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Changing behaviour to combat tooth decay

A low-cost talking intervention has been shown to prevent tooth decay in children. NHS dental nurses are now offered training in the technique, and commissioners in the North West have committed to introducing the intervention into dental services.

Published: 18 April 2022

Children at high risk from tooth decay

Frequent sugary snacks and sweetened drinks combined with lack of twice-daily tooth brushing with fluoride toothpaste puts many children at high risk for tooth decay (caries). Most tooth decay is untreated in young children, and extraction of decayed primary teeth is the most common reason for children under 11 years to be treated in hospital.

While older children’s teeth can be removed by the dentist using local anaesthetic, many young children are admitted to hospital for extraction under general anaesthetic. In 2017-18, more than 30,000 children aged 9 or under were admitted to hospital for tooth extraction. The experience can be traumatic for children and costly for the NHS, with each extraction costing around £1000.

While surgery removes the immediate problem of decayed teeth, it doesn’t change people’s behaviour to help prevent future caries in other baby or new adult teeth. Research has shown that nearly 9 out of 10 children who had decayed baby teeth extracted between the ages of 5 and 7 went on to develop new caries. As a result, these children are also more likely to have their first permanent molars extracted due to tooth decay.

Motivational interviewing is an approach used by health professionals to help guide and strengthen patients’ goals to change their behaviour, without giving direct or unsolicited advice. The NIHR funded a team of researchers to explore whether motivational interviewing, along with behaviour change techniques, could help parents prevent their children developing new caries within 2 years after having a decayed tooth extracted. The Dental RECUR trial, funded by the NIHR Research for Patient Benefit Programme, was led by Cynthia Pine CBE, Professor of Dental Public Health at Queen Mary University of London.

The aim of our intervention was to work with parents to help them appreciate their important role regarding their children’s future oral health, and to support them in developing specific goals to reduce the chance of recurrence of tooth decay after tooth extraction.
- Professor Cynthia Pine CBE, Professor of Dental Public Health at Queen Mary University of London

Talking about prevention

Professor Pauline Adair, a Clinical and Health Psychologist at Queen’s University Belfast, and Professor Pine developed the Dental RECUR Brief Negotiated Interview, or DR-BNI. This is a therapeutic conversation between specially trained dental nurses and parents or primary caregivers of children with tooth decay, focused on keeping newly erupting teeth healthy.

DR-BNI begins by describing to parents the benefits of brushing their children’s teeth twice a day with a fluoride toothpaste, controlling sugar intake (especially near bedtime) and regularly attending a dentist rather than only visiting when their child is in pain. The next step is not to tell parents what to do to prevent their child getting future decay, but to help them develop specific goals for their child that they feel they could work towards to develop healthy behaviours.

Although nearly a quarter of all 5 year olds in the UK experience tooth decay, children from the most deprived areas have more than twice the level of decay than those from the least deprived. The team therefore asked families from Salford, where one in two children aged 5 years old has tooth decay, to help develop the study’s design and make it relevant to families in greatest need of support.

More than 200 families of 5- to 7-year-old children who were having at least one baby tooth extracted at one of 12 centres around the UK were then recruited. In addition to funding the trial, research nurses funded by NIHR supported recruitment in one of the hospitals. Each family was randomly allocated to receive either a 30-minute DR-BNI or a conversation about new adult teeth (the control group) with a DR-BRNI-trained dental nurse at each centre. Both groups received advice to visit a general dental practice.

I find that if we give lots of information and guidance at once it can be overwhelming for parents. In this trial, we helped families choose one or two actions. It might be to help brush their child’s teeth at night or stop giving a sugary snack at bedtime. It became their goal not ours and they could see a way forward.
- Louise Morris, a Senior Dental Nurse in Salford

Children who undergo a tooth extraction for caries often don’t visit the dentist regularly and miss out on preventative care. Therefore, after agreeing caries-prevention goals with parents, the dental nurses helped families arrange a follow-up appointment with a dentist.

The team assessed the children’s teeth 2 years after their extraction and recorded details from their dental practices about any visits and dental care received. Nearly two thirds of children from both groups had visited the dentist, but the control group had experienced more tooth decay and received more fillings. The DR-BNI children had significantly healthier teeth and had nearly a third lower risk of new tooth decay compared with those in the control group. The trial results were published in the Journal of Dental Research.

A separate cost analysis of delivering the DR-BNI showed that the NHS could save £1 million in costs by preventing one filling or extraction for every 50,000 children whose families received the intervention, showing that it would be a cost-effective and simple measure to improve children’s oral health. The health economic analysis was published in Applied Health Economics and Health Policy.

This trial is important because it shows how we can support families to improve their children’s dental health in ways that work for them and, at the same time, make savings for the NHS.
- Professor Cynthia Pine CBE

Promoting behaviour change

The significantly lower risk of new caries for children whose families received the Dental RECUR intervention led to Health Education England funding the development of the DR-BNI into a training module. NHS dental nurses can now train as Dental RECUR Facilitators, helping them change oral care behaviour outside of the clinic and support improved oral health among children at high risk of caries. Dental service commissioners in Greater Manchester, Cheshire and Merseyside have committed to introducing DR-BNI into dental services. This year, NHS Tayside in Scotland is investing in training their Oral Health Promotion Team to become Dental RECUR Facilitators.

Using this therapeutic communication approach to support families in preventing tooth decay in their children has the potential to improve child health and to change paediatric dental practice internationally.
- Professor Cynthia Pine CBE

Following the success of the Dental RECUR trial in the secondary care setting, the NIHR has funded a new 5-year trial, CHOICE, to investigate whether motivational interviewing at an earlier stage can reduce both the number of decayed teeth children develop and their need for extractions. The trial, funded by the NIHR Health Technology Assessment Programme, is currently underway and will recruit around 900 children aged 3 to 7 years with at least one decayed tooth and their families. They will have half-hour meetings with dental nurses to support them in choosing changes to their children’s oral care behaviour and routines.

“We are looking forward to taking this intervention into primary care dental practices across the UK as we move forward with practice and participant recruitment in the CHOICE trial,” said Professor Pine. “This new study will enable us to understand more about how the intervention works and whether it will help us address oral health disparities across our diverse society.”

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