The committee's discussion
The committee noted that in the Adult dental health survey 2009 (Health and Social Care Information Centre) only 9% of adults with teeth and 7% without teeth recalled being asked by their dentist about smoking. Similarly, only 36% recalled being asked about their diet. According to the survey, 78% of adults recalled being given advice at the dentist on cleaning their teeth or gums.
The committee also noted that in England, 75% of adults with natural teeth reported that they brush their teeth at least twice a day (76% of them using high or medium strength fluoride toothpaste). But 66% of adults in the same survey had plaque on at least 1 tooth and 68% had calculus (tartar or hardened dental plaque) in at least 1 sextant of the dental arch. One of the six equal parts into which the dental arch (the curved structure formed by the teeth in their normal position) may be divided. In addition, 37% of people who regularly go to the dentist said they do not use oral hygiene products such as dental floss and interdental brushes.
The coding frame used in the Adult dental health survey 2009 classified over-the-counter toothpastes by fluoride concentration. This was divided into 3 levels: high (1350 to 1500 parts per million), medium (1000 to 1350 parts per million) and low (550 parts per million or less).
The committee was aware that around 20% of adults were not satisfied with their dentist. People in this group tend to rate their own oral health lower, leave longer intervals between visits to the dentist and are more likely to be extremely anxious about going. Therefore the committee agreed it is important to address the reasons why some people do not wish to use services regularly.
The committee recognised that separate activities are needed to encourage some people to go to the dentist for a check‑up. Members also acknowledged that NICE's guideline on oral health: local authorities and partners includes recommendations about community‑based oral health.
The committee noted that population- and community‑level schemes were beyond the remit of this guideline. But members recognised that evidence on larger‑scale oral health interventions, such as water fluoridation, suggest such interventions may reduce levels of tooth decay.
During development of this guideline, key elements of the proposed NHS dental reforms were being piloted, including weighted capitation payments to support a preventive approach. The recommendations were written on the assumption that the revised dental contract will recognise the value of good self‑care and will reward dental teams that focus on encouraging this.
The committee discussed ways to encourage dental practices to adopt a more preventive approach. However, making recommendations on the type of incentives needed to encourage this was beyond the remit of the guideline.
The committee recognised that dental practice teams have an opportunity to offer a range of health improvement advice. For example, on why it is important to stop smoking and reduce alcohol intake to improve oral health. (Smoking can affect the health of gums and increase the risk of oral cancer, and alcohol also increases the risk of oral cancer.) Teams also have the opportunity to refer patients on, for example, to local services for smoking cessation.
Other risks to health (for example, drug misuse) were considered, but there was a lack of evidence on how dental practice teams could tackle these.
The committee recognised that interventions need to provide patients with support to help them change their behaviour, and that many staff in dental practice teams may need training to deliver them. But there was insufficient evidence to identify the specific behavioural components of interventions that might lead to improved oral hygiene practices, or the training that would be needed to deliver them.
The committee was aware that behaviour change techniques have been successfully used by healthcare professionals to support health improvement in other areas. For example, to train practitioners to help people stop smoking. The committee was also aware that behaviour change is referred to in Delivering better oral health (Public Health England).
The committee noted the importance of helping children to establish life‑long oral health‑promoting behaviours. Members also noted the importance of parents' and carers' attitudes and behaviours in helping children establish good oral hygiene practices and the use of fluoride.
The committee was aware that patients, parents and carers may have a different view from practitioners about the effect of poor oral health on their children's lives. For example, a patient may focus on the social impact, such as having difficulty speaking or socialising normally. Dentists, on the other hand, tend to focus more on clinical outcomes, such as decayed teeth.
The committee noted that there are large inequalities in oral health. These variations are linked to factors such as age, ethnicity, socioeconomic group and geographical location. 'Delivering better oral health' states that everyone should be given advice, regardless of how good or bad their oral health is. But members agreed that particular attention should be given to those who have poor oral health.
They also recognised that the cost of toothbrushes and toothpaste could be prohibitive for some people. But they noted that certain retail outlets sell them very cheaply – and that there may be a role for dental teams in promoting these cheaper options.
There was limited and inconsistent evidence from the review of effectiveness about interventions to improve oral health. Several interventions that changed intermediate outcomes, such as people's knowledge about oral hygiene, were identified. But only those interventions providing fluoride toothpaste reduced tooth decay.
Generally, the interventions in the effectiveness review only tended to measure short‑term outcomes (1 year or less). This did not allow enough time to see an effect on clinical outcomes (especially tooth decay). Most of the evidence identified related to oral cleanliness. The committee noted that promoting tooth brushing among children and young people can help establish life‑long habits that will protect against gum disease and caries.
The committee acknowledged that sugary foods and drinks are a major cause of tooth decay. But no evidence was identified on effective methods to deliver oral health advice that will encourage people to change their diet. This may be because the studies did not include a long enough period for follow‑up (see the Health economics section).
There is growing interest in the use of new technology, including phone and tablet apps, to deliver behaviour change interventions. But the committee noted there was a lack of formal evaluations of their effectiveness in relation to oral health.
Published economic evaluations of methods used by general dental practice teams to deliver oral health improvement messages are scarce and generally poor quality.
A valuation study was conducted to inform the economic modelling for this guideline because there was a lack of evidence on health state utility values related to oral health. Based on other effectiveness reviews, the economic models used measures of decayed, missing and filled teeth; decayed, missing and filled surfaces; gum problems; and dental pain as the oral health outcomes.
The economic review identified 2 studies for children (1 on primary teeth and 1 on permanent teeth) and 1 for adults that were sufficiently robust and included outcomes that were suitable for economic modelling.
The economic model for children estimated the expected reduction in dental decay in primary teeth and NHS costs associated with one‑to‑one health counselling.
The intervention modelled was aimed at parents of children aged 1 to 6. It used data from the Blinkhorn randomised controlled trial, which showed a non‑significant reduction in decay in primary teeth. It comprised:
Initial counselling over 2 visits. This included advice on the use of fluoride toothpaste and sugar control, and a hands‑on demonstration of how to clean teeth.
Six follow‑up sessions over 2 years.
At least 2 tubes of fluoride toothpaste, toothbrushes as needed and leaflets.
This was compared with providing just 1 session and 1 tube of fluoride toothpaste.
The initial analysis suggested it could be cost effective for children at high risk (that is, above twice the average risk) of tooth decay. However, the Committee questioned whether some of the assumptions made in the modelling were realistic and requested further economic analysis.
At the suggestion of the committee, the cost of the intervention was increased from £43 to £230. At this level the model suggested the intervention would not be cost effective, except possibly for children at very high risk of tooth decay (above 4 times average risk).
As noted above, the further analysis was based on the Committee's suggestions and expert opinion. The main aim was to estimate whether 3 levels of intervention were cost effective:
advice from a dentist as a 5‑minute extension to an existing consultation
a one‑off 20‑minute advice session by a dental nurse with additional skills in prevention
a programme of 8 advice sessions with a dental nurse with additional skills in prevention over 2 years (similar to the Blinkhorn intervention).
Costs and effects were estimated over a 3‑year period for children aged 5 and 12 years by varying the value of key assumptions such as:
the risk of tooth decay over 3 years
the reduction in risk associated with the interventions
the proportion of extractions performed under general anaesthetic
non‑attendance rates for appointments with a dental nurse with additional skills in prevention.
The range of values used was suggested by the committee.
This analysis suggested that extending an existing consultation by 5 minutes to give advice from a dentist might be cost effective if:
the children had at least twice the average risk of tooth decay and
it led to a 10% reduction in the risk of tooth decay over 3 years.
However, the committee felt there was not sufficient evidence on interventions that matched these assumptions to recommend a standalone intervention.
The analysis also showed that a 20 minute appointment with a dental nurse with additional skills in prevention might also be cost effective for high‑risk groups. But this depends on the cost and how effective it is and more evidence is needed. Finally, the further analysis suggested that a more intensive programme of oral health advice, consisting of a series of appointments, was unlikely to be cost effective except for children at very high risk (above 4 times the average risk).
For adults, the model estimated the effect of adding an oral education programme to standard non‑surgical treatment for gum disease, based on the study identified in the economic review. This suggested that the benefits associated with a reduction in gum disease were outweighed by the estimated costs of the intervention.
The results of the economic analysis were mixed and highly uncertain. It showed that the cost–benefit of dental practice teams delivering oral health improvement messages to adults and children depends on: what information is provided, to whom and in what context. Ultimately it also depends on how effective it is at encouraging people to change their behaviour. Given the lack of empirical evidence, it was not possible to make more specific recommendations because the committee was not confident that they would be cost effective.
The economic models for children did not consider benefits beyond 3 years because there was insufficient epidemiological data on which to base estimates of the long‑term effect of oral health improvement.
Details of the evidence discussed are in evidence reviews, reports and papers from experts in the area.
The evidence statements are short summaries of evidence. Each statement has a short code indicating which document the evidence has come from.
Evidence statement number 1.1 indicates that the linked statement is numbered 1 in review 1. Evidence statement number 2.1 indicates that the linked statement is numbered 1 in review 2. If a recommendation is not directly taken from the evidence statements, but is inferred from the evidence, this is indicated by IDE (inference derived from the evidence).
Recommendations 1.1.1–1.1.5: evidence statements 1.1, 1.2, 1.3, 1.5; IDE
Recommendations 1.2.1–1.2.7: evidence statements 1.6, 1.10; IDE