, 80% of adults become addicted to smoking during their adolescent years [42]. Researchers recommend provision of smoking cessation in the dental setting for adolescents as an early intervention strategy [43]. Self-reporting by patients completing their medical history should be used as a trigger by all clinicians in NSW Public Oral Health Services to provide smoking cessation advice [27]. Therapists identified adolescents for smoking cessation advice commencing at age 13 and the numbers given advice slowly increased with patient age. Nonetheless, despite this policy smoking cessation advice was rarely offered. Trotter and Worcester’s [44] study reported lack of resources and patient materials, clinician doubts regarding being effective, lack of confidence to tackle the issues and support patients to quit smoking and insufficient time as barriers to perform preventive activities. Our study suggests that further review and on-going training support for Therapists is required if smoking cessation is going to be offered routinely in line with the NSW Policy.

Adolescence is a critical developmental life stage whereby clinicians may engage with patients to promote self-efficacy towards improved oral health practices for long term health outcomes [21, 31]. In this study the offer of oral hygiene education to adolescents to promote brushing with fluoride toothpaste was low across all LHDs.

Oral hygiene is an individual’s personal maintenance plan to disrupt the plaque biofilm to prevent its accumulation on teeth and gingiva [45]. The promotion of brushing twice a day with a fluoride tooth paste to prevent dental caries is an important part of this activity. Oral hygiene education guidelines for adolescents are lacking, but, toothbrushing with a fluoride toothpaste are part of the NSW Health Fluoride Use Policy [25]. Therefore, Therapists should be supported in the clinical setting with the provision of oral health products (fluoride toothpaste and tooth brush) to issue to patients for home-care use in line with the Ottawa Charter ‘supportive environment’ principle [46]. There was a decline of oral hygiene education for older adolescents which is a concern considering evidence of adolescents’ levels of caries experience [5, 14] and their prospective as young parents.

Studies linking periodontal disease with systemic disease suggest that Therapists should offer professional prophylaxis in association with oral hygiene instruction [47, 48]. This study illustrated that professional cleaning (plaque and calculus removal) clinical activities provided for adolescents could be improved, and this may happen as the proportion of dually qualified Therapists and Hygienists increases.

There is overwhelming evidence regarding the role of sugar and its frequent consumption in the aetiology of dental caries [49, 50], however dietary advice was given little time by Therapists in NSW. Somewhat surprisingly, given the higher levels of dental caries this study found that in six rural LHDs, Therapists provided lower levels of dietary advice to adolescents when compared with Therapists in metropolitan LHDs. There is certainly scope for further research to investigate why Therapists offering dietary advice is so variable across LHDs. Therapists in public health settings have opportunities to provide dietary advice for adolescents utilising different strategies such as adopting Motivational Interviewing techniques and utilising easy to translate diet tip sheets [21, 31].

There is a plethora of evidence regarding adolescent’s dietary habits. Parents and health practitioners face fierce media advertising of carbonated beverages, sport drinks and sugary snacks [51‐53]. Nevertheless, it is important that Therapists work in collaboration with allied health professionals for example dieticians, diabetic educators, health promotion professionals and local community agencies to offer advice to young people so they have the knowledge to change their behaviour. This aligns with the Common Risk Factor Approach principles [16, 17] so that advice on oral health fits in with the general health concerns of trying to reduce obesity and early onset of diabetes [1, 54] and systemic diseases [47].

This is the first study undertaken in NSW to record the provision of preventive care provided by Therapists to adolescents accessing the Public Oral Health Service. The re-use of the ISOH data for research purposes requires more investigation. A useful first step would be to assess the reliability of the data in more detail. In addition, the way preventive items are coded should be the subject of a review as currently preventive activities are not captured in any great depth and useful data may be missed.