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National Guidelines for Adult Dental Care – summary

In the national guidelines for adult dental care, the National Board of Health and Welfare highlights recommendations for treatments within seven guideline areas. With these, the authority aims to promote a range of care which shall lead to effective treatment alternatives and can be offered to patients on equal terms all over the country.

The National Board of Health and Welfare provides recommendations in the following areas:

  • methods for influencing behaviour
  • caries
  • diseases in tissues surrounding teeth and dental implants
  • diseases of the dental pulp and the periradicular tissues
  • pain and functional disorders of the mouth, face and jaws
  • malocclusion
  • complete and partial edentulousness

In the guidelines, the National Board of Health and Welfare also presents a number of possible financial and organizational consequences that the recommendations can have for the adult dental care sector. A couple of situations where the recommendations can constitute changes in clinical practice, is in the treatment of deep caries damage, and in the way the dental care sector relates to the prescription of antibiotics. Yet another area with implications for the dental care sector is patient education and the work regarding influencing behaviour. Today new knowledge exists which means that there is a need for a national education plan and, in the long run, significant educational efforts as well as a strategy for how this method is best applied.

In this document, the National Board of Health and Welfare has selected a number of recommendations that may be particularly important for the dental care sector from a management and control perspective.

At the National Board of Health and Welfare's website, you can use the search function for all the recommendations. All conditions, measures and recommendations, along with motivations, are described and ranked in the Condition and Remedy list (tillstånds- och åtgärdslista).

Methods for influencing behaviour – behavioural medicine prevention and treatment is effective

The person's own involvement is important for both health promotion and disease prevention as treatment measures. Therefore it is important that the dental health care sector has effective methods for patient education in order to influence long-term behaviours that are important to oral health. It is important for the dental health care sector to observe the new knowledge which has recently emerged.

The dental health care sector should give brief health promotional feedback to persons who are still healthy. The aim is to increase their participation while reinforcing good behaviours that are important for oral health, or preventing behaviours that are adverse to it. The measure aims to maintain good oral health.

In a near future it should be possible to offer persons with a disease, theory based behavioural medicine prevention and treatment. This applies primarily to patient education for conditions where lack of oral hygiene or smoking is considered risk factors.

Behavioural medicine prevention and treatment regarding education in relation to quitting smoking, is a measure which is currently carried out mainly within the health and medical care. The dental health care sector therefore needs to consult with the management of health and medicinal care sector to decide whether the role of the dental health care sector should only be to establish contact between the patient and the health and medical care sector, or if the dental health care sector should play a more active role in providing methods for offering support and aid for people to stop smoking.

Caries – the big picture is important

The dental care sector can decrease the need for future dental care efforts, by working to prevent caries and by treating diseases. A risk evaluation or cause investigation is necessary to clarify which factors are of importance when it comes to caries in the individual. Brushing with fluoride toothpaste twice a day gives most people a good basis for preventing caries.

When a person has an increased risk of developing caries or shows signs of an active caries disease, the dental care sector should suggest that the patient rinses with a 0.2 per cent fluoride solution. The dental care sector should also support people, who at the same time have a high sugar intake, to change adverse eating habits. Another alternative is for the dental care sector to offer fluoride varnishing. In contrast, the dental care sector should avoid encouraging people (with normal salivary function, and who brush their teeth with fluoride toothpaste twice a day) to use fluoride tooth picks, fluoride tablets or fluoride chewing gum since they have a small additional effect on the daily teeth brushing with fluoride toothpaste.

Once a tooth has been damaged due to caries and the damage has reached a certain size, it becomes necessary to remove the caries-damaged tissue. When the damage is close to the dental pulp and there is a risk of the dental pulp being exposed, the dental health care sector should offer stepwise excavation to reduce the risk of dental pulp exposure.

Diseases of the tissues around the teeth and dental implants – good oral hygiene is important

The diseases that occur in the tissues around teeth and dental implants are caused by bacteria and are therefore infectious diseases.

Early diagnosis and treatment of disease of the tissues around teeth and dental implants, with the goal of gaining control of the infection, involves a less extensive future treatment need and less suffering for the person.

Good oral hygiene is very important for the treatment and prognosis of the disease. When there are deficiencies in oral hygiene, the dental care sector should therefore offer oral hygiene education to people with chronic and aggressive periodontitis, and to those with peri-implantitis. The dental care sector should however avoid advising people with periodontitis and peri-implantitis to rinse daily with antiseptic mouthwash, as a complement to brushing.

For people with chronic and aggressive periodontitis, the dental care sector should offer non-surgical, mechanical cleaning of root surfaces in order to control the infection. The dental care sector should also offer flap surgery for teeth with deeper periodontal pockets that are hard to reach. The dental care sector should also offer advanced flap surgery to people with peri-implantitis since it is harder to achieve infection control with non-surgical treatment of deeper pockets in dental implants, compared to treatment of chronic and aggressive periodontitis. The dental care sector should also ensure that people with chronic and aggressive periodontitis, and peri-implantitis, are offered measures to prevent relapse after concluded treatment.

Diseases of the dental pulp and the periradicular tissues – be restrictive in the use of antibiotics

In Sweden, the need for treatment of the dental pulp and root-canals is still great. Common causes of damage to the dental pulp are deep caries, dentinal cracks, inadequate tooth restorations or dental trauma. The condition is often completely without symptoms, but can cause toothache which is sometimes severe. When performing root canal treatment, the root canal system is cleaned and sealed with a tight root filling. Without root canal treatment, a tooth with serious pulp inflammation or periapical disease will be lost.

For people with deep caries lesions, close to the dental pulp, the dental care providers should offer stepwise excavation to reduce the risk of dental pulp exposure. If the dental pulp has been exposed at caries excavation, the National Board of Health and Welfare has ranked pulpectomy (cleaning and obturation of the root canal) higher than a pulp capping, since there is a great risk that the dental pulp will be necrotic after a pulp capping with a subsequent infection of the root canal system. The prognosis for the root canal treatment that will still be required is less favourable than for treating the non infected root canals by pulpectomy and root-filling. In this case, the National Board of Health and Welfare's recommendation may differ from the way the dental care often provided as shown by the Swedish Council on Health Technology Assessment (SBU), in a practice report where the majority of dentists offer pulp capping when the pulp is exposed at caries excavation.

Antibiotics should be used restrictively, primarly only to people with symptoms due to apical periodontitis, where the infection around the root-tip shows signs of dissemination and where the person's general health is affected. The dental care sector thus contributes to promoting a rational use of antibiotics.

Oro-facial pain and dysfunction – common, neglected and treatable conditions

Pain and dysfunction in the oro-facial region are common in the adult population. The need for treatment owing to these symptoms is estimated in the range 5–15 per cent. Available statistics show that only a minority in Sweden (0.5–1.5 per cent) seem to receive related treatment within the framework of the national dental care scheme, which may indicate a neglect in diagnosis and treatment of these conditions.

The consequences for the individual are varied degrees of discomfort, in relation to basic functions such as eating, chewing and speaking, in social relations as well as in negatively affected quality of life. The aims of the treatment are to reduce pain and discomfort, give the patient support and methods to manage the pain and discomfort, and to improve the jaw function.

The dental health care sector are recommended to primarily provide reversible treatments, such as individual counselling or behavioural treatments, both aiming at a change in harmful behaviours. Further recommended treatment regimes are occlusal appliances and various forms of mobilising exercises which during a limited period in time, can be combined with non-steroidal anti-inflammatory drugs (NSAIDs).

The dental health care sector should not offer occlusal adjustments to people with acute pain and inflammation in the temporomandibular joint.

Malocclusion – most malocclusions can be treated with orthodontics

Malocclusion is as common in adults as in children and adolescents. Despite this fact, approximately 90 per cent of the people who receive treatment are still growing. The most common consequence of malocclusion is that it affects the psychosocial experience of the person, i.e., venturing to open their mouth, smiling and laughing. Some people may even find it harder to chew and bite.

Through orthodontics (usually fixed braces), most malocclusion can be treated even in adults. For a diastema in the incisor area (3:a to 3:a), the dental care sector should consider several treatment options. A diastema in the mandible is possible to treat both with orthodontic treatment as a tissue preservative alternative; or with a prosthetic replacement. The dental care sector should also offer orthodontic treatment to people with teeth that are crowded and malaligned in the dental arch. A prerequisite to being able to offer orthodontic treatment is to also have access to specialist dental care in the region and that there are procedures for cooperation between public and specialist dental care.

Complete and partial edentulousness - treat only when functionality is disturbed

The loss of teeth can be caused by diseases such as caries and periodontitis, or be a result of a congenital lack of tooth or teeth. Accidents can also be the cause of edentulousness. It is not evident or urgent to replace all missing teeth. Primarily, only the edentulousness that leads to functional disturbance in the form of having difficulties chewing, eating and speaking, or which affects the person negatively – aesthetically or psychosocially; should be replaced.

For people who have complete edentulousness in the upper jaw, the dental care sector should offer an implant-supported fixed dental prosthesis, implant-supported removable partial dental prosthesis or removable complete dental prosthesis. For those who have complete edentulousness in the lower jaw, the dental care sector should primarily offer an implant-supported fixed dental prosthesis, secondly implant-supported removable partial dental prosthesis and thirdly removable complete dental prosthesis.

For people with multiple tooth loss, the dental care sector should offer fixed partial dental prosthesis or an implant-supported bridge. However, treatment with a bonded fixed partial dental prosthesis should be avoided.

In the absence of a tooth in the lower anterior area, the dental care sector should primarily offer a fixed partial dental prosthesis or orthodontic treatment and secondly an implant-supported crown. The dental care sector can offer a bonded fixed dental prosthesis in both the upper and lower anterior area.

Indicators to measure the quality of dental care

The National Board of Health and Welfare's mission also includes the development of national indicators that reflect good dental care. An indicator is a measure that reflects quality and can be used as a basis for development, transparency of the procedures of the dental care sector, as well as results and costs. The authority has developed 50 indicators, covering all seven subject areas, which constitute the guidelines for adult dental care. Approximately half of the indicators cannot be monitored on a national level using the follow-up systems presently available; and are called development indicators. Several of the indicators may however function well at follow-ups made at a local and regional level.

During 2012, the National Board of Health and Welfare will conduct an open comparison in order to evaluate the processes, results and costs of the dental care sector. The follow-up will mainly be based on the indicators that the National Board of Health and Welfare has developed as national indicators for the adult dental care, along with the general indicators for Good dental care.

Patient involvement and influence is important

The patient's role and involvement in the care is of central and often crucial importance. Within the dental care sector, there is a clear division of responsibility where the caregiver is to plan, lead and control the activity in a way which leads to the fulfilment of the requirements for good care and where the dentist and the dental hygienist carries out their work in accordance with science and best practice. But it is especially important that the treatment is designed and implemented in consultation with the patient and that the patient is shown consideration and respect. An evidence based practice means that knowledge of scientific effect (evidence) is combined with the clinical expertise of the profession and the circumstances and wishes of the patient.