Original Statements - Oral Health

Original Protocol Statements

(Original Welsh protocol intervention in brackets)

The original Protocols for Investment in Health Gain were written in the early 1990s to suggest areas where the introduction, or more widespread use, of certain practices could lead to worthwhile improvements in health for the people of Wales. The documents also highlighted current practices which were of questionable value.

In certain areas, elements of the original statements have not been included into the revised statements. Where this occurs, reasons for omission are given. The original Welsh Protocol intervention is given in brackets after each statement, these refer to the following;

Original Welsh Protocol intervention

Interventions that increase health gain
Interventions that appear promising but require further evaluation
Interventions with uncertain effects which require further evaluation
Interventions that should be abandoned in light of available evidence

1. Tooth decay

PREVENTION AND PROMOTION: Water fluoridation (1); Fluoride drops and tablets (1); Plaque control using fluoride toothpaste (1); Regular dental attendance (1); Education (1); Resin based fissure sealant (1); Dietary control (1); Reduction in sugar-based medicine (1); Stop bottle feeding not later than 12 months (1); Topical fluoride for special needs groups (1); Fluoride varnish (2); Glass ionomer cement (3)
DIAGNOSIS AND ASSESSMENT: Visual and gentle tactile examination of teeth (1); Bitewing radiographs (1); Orthodontic decision on extraction (1); Gentle investigation of root lesions (2); Use of transillumination fibre optic light (3); Use of sharp probe (4)
TREATMENT AND CARE: Permanent fillings and crowns (1); Extractions for relief of pain and infection (1); Temporary filling for young children (2); Preventive resin fillings (2)
REHABILITATION AND CONTINUING CARE: Regular dental attendance (1); Dentures (1); Bridges (1); Dental implants (1)
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Record of elements of the original statements not incorporated into the revised statements

Subject	Reasons for omission
The role of glassionomer cement in the prevention of dental caries.	Unconvincing evidence
Orthodontic decision on extractions	Covered in Chapter 3 ‘Dento-facial anomalies’
Gentle investigation of root lesions	Unconvincing evidence
Use of sharp probe	Expert opinion is that this practice is unsound
Permanent fillings and crowns	Insufficient evidence
Extractions for relief of pain and infection	Insufficient evidence
Temporary filling for young children	Insufficient evidence
Preventive resin fillings	Insufficient evidence

Recommendations to Office of R & D for possible further research:: To validate the use of laboratory predictors of clinical performance of filling materials; To develop an accredited range of products supported by independent research evidence

2. Periodontal Diseases

PREVENTION AND PROMOTION:: Regular dental attendance (1); Plaque control skills (1); Reduce smoking (1); Community and school-based oral health education programmes(2); Chemical plaque control (2)
DIAGNOSIS AND ASSESSMENT:: Visual examination (1); Measurement of: -Bleeding (1) -Loss of attachment (1) -Tooth mobility (1) -CPITN (1) -Tissue breakdown products (2); Culture of microorganisms (2)
TREATMENT AND CARE:: Regular dental checkups (1); Plaque and calculus removal (1); Selective root planing + or - surgical exposure of root by flap surgery (1); Full mouth free flaps (3); Local and systemic antimicrobials (2)
REHABILITATION AND CONTINUING CARE:: Regular dental attendance and monitoring (1); Plaque control (1); Short term periodontal splinting techniques (3)
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Record of elements of the original statements not incorporated into the revised statements

Subject	Reasons for omission
Measurement of Community Periodontal Index of Treatment Need (CPITN)	Superceded by the Basic Periodontal Examination (BPE)

3. Dento-facial anomalies

PREVENTION AND PROMOTION: Genetic counselling (2)
DIAGNOSIS AND ASSESSMENT: History (1); X-rays (1); CT scans (1); Study models (1); Visual examination (1); Palpation (1); Orthodontic assessment -; use index of orthodontic treatment need (IOTN) (2); use peer assessment rating index (PAR) (2)
TREATMENT AND CARE: Orthognathic surgery (1); Speech therapy (1); Multidisciplinary team work (1); Prevent decay (1); Prevent gingivitis (1); Orthodontic work -; index of orthodontic treatment need (IOTN) groups 4 and 5 (1); IOTN group 3 following consultant opinion (2); IOTN groups 2 and 1 (4); Extract filled or decayed teeth rather than sound teeth (2)
REHABILITATION AND CONTINUING CARE: Prevent decay (1)

Additional comments/suggestions:

Cleft lip and palate are the subject of an ongoing
National investigation by the Clinical Standards Advisory Group on Cleft Lip and Palate (CSAGCLP).
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4. Oral Cancer

PREVENTION AND PROMOTION: Reduce smoking (1); Regular oral examinations (1); Reduce alcohol intake (2); Screening of at-risk groups (2); Health education of at-risk groups (2); Education of medical and dental professionals (2); Education of pharmacists (2); General population screening (3)
DIAGNOSIS AND ASSESSMENT: Biopsy (1); Palpation (1); X-rays (1); CT scans (1); Early diagnosis by visual examination of soft tissue (1); History (1); Opportunistic advice from pharmacists (2)
TREATMENT AND CARE: Early referral (1); Surgery (1); Radiotherapy (1); Reconstructive surgery (1); Chemotherapy (1)
REHABILITATION AND CONTINUING CARE: Implants; Implant-supported prosthesis (1); Restorative dentistry (1); Psychological support (1); Speech therapy (1); Regular follow-up examination (1)

Record of the elements of the original statements not incorporated into the revised statements

Subject	Reason for omission
General population screening	Lack of evidence
Screening of at-risk groups	Lack of evidence
Education of pharmacists	Lack of evidence
Opportunistic advice from pharmacists	Lack of evidence

5. Temporomandibular joint disorders and complex facial pain

TMJ - DIAGNOSIS AND ASSESSMENT: History (1); Examination (1); X-rays (1); Biopsy; Early diagnosis by visual examination of soft tissue (1); Initial advice from pharmacist (2)
TMJ - TREATMENT AND CARE: Counselling (1); Physiotherapy (2); Pharmacotherapy (2); Occlusal treatments (2); Surgery (2)
COMPLEX FACIAL PAIN - PREVENTION AND PROMOTION: Avoid and reduce stress (2)
COMPLEX FACIAL PAIN - DIAGNOSIS AND ASSESSMENT: Multidisciplinary diagnositic approach (1); Complex facial pain - Treatment and care; Pain clinics (1); Behaviour therapy (2)

6. Tooth wear and hypersensitivity

TOOTH WEAR

PREVENTION AND PROMOTION: Appropriate toothbrushing (1); Fluoride varnish (1); Fluoride mouthrinse (1); Reduce excess intake of - citrus fruits and drinks (1); - carbonated drinks (1); Avoid stress (2); Topical fluoride (2)
DIAGNOSIS AND ASSESSMENT: Dietary history (1); Medical history (1); Referral to medical personnel (1)
TREATMENT AND CARE: Fillings (1); Crowns (1); Treatment by medical personnel - muscle relaxants (2); - antidepressants (2); Bite raising appliances
REHABILITATION AND CONTINUING CARE: Reduce consumption of acid fruits and beverages (1); Stress counselling (2)

DENTINE HYPERSENSITIVITY

PREVENTION AND PROMOTION: Reduce gingival trauma (1); Correct toothbrushing (1); Reduce intake of diatary acids from food and drink (1); Reduce periodontal disease (2)
DIAGNOSIS AND ASSESSMENT: Toothbrushing (1); Erosive agents (1); Cold air (1); Gentle tactile examination (1); History taking and elimination of other causes (1)
TREATMENT AND CARE: Advice on aetiology (10; Block dental tubules (1); Block nerve transmissions at pulpal surface (2); Use of therapeutic toothpaste (2); Glass ionomer cement (2)
REHABILITATION AND CONTINUING CARE: Appropriate toothbrushing (1)

Record of elements of the original statements not incorporated into the original statements

Subject	Reasons for omission
The reduction in tooth surface loss by topical fluoride or by fluoride mouthrinse	Would be difficult to evaluate
Referral to medical personnel	No evidence

Recommendations to Welsh Office (where appropriate) to inform Targets & Priorities Group:

Re: Research and Development; Consolidation of evidence required

7. Dental Injuries

PREVENTION AND PROMOTION: Mouth protectors (1); Seatbelts (1); Head protection (1); Education of parents/school and sports staff in first aid measures for dental injuries (1); Education of dental team in detection of non-accidental injury
DIAGNOSIS AND ASSESSMENT: History (1); Visual examination (1); Palpation (1); Xrays (1); Transillumination (2)
TREATMENT AND CARE: Composite restorations (1); Reimplantation (1); Store teeth in isotonic solution of milk (1); Endodontic treatment (1); Splint for short period (2); Jacket crowns for young permanent teeth (4); Pinned restorations for young permanent teeth (4)
REHABILITATION AND CONTINUING CARE: Regular follow-up (1)

Record of elements of the original statments not incorporated into the revised statements

Subject	Reasons for omission
Jacket crowns for young permanent teeth (4)	Expert opinion is that they are harmful.
Pinned restorations for young permanent teeth (4)

Additional comments/suggestions:

Evidentially based example of good practice:

Mouthguards have been mandatory for football in the USA since 1962 when the National Alliance Football Rules Committee adopted themⁱ.

i. Scott J, Burke FJT, Watts DC. A review of dental injuries and the use of mouthguards in contact team sports. British Dental Journal. 1994; 176: 310-314.

8. Inherited Dental Anomalies

PREVENTION AND PROMOTION:: Early diagnosis (1); Counselling (2); Diagnosis and assessment:; Regular attendance at dentist (1)
TREATMENT AND CARE:: Preformed stainless steel crowns (1); Prevent caries (1); Prevent periodontal disease (1); Fluoride varnish (2); Glass ionomer cements (2); Enamel microabrasion (2); Overdentures (2)
REHABILITATION AND CONTINUING CARE:: Crowns (1); Bridges (1); Dentures (1); Prevent decay (1); Prevent periodontal disease (1); Implants (2)

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Health Evidence Bulletins: Wales, Duthie Library, UWCM, Cardiff CF14 4XN. e-mail: weightmanal@cardiff.ac.uk