Part C 31 – Text Booklet

Part C -Text 1 – Toothpaste with fluoride

If your toothpaste is fluoride-free, brushing and flossing alone aren’t enough to keep cavities away, according to a recent study. The fluoride is what helps you avoid cavities, says lead researcher Philippe Hujoel, PhD, a Seattle periodontist and professor of oral health sciences at the University of Washington. “It’s not [simply keeping the teeth cleaner. ” For years, dental professionals have debated the importance of the “clean tooth” hypothesis versus the “sound tooth” hypothesis in preventing cavities. Those in the first camp say good oral hygiene will remove the sticky film of acid-producing plaque that breaks down the enamel and allows cavity causing bacteria to invade the teeth.

Others argue that brushing and flossing, no matter how intense, isn’t enough to prevent cavities. “The plaque is inaccessible and you can’t get to it”, Hujoel says. While oral hygiene may help a bit, it’s the fluoride that makes the difference in getting to the plaque and breaking it down, he says. Cavities begin in tiny cracks and crevices in the enamel. Exactly how fluoride helps prevent cavities is not certain, according to Hujoel. “There is some evidence it may inhibit the enzymes that break down the tooth,” he says. In general, experts believe fluoride helps restore minerals to the enamel, helps strengthen the tooth, and even helps reverse the early cavity process.

While fluoride has been recommended for years, Joel’s team wanted to focus on the intensity of oral hygiene to see if it made a difference in cavity prevention. They searched the published medical literature from 1950 to 2017 and found three randomised clinical trials including 743 preteens and teens that were sound enough to include and analyse. Two were conducted in the U.S. and one in the UK. None were funded by commercial companies. In the studies, researchers assigned children to an intense oral hygiene group or to a usual or less intense hygiene group of brushing and flossing. In the intense group, the children had supervision of their oral hygiene, with plaque removal, at school, but no fluoride toothpaste was used at school. In the U.K. study, all used toothpaste with fluoride at home. “Some in the U.S. studies used fluoride toothpaste and some did not at home,” Hujoel says. While the design was not ideal, the key point was to compare intense hygiene with less intense hygiene, he says. Two studies were done in communities with non-fluoridated water supplies “There was no significant difference in cavities between the groups” Hujoel says “These intensive oral hygiene interventions, which were successful in removing the biofilm, did not have an impact on the cavities’’.

The study “supports what the dental association has said for years, that brushing with fluoride is good” says Matthew Messina, DDS, a dentist in Columbus, Ohio, who is also a consumer advisor for the American Dental Association and assistant professor of dentistry at The Ohio State University in Columbus. To earn the ADA Seal of Acceptance, a toothpaste must contain fluoride, he says. The ADA recommends brushing twice a day with a fluoride-containing toothpaste, flossing once a day, eating a healthy diet, and seeing a dentist on a regular basis. ‘’We know that works, and that is lifelong advice as cavities don’t just affect children,” he says. “We are seeing an increase in the rate of cavities in the older population. That’s partially due to improved dental techniques allowing people to keep their natural teeth longer; but dry mouth, a side effect of numerous medications taken by older adults, can also make teeth more prone to decay,” he adds.

‘’Fluoride offers one way to strengthen teeth and does have potential benefits’’, says Darryl Bosshardt, a spokesman for Redmond, which makes a fluoride-free toothpaste, Earth paste. But tooth decay is not caused by fluoride deficiency, he says, and fluoride supplementation can’t reverse active cavities. “It can also have some potential negative aspects that some consumers would like to avoid if possible” he says. As one of many examples, he cited as study finding fluoride-containing toothpaste ingestion as a main source of fluoride toxicity, according to the Association of Poison Control, especially in young children. “We are also quick to point out that a non-fluoride toothpaste may not be the best option for everyone. However, we similarly acknowledge that mandatory fluoride supplementation in all water supplies and in all oral care products may also not be the ideal solution for everyone.’’ He encourages people to weigh the pros and cons with their dentist.

While toothpaste with fluoride “is the best choice for oral health, we also recognise that not all the people that choose our brand want fluoride in their toothpaste, and we offer a fluoride-free alternative,” says Rob Robinson, a spokesman for Tom’s of Maine. The fluoride-free toothpaste from Tom’s does not carry an anti-cavity claim.

For those who do not want to use fluoride-containing toothpastes, another option is going on a very low-carb diet, generally less than 50 grams a day, Hujoel says. ‘’Doing so cuts back drastically on the sugars that can attack the teeth and lead to cavities,’’ he says. That’s the path he takes, but, he acknowledges, few can follow such a strict diet and so should use fluoride containing toothpaste as part of their oral hygiene routine.

Part C – Text 2 Stress and Burnout

Intensive care medicine (ICM) is an evolving high stakes specialty. Emerging evidence raises questions about the welfare and sustainability of the ICM workforce. Clinician burnout is a phenomenon resulting in consequences for both intensive caregivers and patients. While resident doctors, fellows and new consultants across many specialties display high levels of stress and burnout relative to the general population, ICM clinicians are disproportionately affected rating higher on stress, burnout and compassion fatigue Indices. Paediatric intensivists have markedly higher burnout rates than general paediatricians. An Australian ICM study described an 80% rate of psychological stress and discomfort in a practising ICM specialist population, with many reporting burnout symptoms.

Burnout is a state of psychological distress related to chronic stress. Prevalence estimation using different tools, alternate metrics and cut-off points have made epidemiological studies of ICM clinician burnout challenging. The Maslach Burnout Inventory is the most commonly used burnout instrument in this area and scores three major characteristics of burnout: emotional exhaustion, depersonalisation and low levels of personal effectiveness. Intensive care unit (ICU) physicians and nursing staff have similar rates of burnout symptomatology, with ICU nurses reporting higher emotional exhaustion rates and ICU physicians reporting higher rates of depersonalisation and reduction in professional achievement. These trends indicate specific risk factors within the ICM Environment.

The burnout syndrome has been described in Australian emergency medicine clinicians. Some protective influences appear to be ongoing professional development, dedicated non-clinical time, and a feeling of teamwork. Burnout does not necessarily correlate with job satisfaction, with predisposing factors in this group including younger age, workplace conflict, a lack of exercise, and excessive alcohol consumption. In addition to many of these stressors, intensive care clinicians are repeatedly exposed to high stakes, ethically challenging decision-making processes. The high density of ethical decision making in ICM contributes to moral distress and may be exacerbated by the provision of disproportionate care”, where there is a perceived inappropriate or harmful mismatch between the level of care provision and a patient’s needs.

Care of the health care provider and quality of patient care are interconnected. Physician burnout has been associated with lower patient satisfaction, reduced health outcomes and medical error. Burnout symptoms reduce potential ICM workforce capacity through increased sick leave and decreased staff retention. The consequences of burnt out clinicians may ripple through an entire organisation, compromising interactions between individuals and teams.

Evolving trends in Australia may further exacerbate the problem of burnout. These changes include greater intensivist coverage and shift work, an increasingly fractionalised workforce with unequal gender balance, and an evolving external and ward ICM responsibility. The move towards physically larger Australian ICUS has coincided with enhanced public expectations of clinical outcome and an increase in interventional medicine. The prevention and remediation of burnout requires consideration of both individual and systemic factors. At an individual level, a holistic approach to the ICM clinician, not just as a service provider, is required. A balance must be facilitated between work, life, clinical and non-clinical duties and career progression. Stress prevention and resilience strategies include mindfulness and cognitive techniques, coaching, mentoring and perhaps most importantly, peer discussion. Leadership from clinicians will be important to drive change at an Institutional level. Compassionate staffing, flexible rostering, ensured leave and ongoing employee assistance programs should be broadly available. Clinicians themselves will need to foster an acceptance of their own vulnerability and cultivate an environment where open dialogue about stressors is respected.

The College of Intensive Care Medicine and the Australian and New Zealand Intensive Care Society have roles to play in the development of performance indicators for workplace stress and burnout, with complementary advocacy for a safe, sustainable workplace. The ICM training model should encompass self-assessment and resilience skills, supported by commensurate training of trainee supervisors and senior staff. A broader societal discussion about the antecedents of moral distress and disproportionate care is required. Shared health goal setting before crises and preparing for realistic appropriate decisions at the end of life continue to be of great importance. Such projects may be supported at government level, with direct expert input from ICM clinicians.

While there is increasing evidence of the physical and emotional effects of the unique ICU environment on inter-professional practitioners, there remains a paucity of coordinated interventions aimed at understanding and addressing ICM clinician burnout. It has therefore been suggested that a multilevel response is required in order to improve the welfare and sustainability of the Australian ICM workforce.

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