Although much of this guideline is concerned with the practice of dentistry within the dental surgery, other health professionals also have an important role in the prevention of dental caries in children.¹⁰²

Areas where non-dental health professionals have a role to play include:

• care of the medically compromised
• care of those who do not attend a dentist regularly
• care of those at "high risk" of caries development
• prescription of liquid medications, which should be sugar-free if possible
• advice on sugar-free over-the-counter (non-prescription) medicines.

A brief description of the process of the development of dental caries aimed at the non-dental health professional is given for background information.

5.1 Dental caries development

Dental caries is a disease of mineralised tissue of teeth caused by the action of micro-organisms on dietary carbohydrates, especially sugar. These micro-organisms live in a dense layer or bio film called dental plaque which forms on the tooth surface as soon as the tooth has erupted and reforms over hours following removal.

There are many bacteria in dental plaque, but the most important in the aetiology of dental caries are Streptococcus mutans and lactobacilli. These bacteria metabolise sugars to generate local concentrations of organic acid in the inner layers of plaque on the tooth surface, which lowers the pH at the tooth surface. When the pH at the tooth surface falls, a process of demineralisation occurs and calcium and phosphates diffuse out of the tooth enamel. When the pH at the tooth surface rises again this process is reversed and remineralisation occurs. However, if demineralisation predominates over remineralisation over a period of time in a susceptible tooth, sub-surface softening of the enamel occurs. If the lesion progresses this is followed by "cavitation", forming a carious cavity. Caries development is more likely at inaccessible areas where plaque is undisturbed.

The mean time for caries to be confined to the enamel radiographically varies considerably but a mean of 3-4 years was suggested some years ago. Mean times are more extended now, although progression is faster in high caries risk individuals.

Decreasing the amount and frequency of sugary intake and increasing the presence of saliva are important factors in the reduction and control of dental caries. Prevention can also be achieved by effective removal of plaque by diligent brushing and flossing, and tooth strengthening by provision of fluoride and fissure sealants. Tooth brushing with fluoride toothpaste both removes plaque and provides fluoride.

Dental erosion (tooth surface loss) is a different process from dental caries and is outwith the scope of this guideline. In erosion the enamel of the tooth is attacked by acid not created by micro-organisms in the plaque but by acid from outwith the mouth, commonly ingested but possibly due to reflux. Erosion in 6-16 year olds is often seen in combination with high consumption of carbonated drinks and fruit juices.

5.2 Sugar consumption

The evidence that sugar causes dental caries is widely accepted. Within a few minutes of ingesting sugar, the pH at the surface of the tooth falls and may take between 20 minutes and several hours to fully recover. The length of time it takes for the tooth surface pH to return above the critical level (at which demineralisation occurs) depends upon the quantity and "stickiness" of the sugar intake. If further sugary loads are taken before the pH at the tooth surface recovers, prolonged demineralisation occurs.

Patients should be advised to decrease both the quantity and frequency of their sugar intake. In particular they should avoid sugary snacks between meals and immediately before bedtime.

There may be a small number of children who have special dietary requirements affecting sugar intake and these patients need to be managed appropriately.

5.3 Dry mouth

The importance of saliva in counteracting demineralisation is often underestimated. The importance of saliva is most clearly appreciated in its absence. Patients with severe dry mouth are at risk of rampant caries (sudden rapid destruction of many teeth, frequently involving surfaces that are ordinarily caries-free).

There are several mechanisms by which saliva acts to prevent dental caries:

• it has a buffering effect which alters the plaque pH
• it washes away plaque and food debris
• it has an antibacterial action
• it contains a reservoir of minerals such as calcium and phosphates and, under certain circumstances, fluoride

Certain foodstuffs, e.g. cheese and sugar-free gum cause the stimulation of salivary flow. These foodstuffs therefore have a beneficial effect after a meal.

Dry mouth can be caused by drugs, e.g. anticholinergics and tricyclic antidepressants, disease, e.g. Sjogren/Sicca syndrome, diabetes, ectodermal dysplasia, and may occur following radiotherapy. Patients may not realise that dry mouth is a symptom for concern, especially if they perceive themselves to be coping, e.g. by taking frequent drinks. Knowledge of the importance of dry mouth to the dentition may encourage direct questioning to ascertain the presence of predisposing risk factors for dry mouth.

Artificial saliva is available on prescription. Only one (Luborant) is licensed for any condition causing dry mouth. Others are accredited for Sicca syndrome or post-radiotherapy only.

Non-dental professionals should be aware of the markedly increased risk of dental caries in the presence of dry mouth.

Low sugar artificial saliva and/or sugar free chewing gum should be considered for patients with dry mouth as appropriate.

5.4 Sugar-free medicines

Sugar-free medicines are defined as oral liquid preparations that do not contain fructose, glucose or sucrose. Preparations containing hydrogenated glucose syrup, manitol or sorbitol are also classified as sugar-free as there is evidence that they are not cariogenic.¹⁰³

Although it is easy to imagine that the amount of sugar in sugar-containing oral medicines is not significant, research has shown an association between sugar-containing oral medicines and dental caries.^{40, 41, 104} Prescription of sugar-free medication is particularly important if treatment is long-term (daily or alternate days for more than three months). This is particularly important because many of the children receiving long term medication are medically compromised and their dental treatment is already associated with increased difficulty.

The 1989 Report from the Committee on Medical Aspects of Food and Nutrition Policy (COMA) recommended that the Government should seek means to reduce the use of sugar liquid medicines.¹⁰⁵ This is within the power of the prescribing doctor in most cases. The Scottish Executive has also published a report by the National Pharmaceutical Advisory Committee⁴³ which advises that sugar free medicines should be used wherever possible.

Doctors should be aware of the risk of dental caries from sugared medicines and consider this when making their prescribing choices.

Dispensing pharmacists should be encouraged to substitute sugar-free versions of prescribed and non-prescribed medicines whenever it is appropriate and in the interests of the child to do so.

There are now sugar-free alternatives to most commonly used liquid medicines. Long term treatment with anti-convulsants and antibiotics for cystic fibrosis and recurrent urinary tract infections, the most common indications for long-term treatment¹⁰⁶ are possible in most cases without the use of sugared medicines. There are sugar-free versions of most common antibiotics, cough medicines and paracetamol mixtures which can be prescribed by doctors. Simple linctus is frequently prescribed although it is high in sugar content. Traditional honey and lemon cough medicines available over the counter are also popular and high in sugar content. In the case of Methadone, which may be prescribed to teenagers at the older end of the guideline age range, there is a sugar-free variant.

Prescribers should also be aware that the timing of medication has an impact on caries prevention. For example, lactulose, which is commonly used for the treatment of constipation in childhood, is less cariogenic than sucrose but it is often given at night before retiring when it could be given with an evening meal. ¹⁰⁷

To ensure a sugar-free preparation is dispensed a medical practitioner should add "sf" to the prescription. In the 85% of GP practices in Scotland using GPASS, the sugar-free preparations of a selected drug are listed in the menu of alternatives. If a prescription is not written specifically for a sugar-free preparation, the pharmacist can endorse the prescription, dispense a sugar-free preparation and be reimbursed by the Pharmacy Practice Board. In many cases the sugar-free alternative is the same price as the sugared preparation or only marginally more expensive.

5.5 Those who do not attend a dentist regularly

Regular dental examination, at least once a year, is important for caries prevention and management. However, only 55% of Scottish children under 18 were registered with a dentist in 1995/96.¹⁰⁸ This suggests that many children in the target age group of this guideline do not undergo regular dental checks.

The main barriers to attending a dentist have been identified as fear, the organisation and image of dental practices and cost¹⁰⁹ (although direct patient charges are not an issue for children). Dental indifference and apathy also play a part.

In other age groups patients have been successfully encouraged to register with a dentist by a member of their primary care team.¹⁰¹ The primary care team may be able to counsel patients who do not attend a dentist, and help them to overcome their own particular barriers to dental care. Medical practitioners can also help promote good oral health by providing dental advice to their patient when dental caries is discovered. Dental advice could also be introduced into appropriate clinics, such as an asthma clinic.

GPs should actively encourage high caries risk children to attend for dental care.

5.6 Medically compromised

This group includes those with a condition that makes dental treatment more hazardous, and includes patients with:

• cardiac disease
• immunosuppression, including HIV
• haemophilia and other bleeding disorders
• disability.

Patients in these groups may be more susceptible to poor oral health and subsequent caries development and / or dental treatment may be hazardous. By careful attention to preventive dental care, the need for dental treatment may be minimised. Many of these patients see their doctor, primary care team member, or hospital specialist regularly. There is an opportunity, therefore, for the non-dental health professional to promote caries prevention in these patients by encouraging them to attend a dentist.¹⁰¹

Congenital heart disease is important in this age group. There is an increasing number of children who have undergone successful cardiac surgery but may still be predisposed to infective endocarditis. Children with heart defects should receive maximal preventive dental care, to minimise the need for dental surgical procedures. However, there is evidence from the North East of England that such children are under-registered.¹¹⁰

To address the prevention of infective endocarditis, the recommendations of the British Society for Antimicrobial Chemotherapy¹¹¹ have been widely accepted and are reproduced in the BNF. It is important that patients at risk are well informed about the problem. Obtaining an accurate medical history is the simplest way to identify these patients. However, medical history given to a dentist by a patient may not be accurate.¹⁰¹ A recent review of 53 cases involving litigation between the infective endocarditis patient and their dental practitioner found that in 10 of the 53 cases no medical history had been obtained. ¹¹² In a further 31 cases the medical history was inadequate or out of date.

5.7 Orthodontic appliances

Wearing orthodontic appliances is a risk factor for the development of dental caries. Ordinarily a patient receiving orthodontic treatment is seen regularly by their dentist. However, patients sometimes default from dental care and treatment, so non-dental health care professionals should be aware of the risk of caries in children wearing orthodontic appliances.