3 Context

Introduction

Oral health is important to general health and wellbeing. Poor oral and dental health can affect a person's ability to eat, speak and socialise normally (for example, due to social embarrassment, pain) (Dental quality and outcomes framework, Department of Health 2011). Oral diseases are also associated with coronary heart disease (Humphrey et al. 2008; Mathews 2008); diabetes complications (Grossi and Genco 1998; Stewart et al. 2001; Taylor 2001); rheumatoid arthritis (Ortiz et al. 2009); and adverse pregnancy outcomes (Xiong et al. 2006).

Tooth decay (dental caries) and gum disease (periodontal disease) are the most common dental problems in the UK. They can be painful, expensive to treat and can seriously damage health if left unchecked ('Dental quality and outcomes framework'). However, both problems are largely preventable (Levine and Stillman-Lowe 2009).

Oral health in England

While oral health in England has improved significantly across the population as a whole over recent decades, marked inequalities persist. The adult dental health survey 2009 (The Health and Social Care Information Centre 2011) reported that the proportion of adults in England without any natural teeth fell over the last 30 years from 28% to 6%. However, the survey also showed a clear socioeconomic gradient. For example, people from managerial and professional occupation households had better oral health (91%) compared with people from routine and manual occupation households (79%).

The NHS dental epidemiology programme for England oral health survey of children aged 12 showed that levels of dental disease among this group are decreasing, in line with previous survey years.However, from May 2006, data are collected about children only if written information and consent has been provided. Previously, consent was assumed if a letter was sent to the parents or guardians and no objection was received. These consent arrangements suggest a bias towards the participation of those who are less likely to have tooth decay (Davies et al. 2011).

Data collected between 2008 and 2009 show 66.6% of 12 year old children were free from visually obvious dental decay. However, 33.4% are reported as having dental caries (with 1 or more teeth severely decayed, extracted or filled). The same survey reported a higher prevalence and severity of oral disease among those living in Yorkshire and the Humber, the north west and north east compared to those in the midlands and south west; with the lowest levels of disease reported in the south and east (The NHS dental epidemiology programme for England: oral health survey of 12 year old children 2008/2009, North West Public Health Observatory 2010).

The National dental epidemiology programme for England oral health survey of 5 year old children 2012 (Public Health England 2013) indicates wide variations in dental health across the general population. A significant proportion of children (72.1%) are free from obvious dental decay, with 27.9% having at least 1 decayed, missing or filled tooth. However, at the local authority level, the prevalence of dental caries ranges greatly: from the lowest reported of 12.5% in Brighton and Hove to the highest of 53.2% in Leicester.

Improving the oral health of local populations

The risk factors for poor oral health – diet, smoking, alcohol use, hygiene, stress and trauma – are the same as those for many chronic conditions (Watt and Sheiham 2012).

Risk factors for severe dental caries in the UK include: living in a deprived area; being from a lower socioeconomic group or living with a family in receipt of income support; belonging to a family of Asian origin; or living with a Muslim family where the mother speaks little English (Rayner et al. 2003). Other risk factors include substance misuse or having a chronic medical condition (Valuing people's oral health: a good practice guide for improving the oral health of disabled children and adults, Department of Health 2007).

The oral health of local communities is important for their general health and wellbeing and their quality of life. It may be improved by adopting a 'common risk factor' approach and by providing evidence-based oral health promotion programmes and interventions. The aim of the latter is to improve people's:

  • diet – this includes reducing the amount of sugar consumed and how frequently

  • oral hygiene

  • access to fluoride products

  • access to a dentist.

The role of local authorities in improving oral health

Since April 2013, NHS England (previously the NHS Commissioning Board) has been working with local authorities and Public Health England to develop and deliver oral health improvement strategies and commissioning plans specific to the needs of local populations (Securing excellence in commissioning primary care, NHS Commissioning Board 2012; Commissioning better oral health for children and young people, Public Health England 2014).

Oral health needs assessments are required to inform joint strategic needs assessments. Local authorities have the responsibility for commissioning surveys of dental health, dental screening and improving the oral health of their populations.

Delivering better oral health toolkit

Below (box 1) is an edited extract from: Delivering better oral health: an evidence-based toolkit for prevention (Public Health England 2014). This toolkit provides practical, evidence‑based guidance to help dentists and their teams promote oral health and prevent oral disease among their patients.

Box 1 Summary guidance for primary care dental teams: Advice for patients

Prevention of caries in children aged 0–6 years

Children aged up to 3 years:

  • Breastfeeding provides the best nutrition for babies

  • From 6 months of age infants should be introduced to drinking from a free-flow cup, and from age 1 year feeding from a bottle should be discouraged

  • Sugar should not be added to weaning foods or drinks

  • Parents or carers should brush or supervise toothbrushing

  • As soon as teeth erupt in the mouth brush them twice daily with a fluoridated toothpaste

  • Brush last thing at night and on one other occasion

  • Use toothpaste containing no less than 1000 parts per million (ppm) fluoride

  • It is good practice to use only a smear of toothpaste

  • The frequency and amount of sugary food and drinks should be reduced

  • Sugar-free medicines should be recommended

All children aged 3–6 years:

  • Brush at least twice daily, with a fluoridated toothpaste

  • Brush last thing at night and on one other occasion

  • Brushing should be supervised by a parent or carer

  • Use fluoridated toothpaste containing more than 1000 ppm fluoride. It is good practice to use a pea-sized amount

  • Spit out after brushing and do not rinse, to maintain fluoride concentration levels

  • The frequency and amount of sugary food and drinks should be reduced

  • Sugar-free medicines should be recommended

Children aged 0–6 years giving concern (for example, those likely to develop caries, those with special needs). All advice as above, plus:

  • Use fluoridated toothpaste containing 1350–1500 ppm fluoride

  • It is good practice to use only a smear or pea-sized amount

  • Where medication is given frequently or long term, request that it is sugar free, or used to minimise cariogenic effects

Prevention of caries in children aged from 7 years and young adults

All children and young adults:

  • Brush at least twice daily, with a fluoridated toothpaste

  • Brush last thing at night and on at least 1 other occasion

  • Use fluoridated toothpaste (1350–1500 ppm fluoride)

  • Spit out after brushing and do not rinse, to maintain fluoride concentration levels

  • The frequency and amount of sugary food and drinks should be reduced

Those giving concern (for example, those with obvious current active caries, those with ortho appliances, dry mouth, other predisposing factors, those with special needs). All the above, plus:

  • Use a fluoride mouth rinse daily (0.05% NaF-) at a different time to brushing

Prevention of caries in adults

All adults

  • Brush at least twice daily with fluoridated toothpaste

  • Brush last thing at night and on at least 1 other occasion

  • Use fluoridated toothpaste with at least 1350 ppm fluoride

  • Spit out after brushing and do not rinse, to maintain fluoride concentration

  • The frequency and amount of sugary food and drinks should be reduced

Those giving concern (for example, with obvious current active caries, dry mouth, other predisposing factors, those with special needs). All the above, plus:

  • Use a fluoride mouth rinse daily (0.05% NaF-) at a different time to brushing

Prevention of periodontal disease – to be used in addition to caries prevention

All adults and children:

Self-care plaque removal

  • Remove plaque effectively using methods shown by dental team. This will prevent gingivitis and reduce the risk of periodontal disease

  • Daily effective plaque removal is more important to periodontal health than tooth scaling and polishing by the clinical team

Tooth brushing and toothpaste

Brush gum line and each tooth twice daily (before bed and at least on 1 other occasion). Use either:

  • a manual or powered toothbrush

  • small toothbrush head, medium texture

All adults and ages 12–17

Interdental plaque control

Clean daily between the teeth to below the gum line before toothbrushing:

  • For small spaces between the teeth use dental floss or tape

  • For larger spaces use interdental or single tufted brushes

  • Around orthodontic appliances and bridges use kit suggested by the dental professional

Risk factor control

Tobacco

All adults and adolescents:

  • Do not smoke

  • Smoking increases the risk of periodontal disease, reduces the benefits of treatment and increases the chance of losing teeth

Diabetes

Patients with diabetes should try to maintain good diabetes control as they are:

  • At greater risk of developing serious periodontal disease

  • Less likely to benefit from periodontal treatment if the diabetes is not well controlled

Medications

Some medications can affect gingival health

Prevention of peri-implant disease

All adults with dental implants:

  • Dental implants require the same level of oral hygiene and maintenance as natural teeth

  • Clean both between and around the implants carefully with interdental kit and toothbrushes

  • Attend for regular checks of the health of gum and bone around implants

All adolescents and adults:

Tobacco use, both smoking and chewing tobacco, seriously affects general and oral health. The most significant effect on the mouth is oral cancers and pre-cancers.

  • Do not smoke or use shisha pipes

  • Do not use smokeless tobacco (such as, paan, chewing tobacco, gutkha)

If the patient is not ready or willing to stop they may wish to consider reducing how much they smoke using a licensed nicotine-containing product to help reduce smoking. The health benefits to reducing are unclear but those who use these will be more likely to stop smoking in the future.

All adolescents and adults:

  • Drinking alcohol above the recommended levels adversely affects general and oral health with the most significant oral health impact being the increased risk of oral cancer.

  • Reduce alcohol consumption to low risk (recommended) levels.

Recommended levels (May 2014)

  • Men should not regularly consume more than 3 to 4 units per day

  • Women should not regularly consume more than 2 to 3 units per day

  • All drinkers should avoid alcohol for 2 days following a heavy drinking session to allow the body to recover

  • Pregnant women or women trying to conceive should avoid drinking alcohol but if they choose to drink they should limit this to no more than 1 to 2 units once or twice a week and avoid getting drunk

All ages:

  • The frequency and amount of consumption of sugars should be reduced

  • Avoid sugar containing foods and drinks at bedtime when saliva flow is reduced and buffering capacity is lost.

  • National Institute for Health and Care Excellence (NICE)