1 Recommendations

1 Recommendations

Recommendation 1 Ensure oral health is a key health and wellbeing priority

Health and wellbeing boards and directors of public health should:

  • Make oral health a core component of the joint strategic needs assessment and the health and wellbeing strategy. Review it as part of the yearly update.

  • Set up a group that has responsibility for an oral health needs assessment and strategy. Ensure the following contribute to the work of the group:

    • a consultant in dental public health

    • a local authority public health representative

    • an NHS England commissioner of local dental services

    • a representative from a local professional dental network

    • a representative from the local dental committee

    • representatives from children and adult social care services

    • a local Healthwatch representative

    • a senior local government representative to lead on, and act as an advocate for, oral health

    • representatives from relevant community groups.

Recommendation 2 Carry out an oral health needs assessment

The group responsible for the oral health needs assessment and strategy (see recommendation 1) should:

  • Define the scope of an oral health needs assessment for the local population. This should include:

    • What the assessment will and will not cover, for example, access to services for groups at high risk of poor oral health, certain age groups or in certain settings (see recommendation 3).

    • The responsibilities of each partner organisation and how they will work together to make best use of resources (for example, detailing how data could be collected across organisations).

    • The need to consider recommendations and outcomes from any previous oral health needs assessment (if available).

  • Ensure the oral health needs assessment is an integral part of the joint strategic needs assessment and clearly linked to strategies on general health and wellbeing (see recommendation 1).

  • Conduct the oral health needs assessment as part of a cyclical planning process geared towards improving oral health and reducing health inequalities. It should not be a one-off exercise that simply describes the target population.

Recommendation 3 Use a range of data sources to inform the oral health needs assessment

The group responsible for the oral health needs assessment and strategy should:

  • Use local demographic and deprivation profiles to identify groups that may be at high risk of poor oral health.

  • Use national surveys of oral health (adult and child) and NHS dental epidemiological programme data to gain an idea of local oral health needs relative to the national picture and comparator areas.

  • Use national demographic and socioeconomic data and the established link between these factors and oral disease to determine likely local needs.

  • Use local expertise and local health and lifestyle surveys and consultations to understand local oral health needs in the context of general health.

  • Consider seeking advice on survey design and the collection, analysis and interpretation of epidemiological data relevant to oral health.

Recommendation 4 Develop an oral health strategy

The group responsible for the oral health needs assessment and strategy (see recommendation 1) should:

  • Develop an oral health strategy based on an oral health needs assessment (see recommendations 2 and 3). This should set out how the local authority and its health and wellbeing commissioning partners will:

    • Address the oral health needs of the local population as a whole (universal approaches).

    • Address the oral health needs of groups at high risk of poor oral health (targeted approaches).

    • Address any oral health inequalities within the local population and between the local population and the rest of England.

    • Identify and work in partnership with people who are in a position to improve oral health in their communities. This includes those working in adult, children and young people's services, education and health services and community groups.

    • Set a good example through their own policies and the policies of organisations they commission to provide services. For example, by ensuring access to free drinking water in all workplaces and public areas and through healthy catering and food policies (see recommendations 5 and 6).

    • Set out the additional support that people working with groups at high risk of poor oral health will be given, including training or resources. (See the NICE guideline on community engagement.)

    • Get all frontline staff in health, children and adult services to use every opportunity to promote oral health and to emphasise its links with general health and wellbeing.

    • Ensure easy access to services to help prevent oral disease occurring in the first place and to prevent it worsening or recurring for everyone, throughout their lives.

    • Evaluate what works for whom, when and in what circumstances.

    • Monitor and evaluate the effect of the local oral health improvement strategy as a whole.

Recommendation 5 Ensure public service environments promote oral health

Local authorities and other commissioners and providers of public services should:

  • Ensure all public services promote oral health by:

    • Making plain drinking water available for free.

    • Providing a choice of sugar-free food, drinks (water or milk) and snacks (including fresh fruit), including from any vending machines on site (see the NICE guidelines on obesity and obesity: working with local communities)

    • Encouraging and supporting breastfeeding (see the NICE guideline on maternal and child nutrition).

      This includes services based in premises wholly or partly owned, hired or funded by the public sector such as: leisure centres; community or drop-in centres; nurseries and children's centres; other early years services (including services provided during pregnancy and for new parents); schools; and food banks.

  • Review other 'levers' that local authorities can use to address oral health and the wider social determinants of health, for example, local planning decisions for fast food outlets (see recommendation 11 in the NICE guideline on prevention of cardiovascular disease).

  • Explore the possibility of linking with local organisations in other sectors (for example, local shops and supermarkets) to promote oral health. This could be part of a broader approach to promoting healthier lifestyles including helping people to reduce their tobacco and alcohol consumption.

Recommendation 6 Include information and advice on oral health in all local health and wellbeing policies

Local authorities and other commissioners and providers of public services should:

  • Ensure all health and wellbeing and disease prevention policies for adults, children and young people (including local government health and social care policies and strategies) include advice and information about oral health. This should be based on the 'advice for patients' in Delivering better oral health. It should be included with information about the common risk factors for ill health.

  • Ensure health and wellbeing and disease prevention policies for children and young people cover oral health. For example, this may include policies covering:

    • nutrition, including breastfeeding and weaning practices (see the NICE guideline on maternal and child nutrition)

    • nutrition and the health and wellbeing of looked after babies, children and young people (including care leavers) (see the NICE guideline on looked-after children and young people)

    • obesity (see the NICE guidelines on obesity and obesity: working with local communities)

    • local food, drink and snacks policies in a range of settings, including nurseries and children's centres

    • private and voluntary providers of childcare services (including childminding services)

    • primary and secondary education (see recommendations 17 to 21)

    • local child and young person safeguarding policies

    • care delivered at home

    • providers of care services offered to children and young people in their own home.

  • Ensure health and wellbeing and disease prevention policies for adults cover oral health. For example, this may include policies covering:

    • health and social care assessments

    • nutrition and health and wellbeing

    • care delivered at home

    • local food, drink and snacks policies in a range of settings, including drop-in centres, lunch clubs, leisure centres and food banks

    • local adult safeguarding policies

    • carer centres

    • providers of adult care services offered in someone's own home.

Recommendation 7 Ensure frontline health and social care staff can give advice on the importance of oral health

Local authorities and other commissioners and providers of public services should:

  • Ensure service specifications include the requirement for frontline health and social care staff to receive training in promoting oral health. This should include:

    • the 'advice for patients' in Delivering better oral health

    • the fact that tooth decay and gum disease are preventable

    • the importance of regular tooth brushing

    • links between dietary habits and tooth decay

    • how fluoride can help prevent tooth decay

    • links between poor oral health and alcohol and tobacco use including the use of smokeless tobacco.

    • where to get advice about local dental services, including costs and transport links

  • Ensure staff understand the links between health inequalities and oral health and the needs of groups at high risk of poor oral health.

  • Ensure frontline health and social care staff can advise carers on how to protect and improve the oral health and hygiene of those they care for.

Recommendation 8 Incorporate oral health promotion in existing services for all children, young people and adults at high risk of poor oral health

Commissioners of health and social care services, including those that support people to live independently in their own home, should:

  • Review all community health and social care service specifications to ensure oral health is included in care plans and is in line with safeguarding policies.

  • Ensure service specifications include a requirement to promote and protect oral health in the context of overall health and wellbeing. Relevant services include substance misuse services and those supporting people living independently in the community. (For example, people who are homeless or living in hostels, those who experience physical or mobility problems, people with learning difficulties, and people experiencing mental health problems.)

  • Ensure service specifications include:

    • an assessment of oral health, including a referral, or advice to go to a dentist or other clinical services (this may be because of pain, concerns about appearance or difficulty in eating)

    • making oral health care, including regular dental check-ups, an integral part of care planning – through self-care or clinical services

    • support to help people maintain good oral hygiene (including advice about diet)

    • staff training in how to promote oral health – during inductions and then updated on a regular basis (see recommendations 7 and 9).

Recommendation 9 Commission training for health and social care staff working with children, young people and adults at high risk of poor oral health

Local authorities and health and wellbeing commissioning partners should:

  • Commission regular, training for frontline health and social care staff working with groups at high risk of poor oral health. This should be based on 'advice for patients' in Delivering better oral health. The aim is to ensure they can meet the needs of adults, children and young people in groups at high risk of poor oral health. The training should include:

    • Basic assessment and care planning to promote and protect oral health.

    • How good oral health contributes to people's overall health and wellbeing.

    • The consequences of poor oral health, for example, dental pain and infection. (This can exacerbate symptoms associated with dementia and can also contribute to malnutrition among older people.)

    • How the appearance of teeth contributes to self-esteem.

    • Causes, symptoms and how to prevent tooth decay (including root caries in older people), gum disease and oral cancer, for example:

      • the role of plaque in gum disease and how it can affect the immunity of people with diabetes

      • the role of high-sugar diets

      • the link between the use of sugar-sweetened methadone and poor oral health

      • smoking and other tobacco products as a risk factor for oral diseases such as gum disease and oral cancer (see the NICE guideline on smokeless tobacco cessation).

    • Techniques for helping people maintain good oral hygiene (including the use of fluoride toothpaste).

    • Local pathways for accessing routine, urgent and home care and specialist services.

    • How to encourage and support people to register with a dentist and how to act as an advocate to ensure others can use services.

    • Entitlements to free dental treatment or help with costs.

    • Information on local voluntary sector organisations that may be able to offer additional advice, help or advocacy services.

    • What advice to give to carers.

Recommendation 10 Promote oral health in the workplace

Public sector employers including local authorities and the NHS should:

  • Work with occupational health and human resource services to promote and protect oral health using the 'advice for patients' in Delivering better oral health. This should be part of efforts to improve general health and wellbeing at work and should be tailored to local needs. (See the NICE pathway on smoking cessation in the workplace and the NICE guideline on preventing type 2 diabetes: population and community-level interventions.)

  • Consider ways to raise awareness of evidence-based oral health information and advice and ways to improve access to dental services, for example, by giving people information about local advocacy services.

  • Consider allowing people time off work to go to the dentist without losing pay (as is common practice for GP appointments).

  • Make information available to staff about local dental services and about national guidelines on oral health. For example, include this information at health promotion events, in leaflets and posters and on noticeboards and the intranet. This information should be written in plain English and should include details of:

    • the links between diet, alcohol and tobacco use and oral health

    • effective oral hygiene techniques, including the use of fluoride products and tooth brushing techniques

    • the benefits of going to the dentist and regular check-ups

    • eligibility for reduced-cost or free treatment

    • how to obtain appropriate forms (for example, for people receiving certain benefits, including pregnancy and maternity benefits)

    • local advocacy services

  • Ensure the workplace environment promotes oral health (see recommendation 6).

Recommendation 11 Commission tailored oral health promotion services for adults at high risk of poor oral health

Local authorities, health and wellbeing commissioning partners and NHS England area teams should:

  • Use information from their oral health needs assessment to identify local areas and groups at high risk of poor oral health (see recommendation 2)

  • Provide tailored interventions to help people at high risk of poor oral health who live independently in the community. This could include outreach services, for example, for people who are homeless or who frequently change location, such as traveller communities. Ensure services deliver evidence-based advice in line with the 'advice for patients' in Delivering better oral health.

  • Ensure services promote and protect oral health, for example, by:

    • giving demonstrations of how to clean teeth and use other oral health and hygiene techniques (as appropriate)

    • promoting the use of fluoride toothpaste

    • providing free or discounted materials including fluoride toothpaste and manual and electric toothbrushes

    • explaining the links between oral health and diet, alcohol and tobacco use.

  • Ensure local care pathways encourage people to use dental services.

Recommendation 12 Include oral health promotion in specifications for all early years services

Local authorities and health and wellbeing commissioning partners should:

  • Ensure all contract specifications for early years services include a requirement to promote oral health and train staff in oral health promotion (see recommendations 7 to 9 and 13 to 14). This includes services delivered by:

    • Midwives and health visiting teams.

    • Early years services, children's centres and nurseries.

    • Child care services (including childminding services).

    • Frontline health and social care practitioners working with families who may be at high risk of poor oral health. (For example, families with complex needs, teenage parents and families from minority ethnic communities where poor oral health is prevalent and people may find it difficult to use services.)

  • Ensure all frontline staff in early years services, including education and health, receive training at their induction and at regular intervals, so they can understand and apply the principles and practices that promote oral health.

Recommendation 13 Ensure all early years services provide oral health information and advice

Local authorities and health and wellbeing commissioning partners should:

  • Ensure all early years services include advice about oral health in information provided on health, wellbeing, diet, nutrition and parenting. This should be in line with the 'advice for patients' in Delivering better oral health. If possible, oral health activities such as tooth brushing should be listed with other general routines recommended for children by established parenting programmes (such as Parenting UK).

  • Ensure all frontline staff can help parents, carers and other family members understand how good oral health contributes to children's overall health, wellbeing and development. For example, by:

    • promoting breastfeeding and healthy weaning, including how to move from breast or bottle feeding to using an open cup by 12 months (see box 1)

    • promoting food, snacks (for example, fresh fruit) and drinks (water and milk) that are part of a healthier diet

    • explaining that tooth decay is a preventable disease and how fluoride can help prevent it

    • promoting the use of fluoride toothpaste as soon as teeth come through (see Delivering better oral health for appropriate concentrations)

    • encouraging people to regularly visit the dentist from when a child gets their first tooth

    • giving a practical demonstration of how to achieve and maintain good oral hygiene and encouraging tooth brushing from an early age

    • advising on alternatives to sugary foods, drinks and snacks as pacifiers and treats

    • using sugar-free medicine

    • giving details of how to access routine and emergency dental services

    • explaining who is entitled to free dental treatment

    • encouraging and supporting families to register with a dentist

    • providing details of local advocacy services if needed.

Recommendation 14 Ensure early years services provide additional tailored information and advice for groups at high risk of poor oral health

Local authorities and health and wellbeing commissioning partners should:

  • Use information from the oral health needs assessment to identify areas and groups where children are at high risk of poor oral health (see recommendation 2).

  • Provide tailored services to meet the oral health needs of these groups (this includes young children who are not attending nursery).

  • Ensure early years services identify and work in partnership with relevant local community organisations (see recommendation 1) to develop and deliver tailored oral health advice and information for families (See the NICE guideline on community engagement).

  • Ensure health and social care practitioners can provide culturally appropriate advice and information on oral health for families with babies and young children.

  • Consider giving midwives and health visitors free tooth brushing packs to offer to families in groups at high risk of poor oral health. (See Childsmile for an example of these packs.) Distribution of packs should be combined with information on when and how to brush teeth, a practical demonstration and information about local dental services.

Recommendation 15 Consider supervised tooth brushing schemes for nurseries in areas where children are at high risk of poor oral health

Local authorities and health and wellbeing commissioning partners should:

  • Use information from the oral health needs assessment to identify areas where children are at high risk of poor oral health (see recommendation 2).

  • Consider commissioning a supervised tooth brushing scheme for early years settings (including children's centres) in these areas. The scheme should include:

    • arrangements for getting informed consent from parents or carers

    • supervised daily tooth brushing with fluoride toothpaste on the premises

    • collaborative working with parents or carers to encourage tooth brushing both at home and at the nursery

    • providing free toothbrushes and fluoride toothpaste (1 set to use on the premises and 1 set to take home)

    • a designated lead person for the scheme at all establishments

    • access to a dental professional for advice if needed

    • support and training for staff to deliver the scheme (this should be recorded and monitored)

    • performance monitoring at least once every school term (that is, at least 3 times a year), against a checklist drawn up and agreed with the group responsible for the local oral health needs assessment and strategy (see recommendations 1 and 4).

Recommendation 16 Consider fluoride varnish programmes for nurseries in areas where children are at high risk of poor oral health

Local authorities and health and wellbeing commissioning partners should:

  • Use information from the oral health needs assessment to identify areas where children are at high risk of poor oral health (see recommendation 2).

  • If a supervised tooth brushing scheme is not feasible (see recommendation 15), consider commissioning a community-based fluoride varnish programme for nurseries as part of early years services for children aged 3 years and older. The programme should provide at least 2 applications of fluoride varnish a year.

  • Ensure early years services work in collaboration with parents and carers to gain parental consent for as many children as possible to take part in the fluoride varnish programme.

  • Ensure families of children who do not visit the dentist regularly are encouraged and helped to use dental services.

  • Monitor uptake and seek parental feedback on the fluoride varnish scheme.

  • If resources are available, consider commissioning both a supervised tooth brushing scheme and a fluoride varnish programme.

Recommendation 17 Raise awareness of the importance of oral health, as part of a 'whole-school' approach in all primary schools

Local authorities (where they have a role in the governance of a school), school governors and head teachers should:

  • Promote a 'whole-school' approach to oral health by:

    • Ensuring, wherever possible, that all school policies and procedures promote and protect oral health (for example, policies on diet and nutrition, health and safety and anti-bullying should include oral health; see Standards for school food in England, Department for Education 2014).

    • Making plain drinking water available for free and encouraging children to bring refillable water bottles to school.

    • Providing a choice of sugar-free food, drinks (water and milk) and snacks (for example, fresh fruit). These should also be provided in any vending machines.

    • Displaying and promoting evidence-based, age-appropriate oral health information for parents, carers and children (this should be relevant to local needs and include details of how to access local dental services).

    • Ensuring opportunities are found in the curriculum to teach the importance of maintaining good oral health and highlighting how it links with appearance and self-esteem. This should use age-appropriate information, adapted to meet local needs and based on the 'advice for patients' in Delivering better oral health.

    • Identifying and linking with relevant local partners to promote oral health (see the NICE guideline on community engagement). This could include oral health promotion schemes commissioned by the local authority and local community networks (see recommendation 3).

Recommendation 18 Introduce specific schemes to improve and protect oral health in primary schools in areas where children are at high risk of poor oral health

Local authorities (where they have a role in the governance of a school), school governors and head teachers should:

  • Use information from the oral health needs assessment to identify areas where children are at high risk of poor oral health (see recommendation 2).

  • Ensure primary schools in these areas, identify school staff who could be trained to provide advice and support to promote and protect pupils' oral health. Train these staff to give:

    • age-appropriate information adapted to meet local needs and based on the 'advice for patients' in Delivering better oral health

    • advice and information about where to get routine and emergency dental treatment, including advice about costs (for example, transport costs)

    • advice and help to access local community networks offering information, advice and support about general child health and development.

  • Ensure trained staff set up and run tooth brushing schemes and support fluoride varnish programmes commissioned by local authorities (see recommendations 19 and 20).

  • Provide opportunities for staff to talk with parents or carers about, and involve them in, improving their children's oral health. For example, opportunities might arise at parent-teacher evenings, open days or by encouraging parents and carers to get involved in developing the school food and drinks policy.

Recommendation 19 Consider supervised tooth brushing schemes for primary schools in areas where children are at high risk of poor oral health

Local authorities and health and wellbeing commissioning partners should:

  • Use information from the oral health needs assessment to identify local areas where children are at high risk of poor oral health (see recommendation 2).

  • Consider commissioning a supervised tooth brushing scheme for primary schools in these areas (for details of these schemes see recommendation 15). If resources are limited, prioritise reception and year 1 (up to age 7).

Recommendation 20 Consider fluoride varnish programmes for primary schools in areas where children are at high risk of poor oral health

Local authorities and health and wellbeing commissioning partners should:

  • Use information from the oral health needs assessment to identify areas where children are at high risk of poor oral health (see recommendation 2).

  • If a supervised tooth brushing scheme is not feasible (see recommendation 15), consider commissioning a community-based fluoride varnish programme for primary schools. This should provide at least 2 applications of fluoride varnish a year (see recommendation 16).

  • Consider commissioning both a supervised tooth brushing scheme and a fluoride varnish programme, if resources are available.

Recommendation 21 Promote a 'whole school' approach to oral health in all secondary schools

Local authorities (where they have a role in the governance of a school), school governors and head teachers should:

  • Promote a 'whole-school' approach to oral health by:

    • Ensuring, wherever possible, that all school policies and procedures promote and protect oral health (for example, policies on diet and nutrition, health and safety and anti-bullying).

    • Making plain drinking water available free and encouraging children to bring refillable water bottles to school.

    • Providing a choice of sugar-free food, drinks (water and milk) and snacks (including fresh fruit). These should also be provided in any vending machines.

    • Ensuring opportunities are found in the curriculum to teach the importance of maintaining good oral health and highlighting how it links with appearance and self-esteem. This should use age-appropriate information, adapted to meet local needs and based on 'advice for patients' in Delivering better oral health.

  • Ensure school nursing services encourage good oral health, including effective tooth brushing, use of fluoride toothpaste and regular dental check-ups.

  • Ensure all school leavers know where to get advice and help about oral health, including dental treatment and help with costs. They should be provided with details of relevant services, including links to local community networks.

  • In areas where children and young people are at high risk of poor oral health consider identifying and training secondary school staff to advise on dental issues (see recommendation 7). This includes giving advice about dental treatment and costs, and promoting oral health among students (for example, by explaining the links between diet, alcohol, tobacco, sexual practices and oral health).

  • Work with local authorities to influence planning decisions on new buildings (for example, to ensure drinking fountains are installed) and fast food outlets (for example, ice cream vans, burger vans and shops).

  • National Institute for Health and Care Excellence (NICE)