Evidence-Based Knowledge to Community Practice

1. Evidence-Based Knowledge to Community Practice Professor Sudaduang Krisdapong, PhD. sudaduang@hotmail.com

2. Vicious restorative cycle • Health promotion rather than tx.based services • Education as a part of Health promotion • From “victiming blaming” to tackling upstream social determinants

3. Oral health behaviours • Sugars consumption • Toothbrushing • Common-risk factor • Social determinants of health • Population approach • Up-mid-downstream • Community participation What we need to stop vicious cycle What we need, to achieve behavioural change How to?

4. Diet and dental caries: the pivotal role of free sugars reemphasized. Sheiham A & James WP. J Dent Res 2015; 94:1341-7 • Infectious disease?  Diet-mediated disease • Multifactorial disease?  Single specific cause

5. Sugars • Non-milk extrinsic sugars (NMES), Free sugars • added sugar เช่นน้ำตาลทราย - honey, fruit juice (with health benefits) • No significant different between types: glucose, fructose, galactose (except lactose) • Added sugar = Empty calorie. No nutrition. No physiological benefit. Lead to unhealthy diet

6. - Previous recommendations: 10% total energy, 15 kg/person/year, 50 g (8 tp)/person/day - WHO 2015 Guideline: “the intake of free sugars should be reduced to less than 10% of total energy intake. A further reduction to below 5% would provide additional health benefits” = 25 g (6tsp)/person/day

7. http://www.actiononsugar.org • A can of sodas = 19-47 gram • 47 gram highest in Thailand 4 grams of sugar is equal to 1 teaspoon of sugar.

8. Sugars - Quantity and frequency are closely related: linear relationship Quantity : population assessment Frequency : individual assessment - Recommendations on frequency <= 4 times per day, including meals (adults) <= 3 (children)

9. No recommendation on total sugarsfor public

10. Sugars • ฉลากส่วนประกอบ ไม่ใช่ฉลากโภชนาการ • include all added sugars • % = ระดับความหวานความเข้มข้น • คำนวณเป็นปริมาณ? • Total sugars • general health, not oral health • for specific group eg. DM patients • no recommended maximum intake

11. คำแนะนำสำหรับประชาชน Xปริมาณ (เอาไว้ขู่) ความถี่ ความเข้มข้น - ปรับลิ้น ลดระดับความหวานที่ชอบ - 6% น้ำตาลเติม: ภาษี, ฉลากทางเลือกเพื่อสุขภาพ

12. กินน้ำตาลอย่างไร ฟันไม่ผุ • กินรวมในมื้ออาหาร ปลอดภัยกว่า 2) ระหว่างมื้ออาหาร = กินเป็นมื้อเล็ก ไม่จุบจิบ/แช่ (เว้น 2 ชั่วโมง ปากปลอดน้ำตาล) 3) ฝึกกินหวานน้อย (<= 6% น้ำตาลเติม) ไม่หวานเลย = Life goal

14. Toothbrushing Twofold benefits: 1. Dental caries = fluoride delivery 2. Gingival health (oral hygiene) = cleanliness

15. Fluoride toothpaste - The benefit of fluoride toothpaste to caries prevention is firmly established (Marinho et al., 2003 - Cochrane Review ) - Reduction in caries across Eurpean countries with generally no water fluorodation (in the US. with fluorosis increase) - Systemic fluoridation not recommended, but topical with “easy, self-care method”

17. F saliva : surrogate of individual caries protective ability

18. แปรงแห้ง • For whom? • Safe? • Natural products marketing • Replaced by more frequent brushing? • Why important? • Daily life pratice, no additional method & cost • Not professionally dependent • Population approach (add F for hi-risk only)

19. Brushing for oral hygiene • No standard recommended method • No “most effective method” • Complex methods are not more effective than simple ones • Simple is practical

20. Brushing for oral hygiene คำแนะนำสำหรับประชาชน • Gentle brushing at cervical area “แปรงเบาๆ ให้โดนคอฟัน” • Bristles: medium, soft • Toothpaste: paste, not powder • Pen grasp • ขยับด้วยวิธีที่ง่าย เป็นธรรมชาติ • Self-check after brushing ***

21. สรุปวิธีแปรงฟัน 1. ยาสีฟันฟลูออไรด์ 1000+ ppm 2. วันละ 2-3 ครั้ง หลังอาหารเช้า, ก่อนนอน 3. แปรงให้ทั่วทุกซี่ทุกด้าน • เริ่มจากด้านบดเคี้ยวเพื่อกระจายยาให้ทั่วปาก • แปรงคอฟัน เบาๆ เน้นบริเวณที่มีหินน้ำลาย 4. แปรงนานอย่างน้อย 2 นาที (บ้วนฟองออกน้อยที่สุด) 5. แปรงแห้ง: ถ่มทิ้ง ไม่ต้องบ้วนน้ำ 6. ไม่กิน/ดื่ม อย่างน้อยครึ่งชั่วโมง ผุ ผุ ผุเหงือก ผุ เหงือก ผุ ผุ

22. Common Risk Factor Approach Obesity Smoking Diet Cancers Diabetes Alcohol Heart Disease Stress Respiratory disease Lack of control Exercise Dental caries Periodontal diseases Risk behaviors Hygiene Trauma Sheiham & Watt, (2000)

24. Radical change in OHP • Behaviours as complex social products • “Clinical prevention and health education approaches alone have been found to be unsuccessful in achieving sustainable improvements in oral health. • Moreover, Inequalities-generated interventions (IGIs) (WHO 2008: Commission on Social Determinants of Health: CSDH)

25. Radical change in OHP • A conceptual movement away from the traditional biomedical “downstream” and victim blaming approaches, to one addressing the “upstream” underlying social determinants of oral health is necessary” (WHO 2008: Commission on Social Determinants of Health: CSDH)

26. Culture– midstream • Make behaviours “naturally occurring” • Gradually & collectively shaped behaviours - social norms, cultural identity - social values, attitudes - peer pressure, support - social acceptance, rewards Ex. ??

27. Environments - upstream • Availability มีให้ • Accessibility ใช้ง่าย • Affordabilityสบายกระเป๋า “ Healthier choices easier choices” Ex?

28. individual Social Effect of SES on individual/social factors

29. High SES - คนรวย - Social individual

30. Low SES - คนจน - individual Social

31. Social strategies • Cultural strategies • Create social values, campaign สร้างกระแส • Social reinforcement: rewards, recognition, peer group sharing same problem • Environmental strategies • Availability • Access • Affordable มีให้– ใช้ง่าย- สบายกระเป๋า

33. All levels are needed, ... but, at a more balance - Environmental/structural - Cultural, community networks - Individuals (tx, education)

34. Upstream: target environments where people live • Environmental change: policy, regulation, control • Available, Access, Affordability of healthier choices • Midstream: target entire population, policy holders preparing for upstream change • Campaign/education programme for all • Education, training for community leaders, teachers • Downstream: target individuals • individual education, professional preventive care • Palliative, short-lived

35. Population vs. High-risk Strategies (Geoffrey Rose, 1985) • “health education phase aimed at changing individuals is, we hope, a temporary necessity pending changes in the norms of what is socially acceptable” • “is the enormous difficulty for medical personnel to see health as population issue and not merely as a problem for individuals”

36. Population strategy • Impossible to cut a tail. New cases will enter risk zone. • Shift the whole curve to the left; not cut a tail • Even a small shift  considerable reduction in disease incidence in whole population

37. Largest burden comes from the majority at low risk!! • 80/20 phenomenon in the UK • 4 y study: caries in highest risk group < 6% of total caries (Batchelor & Sheiham, 2002) • 3 y study: more caries in 80% low risk (Hausen et al., 2000)

38. Over a 4 year period; the contribution of new caries made by individuals to the whole population: • DMFS of 7 or more = less than 6% - DMFS of 3 or more = 20% - DMFS of 0 = 55% Most cases occur among persons with relatively small risk factors.

40. “All levels are needed, ... but, at a more balance” • Social strategies • Culture/social influence • Environment • Up/mid stream • Population approach • Individual strategies • dhe • Preventive care • Down stream • High-risk approach • Prioritization for benefit! - Widespread disease, public health problem -