4 Considerations

This section describes the factors and issues the Public Health Advisory Committee (PHAC) considered when developing the recommendations. Please note: this section does not contain recommendations. (See Recommendations.)

Background

4.1 There is a lack of good quality evidence on the effectiveness and cost effectiveness of community oral health programmes in England. Generally studies do not provide enough detail about local service delivery or the frequency or intensity of particular interventions within programmes. There is a lack of patient-reported outcome measures on quality of life, with studies often reporting only clinical outcomes (such as the number of cavities in teeth). Reported outcomes are confounded by poorly designed community studies implemented over a short timeframe, and longitudinal studies (carried out over long periods of time) that rarely take into account changes in the broader national and local policy context.

4.2 Despite improvements in oral health in England over recent decades, marked inequalities persist. A clear sociodemographic gradient is associated with poor oral health outcomes for children, young people and adults. Risk factors for dental caries (tooth decay) may include: living in a deprived area; experiencing socioeconomic deprivation, social exclusion or isolation; belonging to a particular minority ethnic group; experiencing mental health problems; having impaired physical mobility; or having a chronic medical condition. Those with complex needs, such as older people who are frail, or people who misuse alcohol or drugs, are also at high risk of poor oral health and longer-term oral conditions including oral cancer.

4.3 The term 'high-risk groups' refers to groups in which high levels of oral disease are seen, compared with the national average. It includes 'vulnerable' populations that may have relatively low levels of disease but are badly affected by it. Examples include: people living in relative social deprivation, people who are homeless, traveller communities and older people who are frail but living independently in the community.

4.4 The PHAC agreed that, for the purposes of this guideline, groups of people at high risk of poor oral health could be described as 'vulnerable' populations. Members also agreed that it was important to recognise the general factors that lead people to be vulnerable. This includes socioeconomic deprivation, physical disability and some cultural factors (the latter includes not having English as a first language).

4.5 The risk factors for poor oral health – diet, smoking, alcohol use, hygiene, stress and trauma – are the same as those for many chronic conditions. The PHAC therefore took a 'common risk factor approach' (Watt and Sheiham 2012). As a result, many of the recommendations are relevant not only to improving oral health, but to improving health in general. Members also noted that several pieces of existing NICE guidance are relevant to oral health, including those on maternal and child nutrition, breastfeeding and smoking cessation.

4.6 The effect of sugar on oral health is influenced by when and how often it is consumed, as well as the amount consumed. The PHAC also noted that the level of acidity in the diet affects oral health. For example, fruit juices can be part of a healthier diet, but would be bad for oral health if drunk frequently over a long period of time because they contain natural acids.

4.7 The PHAC noted that the easy availability of sugary drinks and snacks in most environments (school, work and leisure) presents a risk to oral health. Members also noted that it is not always clear which foods and drinks are high in sugar. For example, sports drinks are usually associated with health but often contain a lot of sugar.

4.8 The PHAC noted that there is a lack of evidence on interventions that can reduce sugar intake to within NHS recommended levels ('How much sugar is good for me', NHS Choices).

4.9 Dietary changes can help reduce the risk of tooth decay. Changing behaviours related to alcohol, smoking and unprotected sexual practices, in particular, oral sex, can help prevent periodontal disease and oral cancers. (The human papilloma virus, transmitted by all types of unprotected sexual intercourse, has been linked to oral cancers.)

4.10 The PHAC agreed that tooth decay (dental caries) is seen as a particular problem among children. But it is also a significant problem among adults, particularly older people and vulnerable adults (including people with learning disabilities or mental health problems). Members discussed the use of both traditional promotional materials and social marketing to get oral health messages across to adults. However, evidence is lacking on whether or not the latter would be effective.

4.11 The PHAC noted that the original DH referral was to develop guidance for local authorities about community oral health programmes. Below are additional areas they believed to be important that were not included in the final scope:

  • training for dentists on the importance of children attending the dentist when their first tooth erupts, and on how to encourage parents and carers to ensure this happens

  • policies and interventions that help prevent injury to the jaw and mouth

  • national policies and population-based interventions to promote and protect oral health.

Overarching strategy

4.12 The PHAC adopted a 'life course' approach, examining the evidence on oral health for a defined sequence of events that people are expected to pass through as they progress from birth to death. The aim was to examine the effectiveness of community-based oral health interventions at key 'life course' stages determined by age, common life events (such as getting a job or becoming a parent) and social changes that affect people's lives.

4.13 The PHAC identified whether an intervention should be delivered to everyone (universal) or to particular high-risk groups (targeted). This is in line with the notion of proportionate universalism: interventions are delivered to everyone, with the intensity adjusted according to the needs of specific groups. This approach was used because it can help to reduce the social gradient and benefit everybody.

4.14 The PHAC was clear that interventions for high-risk groups should avoid singling out and selecting specific individuals. For example, the PHAC heard evidence that, to be effective, a school tooth brushing scheme would be offered to all pupils of a particular age – not just some pupils in a particular class.

4.15 The PHAC decided that some interventions are likely to have a beneficial effect on groups only if poor oral health is prevalent in that group. They were unlikely to be cost effective for other groups. The PHAC also noted that an oral health needs assessment was an important way to identify groups at high risk and determine where to invest.

4.16 The PHAC considered partnership working and how current roles, capacity and resources could be used to promote evidence-based oral health.

4.17 The PHAC noted that adults, children and young people with mobility difficulties, or learning or physical disabilities may need help brushing their teeth. In addition, they may need to use aids such as electric toothbrushes and other methods of getting fluoride onto their teeth (such as fluoride varnish). The PHAC also noted that carers who help someone with their daily personal grooming may need training to help them promote and protect the person's oral health.

4.18 The PHAC noted that poor oral health – and a failure to provide access to dental services for adults, children and young people – is recognised as a form of neglect. Sometimes it is classed as abuse.

4.19 Members advised that any relevant NICE guidelines currently in development (or being updated) should consider oral health.

4.20 The PHAC recommended that when the NICE guideline on looked-after children and young people (PH28), is updated, it should include evidence on preventing and responding to poor oral health.

4.21 The PHAC discussed how important it was to take cultural differences into account when promoting oral health. Members also discussed the need to work with local communities to identify culturally appropriate products (such as kosher toothpaste). In addition, they noted that although fluoride varnish contains alcohol, it may be acceptable to people from Muslim communities because it is not intoxicating and is not swallowed.

Oral health needs assessment

4.22 The PHAC acknowledged that undertaking an oral health needs assessment that reflects the effect of poor oral health on quality of life can be hampered by the available evidence and the type of surveys commissioned. It noted that most evidence is based on counting cavities in teeth, rather than measuring quality of life outcomes such as pain and the ability to eat.

4.23 The PHAC discussed how often an oral health needs assessment should be repeated. Members agreed this would vary depending on factors such as the data available, population covered in original assessment and changes to services. The PHAC noted the importance of having criteria in place to decide when and why another assessment should be undertaken.

Early years

4.24 The PHAC agreed that collaboration with families to establish healthier dietary patterns (including a sugar-free diet) is important for both oral and general health. Establishing good oral health routines early in life is also crucial. Members noted that health practitioners, including the dental team and early years workers, can play a key part by creating a welcoming environment and providing evidence- based information and advice. Members also noted the importance of dental appointments for babies from when the first tooth erupts, or from 6 months onwards. The PHAC discussed the potential use of this time to educate parents, carers and other family members as well about oral health.

4.25 The PHAC discussed the feasibility of using established parenting programmes (that teach parents behavioural management techniques) to reinforce good oral healthcare. Although it may not be feasible to add oral health education to current programmes, the PHAC agreed that it might be possible to include tooth brushing as an example of how to improve children's general routines.

Tooth brushing schemes, fluoride varnish programmes and fluoride milk schemes in early years and primary schools

4.26 The PHAC noted that tooth brushing schemes can establish life-long habits that will promote and protect oral health, whereas fluoride varnish programmes do not. Members emphasised that, although beneficial, fluoride varnish is not a solution to poor oral health. They agreed that if both interventions cannot be provided, tooth brushing programmes are preferable.

4.27 The PHAC was aware of several implementation issues for tooth brushing schemes, including safe storage of equipment, staff training and parental consent. Working in partnership with families to promote and protect the oral health of their children was seen as key. Members noted that lessons can be learnt from existing programmes such as Childsmile.

4.28 The PHAC discussed the potential unintended consequences of tooth brushing schemes. For example, members noted that children should not think of tooth brushing as only a school-based activity. To combat this, the PHAC agreed that schemes would need to promote and support tooth brushing in the home as well as school.

4.29 There is limited and inconclusive evidence about the effectiveness of schemes that provide primary schoolchildren with milk containing added fluoride to improve their oral health ('fluoride milk schemes'). The PHAC also discussed the fact that these schemes do not establish good lifelong oral health practices in the same way as tooth brushing schemes.

4.30 Fissure sealant is a thin plastic protective film painted on the chewing surfaces of back teeth. The aim is to make the pits and grooves (fissures) of the teeth into a smooth surface to prevent plaque accumulating. There is limited evidence on the effectiveness and cost effectiveness of using fissure sealants for children and young people in a community setting. Most comes from clinical settings, where it has been shown to reduce dental decay. This is difficult to extrapolate to a community setting where, as a minimum, a mobile dental clinic and dental hygienist would be needed.

4.31 The PHAC was aware of ongoing research into the acceptability, effectiveness and cost effectiveness of using fluoride varnish in community settings, compared with fissure sealants, to improve oral health. The results were not available when this guideline was published.

Adults

4.32 There was limited evidence on the effectiveness and cost effectiveness of community-based oral health promotion programmes among adults in England, particularly for interventions aimed at vulnerable populations. However, there is strong evidence that diet, access to dental services and use of fluoride affects oral health. Hence recommendations were made on increasing access to services and fluoride products, and on training to promote and protect oral health.

4.33 The PHAC noted that the workplace is an environment where oral health could be promoted. Members also noted that local authorities and the NHS could help reduce oral health inequalities: they are large employers, with many of their employees on low incomes.

Specific groups

4.34 The PHAC agreed that young people aged 16 to 24 may need help and encouragement to register with a dentist, to eat a healthier, balanced diet to promote oral health and to maintain oral hygiene. This includes young people leaving care. (Oral hygiene includes regular dental check-ups.) Members acknowledged that this is a period of change – leaving school, leaving home, starting further education or looking for work – and appears to coincide with a decrease in the numbers of young people in this age range who are registered with a dentist. The PHAC noted that young adults who are not in education, employment or training are particularly vulnerable to poor oral health and in particular need of encouragement and support.

4.35 The PHAC noted that pregnant women are at a slightly increased risk of oral health problems and are therefore entitled to free dental treatment. Members highlighted that pregnancy (and just after a baby is born) might be an opportune time to encourage families to use dental services and establish good oral health routines that will benefit both them and their children.

Economic analysis

4.36 The PHAC noted that the 16 relevant studies identified in the systematic review all had methodological weaknesses and limited applicability to England. Therefore a new economic model was developed.

4.37 Because of a lack of evidence on two of the main health outcomes – oral cancer and periodontal disease – the PHAC accepted that the model should focus on the effects of interventions on dental caries.

4.38 As with any modelling exercise undertaken during NICE guideline development, the results are subject to uncertainty and numerous assumptions. For this topic, some members of the PHAC expressed serious concerns about a number of inputs to the model, in particular, the lack of data on the effect of tooth decay on quality of life. The latter meant that the effect on quality of life had to be estimated using a regression analysis, which mapped oral health impact profile (OHIP‑14) scores to utility scores (EQ‑5D). However, some members felt that neither of these measures captured the effect of different aspects of oral health on quality of life. (For example, they did not capture the effect of the stage and severity of decay, or the effect in terms of the number of teeth affected and where in the mouth.)

4.39 The PHAC noted that the long-term impact of interventions on oral health, including levels of tooth decay and gum disease, is rarely evaluated. No published studies were identified that demonstrate a causal relationship between oral health interventions in very young children and a reduced risk of dental caries throughout life. The lack of evaluation studies meant that, during the economic modelling exercise, a number of the assumptions made were based on professional opinion. For example, oral health professionals generally accept that improving oral health behaviours in young children with primary teeth may reduce their likelihood of experiencing oral disease throughout life. This includes caries and gum disease and the need for surgery for tooth extraction. This is especially true for children from vulnerable groups.

4.40 The PHAC was concerned that most interventions identified were for children. Generally, it is considered difficult to accurately measure how children's quality of life is affected by their oral health – making it difficult, in turn, to estimate the cost effectiveness of interventions. Committee members also noted that research is underway to develop a child-centred questionnaire to measure the impact of caries and its related treatment among children aged 5–16 years.

4.41 Some committee members felt that the lack of suitable oral health data to input into the model severely limited the conclusions about cost effectiveness. In addition, the use of some non-UK based data was considered to limit the transferability of the findings. Nevertheless, some committee members felt that the scenarios in the sensitivity analyses could be used to determine whether future interventions might be cost effective.

  • National Institute for Health and Care Excellence (NICE)