Fifty per cent of adults in the UK have not been to the dentist in two years. So how can community pharmacists help people maintain good oral health? Kathy Oxtoby explains…

Figures released by the Health and Social Care Information Centre (HSCIC) in 2015 showed a drop in the number of people seen by an NHS dentist.

The number of dental patients in the two years leading up to April 2015 fell by 0.3% to 30.08 million compared to the previous two-year period. The data also showed that the number of children treated by an NHS dentist in the year to March 31 2015 was 6.9 million, which is just 60% of the child population.

Failing to attend regular dental checkups is not only bad for people’s oral health but also their general well-being. According to oral health charity the British Dental Health Foundation, research has suggested links to heart disease, stroke, and diabetes.

For those afraid of the dentist’s chair, pharmacy can offer a familiar face to help enhance their oral health.  “Oral health is a crucial part of our profession,” says Lila Thakerar superintendent pharmacist, Shaftesbury Pharmacy in Harrow. She views the category as a way of “getting more involved in healthcare of our communities”.

Working with dentists

There are many other opportunities for community pharmacists to engage with dentists to improve the public’s oral care. Atif Shamim is national lead, Pre-registration Pharmacist Recruitment Scheme, lead pharmacist, Community and Primary Care, London, Kent, Surrey and Sussex, Health Education England (HEE). He says pharmacists have “a huge role to play in advising patients on the merits of good oral health, and spotting the signs that would warrant referral to a dentist”.

Conversely, dentists “appreciate the advice pharmacists can offer on potential drug interactions and oral side effects of medicines, and so discussions between the two on how they can help each other and their patients would be beneficial”, he says.

Acknowledging that it can be “very difficult to find the time and space to be able to have these conversations”, Mr Shamim says in 2018 the HEE dental and pharmacy teams joined forces with a host of partners to produce dental health factsheets. “We saw these as a simple aid for pharmacists and their teams to refresh their knowledge when dealing with common dental presentations in pharmacy and illustrate the power of collaborating for the benefit of patients,” he says.

Brendon Jiang, a portfolio pharmacist working in general practice, hospital and the community, and an English Pharmacy Board member, agrees that pharmacy should be engaging with dentists to promote good oral health.  He believes it is “an ideal time” for partnerships with community pharmacists and dentists to take place, in the light of the roll out of Primary Care Networks, and the public health campaign on children’s oral health in May and June this year.

Pharmacists can build strong relationships with dentists to improve lines of communication and information about patients’ oral health. For Sunil Chopra at the Village Pharmacy, Hextable in Kent, the relationship with his local dentists is that they are literally part of the family – all three of his children are dentists and they have a surgery within the practice.

“Five years ago, when we decided to expand the pharmacy, we decided to include a dental surgery to provide two health related services under one roof,” he says.

The response from patients to the surgery has been “very positive,” he says. “People come to the pharmacy with say a toothache or they need an urgent filling done and because we have a dental surgery on the premises we can fit them in at short notice,” he says.

Ms Thakerar has a dental surgery next door to her pharmacy, and this close proximity means she can discuss with the dentist what regular stocks of scrips she needs, check patients are not allergic to penicillin, and what products should be featured in the pharmacy oral health section. And both professionals refer patients to each other.

Having a dental surgery on your pharmacy doorstep is not necessary to engage with the profession. Mr Shamim says on a local level: “It’s sometimes as easy as just talking to your local dentist and sharing ideas on how you can collaborate.”

Advice for patients

Oral health is an important part of general health and wellbeing and pharmacists are "ideally placed to initiate oral health discussions with anyone who walks into their pharmacy”, says Mr Shamim . A number of further free-to-access resources to support these discussions can be found on the HEE Mouth Care Matters website.

Mr Shamim says that while pharmacists are “very good at recognising the extent of their knowledge; they do not take unnecessary risks”. He advises that the HEE dental and pharmacy teams’ factsheets contain information on a number of conditions that serve as a knowledge refresh, including sections that help identify key warning signs that would warrant urgent referral.

Pharmacists have an opportunity with this category to advise patients about the basics of good oral hygiene to help prevent problems not only with their teeth, such as twice-daily brushing, changing their toothbrush every two months, and not rinsing after brushing as this removes fluoride from the teeth.

Hard toothbrushes “are not recommended” as they can damage the gums, advises Terry Maguire a community pharmacist in Belfast. Patients should be advised about the importance of flossing, and while mouth washes are helpful, not to have their mouth “too clean”, as “the mouth is all part of the digestive system, so it’s about keeping it healthy not sterile”, he says.

Oral health is linked to patients’ overall health, and problems may be symptoms of other conditions, such as mouth cancer, so pharmacists with concerns should signpost them to their GP and/or dentist. “It’s important that pharmacists work within their limits within this category and their knowledge. For example we can deal with problems like mouth ulcers, but if they  don’t clear up the patient must go to their dentist or doctor,” says Mr Chopra.

The category is also an opportunity to talk about healthy living advice, such as quitting smoking, and alcohol consumption as an unhealthy lifestyle will have an impact on oral health too.

Children’s dental health

Children’s dental heath is a priority area for Public Health England (PHE). The results of the oral health survey of 5 year old children (2016 – 2017) show a wide variation at both regional and local authority level for both prevalence and severity of dental decay.

Mr Maguire finds that children’s oral health “sadly remains a huge public health issue and in spite of significant campaigns over last number of years, we still are still seeing lots of dental problems both for first teeth and second teeth”.

Sugar consumption, he says, “clearly remains a problem, and we still to get that message out there that sugar is a cause of dental caries “.

Effective oral care for children is “all about preventing tooth decay as soon as the first tooth appears”, advises Ms Thakerar. This means regular brushing, at least twice a day with fluoride toothpaste.

To support dental health locally, pharmacists need to deliver consistent messages to families, children, and new mothers about good oral care. And Mr Jiang stresses the importance of engaging with all stakeholders involved with care pathways for children’s oral health, to raise awareness.

Pharmacists need to educate parents about the importance of their children’s oral health, of brushing regularly, and avoiding sugary products, particularly before bedtime, advises Mr Chopra. And as soon as children can hold a toothbrush, parents should encourage regular brushing, ensuring they get into a routine..

“With children you need to make brushing their teeth fun,” says Mr Chopra. He suggests stocking a range of bright coloured toothbrushes – the Wisdom range - and different flavoured toothpastes.

Products to stock for adults

Pharmacists need to have a wide range products available “because we’re competing with the grocery sector”, says Mr Maguire.  

Stocking the main oral care brands, such as Colgate, Sensodyne, and Oral B, mouthwashes such as Corsodyl and Listerine, and a range of toothbrushes, including electric toothbrushes, and products recommended by dentists, gives customers reassuring choices when purchasing dental products.

More recently, of charcoal toothpaste’s ability to whiten and remove surface stains on teeth have made this type of product popular. However, some pharmacists suggest this type of toothpaste could be more of a ‘health fad’ and question its effectiveness. Mr Jiang asks if charcoal toothpaste can affect deep staining of teeth, and Ms Thakerar believes there is “a lack of evidence” that it is a whitening toothpaste.

Fluoridation and dental health

Fluoridation in drinking water has been an issue for oral health in England for the past fifty years, ever since it was discovered that people who live in areas with high levels of fluoride are less likely to develop dental caries.  Mr Chopra believes fluoride in drinking water is fine “provided people know about it”.  To find out whether the local water supply is fluoridated you can advise customers to visit a link to a fluoride map.

Customers may wish to purchase fluoride tablets to boost their oral health, however Mr Jiang says he would advise against this unless they have been recommended by a dentist “because you can take too much fluoride and be at risk of dental fluorosis”.

In the future, the key to improving oral healthcare will be for pharmacists and dentists to build a relationship based on mutual support and by signposting customers to the best products and appropriate services, and as Ms Thakerar says, “communicating with all health care professionals about oral health.”

Picture: ozgurdonmaz (iStock)