Oral health

Oral health is essential to general health and quality of life. This term encompasses all conditions affecting the mouth and teeth for example gum disease and tooth decay as well as oral cancer.

Nearly all individuals suffer from gum disease or tooth decay at some stage in their life and care is costly. Nearly 5% of all healthcare expenditure is spent on treating oral problems, despite them being largely preventable.

Oral disease in children and adults is higher among poor and disadvantaged population groups. Besides pain and discomfort, the impact on children includes the need for treatment leading to absence from school further disadvantaging their educational opportunities. For the elderly, at a national level 30% of people aged 60-74 have no natural teeth and uptake of care services is low. With the ageing population and associated co-morbidities the problems in caring for this section of society are only likely to increase.

What do we know

Maintaining good oral health is a lifelong process that starts from birth and supported throughout life. The ability to chew, bite and swallow is essential for good health in general and helps support a high quality of life. A poor diet not only leads to dental decay, but is linked to other chronic health problems such as obesity and diabetes. Poor oral health has been associated with a number of other conditions including: coronary heart disease; diabetes; rheumatoid arthritis, and; adverse pregnancy outcomes.

Risk factors for oral diseases include: poor diet, tobacco, alcohol, poor oral hygiene, lifestyle and as with all non-communicable chronic diseases, has strong social determinants. Dental decay is the most common food-related disease which affects all families and which has a parallel impact to that of diabetes, obesity and heart disease.

Most oral diseases are largely preventable. Dietary sugars are the main cause of dental decay. Tobacco usage is linked to both an increased risk in oral cancers and the periodontal diseases. Alcohol consumption is associated with an increased risk of oral cancers, especially among smokers, and both accidental and non-accidental injuries including facial trauma. A safe environment reduces the risk of oral health problems by reducing the likelihood of ortho-facial injuries. Steps to reduce the risk include: safe play areas, traffic safety measures and the use of mouth guards for contact sporting activities.

The greatest reduction in tooth decay in the UK has been seen following the discovery of the benefits of fluoride to teeth, and the introduction of fluoride toothpaste.

Strategies that adopt a strategic ‘whole population’ and ‘directed population’ approach that contain appropriate elements relevant to the life-stage of the individuals involved are likely to provide the greatest success. Examples include the development of and supporting healthy diets throughout life; encouraging good oral hygiene practices from birth using a ‘directed’ approach and helping support care for vulnerable adults especially older people.

Facts, figures, trends

A 2013 survey showed that three-year-olds in Slough have more teeth affected by decay, on average, than in any other local authority in England. Figure 1 illustrates this with Slough children having an average of 1.17 teeth decayed missing or filled by age three. Among those with tooth decay by age 3 in Slough, an average of almost 5 teeth are affected per child.

It must be noted when interpreting these results that this survey only sampled less than 10% of children aged three in Slough, though given the associations between socioeconomic status and oral health this finding is not surprising.

Figure 1: Average number of decayed, missing or filled (dmf) teeth among three year old children in England by upper-tier local authority

Figure 1: Percentage of children with 2 or more dmf teeth.

By age 5, as a 2012 survey showed, 38% of children in Slough will have evidence of tooth decay. This is not only represents the poorest dental health in the South East, and is significantly worse than the national average, but also is amongst the worst rates when comparing similarly deprived regions .

Of the 273 children in Berkshire that had two or more decayed, missing or filled teeth, 67% had no indication of any care intervention.This means that not only is there a large burden of tooth decay in children in Slough, but that also these children are not being treated.

Dental services have the key role in managing disease once it has occurred. A recent oral health needs assessment conducted in Thames Valley (OHNA TV) highlights that Slough also has the lowest uptake of dental health care services for those aged 0-11 years old in the Thames Valley.The data in Figure 2 shows the number of residents who have attended for an NHS dental check-up within the past 24 months in Slough broken down into age bands for the years 2008, 2013 and 2015.

(Source: Thames Valley Oral Health Needs Assessment)

While overall there has been an increase in visits to the dentist, the data highlight the considerable variation in the percentage of uptake within the age groups. Up to the age of 2, service uptake is low, this may be due to an impression among parents that there are few if any benefits of taking their child to a dental practice before all teeth have erupted.
For the early teens, both parents and children are concerned about the development of their teeth, especially whether they need orthodontic treatment as the secondary (adult) dentition replaces the primary (baby) teeth which would suggest that availability of services is not a problem.

The drop in uptake in early adulthood corresponds with the introduction of patient co-payments and for the elderly factors influencing service usage includes perceived need, many of the elderly having none of their own teeth, and again, co-payments.

Figure 4: NHS dental service uptake for Slough residents in 2008, 2013 and 2015

Figure 2:  Decayed teeth by local authority of school 2012. Source: Berkshire Healthcare Foundation Trust.

Source: NHS Business Service Authority Information Services

Oral cancer

A growing oral health problem is oral cancer. The lifetime risk of developing oral cancer and pharyngeal cancer in Europeans is estimated at 1.85% for men and 0.37% for women, with 250 new cases in the Thames Valley per year and 39 new cases per year across Slough, Windsor, Maidenhead and Bracknell. Although the number of cases appears slow, the prognosis is generally poor. The five-year survival rate for oral cancer is lower than for other more common cancers, e.g. cervical, breast or prostate cancers.

Factors associated with an increased risk of oral cancer include: smoking, marijuana usage, alcohol consumption, betel quid chewing, poor diet, human papilloma virus (HPV) and poor oral health. The changing epidemiology, particularly the earlier presentation of the condition is thought primarily to be due to sexually practices but the long-term factors, especially the use of tobacco and alcohol remain central.

National & Local Strategies

There are numerous policy documents that have guided the development of arrangements to improve oral health at a national level. These include those associated with the determinants and those affecting care service delivery. Examples include the document ‘Delivering better oral health: an evidence based toolkit for prevention. 3rd edition’ (Public Health England, 2014) aimed at ensuring that the dental profession were aware of current best practice, and programmes aimed at improving access to services.

More recently NICE have published guidance on how Local Authorities can best use address oral health ‘Oral health: approaches for local authorities and their partners to improve the oral health of their communities’ (NICE, 2014) which makes recommendations on undertaking oral health needs assessments, developing a local strategy on oral health and delivering community-based interventions and activities.

Locally, the former Berkshire Primary Care Trusts have developed the provision of care aimed at improving access by commissioning increased services and supporting the development of specific oral health promotion schemes such as the ‘Brushing for Life’ programme currently operating in Slough.

The brushing for life programme provides a pack containing toothpaste, a toothbrush and oral health advice including information regarding local ‘baby friendly dentists’ to all children in the borough at 8 months of age. Refill packs are available at Children’s Centres for target families only. In August 2015, 60 refill packs were collected, of which over 2/3 were for children under the age of 3 years.

What is this telling us?

Although oral health has improved over the past five years there remain disparities within the population.

A significant number of very young children are experiencing difficulties arising from poor oral health even by 3 years of age. This indicates a need to improve efforts aimed at reducing the factors influencing disease and its sequels in children and supporting parents in a targeted manner.

The increasing prevalence of HPV is leading to an increase in the number of oral cancers diagnosed. Working with young people and informing them of oral cancer as well as all of the other risks of contracting a sexually transmitted disease may help to reduce these figures.

Regarding oral cancer, patients may present to their GPs with symptoms. Increasing the training for general practitioners in the early recognition of oral cancer and urgent referral to dental services may be crucial in improving patient’s prognoses which means working with the Health Education England. This works stress the importance of building close collaborative working between the health care professions.

The problems of poor oral health are growing within the elderly population. Educating and supporting all care workers about the role of good oral hygiene and how good oral health can contribute to the qualities of life as well will be essential in maintaining physical as well as mental health in these patients.

What are the key inequalities?

While overall, oral health has seen significantly improvements in England over the last few decades, marked inequalities persist. Globally, nationally and locally, there is substantial evidence highlighting that people in the poorer and more deprived areas suffer worse oral health when compared to those living in more affluent areas.
The problems of inequalities in disease experience are further compounded by the inequalities in service uptake: those with greater clinical need tend to use services less.

These issues arise for a number of reasons including:

  • Variation in perceived importance of good oral hygiene
  • Low education and literacy levels
  • Cultural differences and language barriers
  • Financial restrictions
  • Fear
  • Low awareness of the risk factors for oral diseases

Priority group who are most likely to experience poor oral health and who are most likely to benefit from preventive interventions are:

  • Early years and parents
  • Vulnerable adults
  • Older people
  • Prisoners
  • Adults with learning difficulties

A recently published report (Fatania et al., 2013) on a pilot study exploring dental care in care homes across Berkshire highlighted a number of issues. Care home staff reported that with other work pressures, oral health was not a priority and reinforced that patients with dementia were particularly challenging. With an ageing population, the number of elderly patients in care and nursing homes is on the rise.

What are the unmet needs/ service gaps?

The current unmet needs are as follows:

  1. 1. The prevalence of children with dental decay highlights that oral health issues have already arisen at 3 years of age. The ‘Brushing for Life’ programme in place in 3 of the Berkshire Local Authorities is designed to help address this and lead to improvements in both overall levels of oral health and reduce inequalities. This programme could also be linked into programmes aimed at helping increase attendance for care.
  2. The growing oral health needs of the elderly population will require appropriate solutions. Work has commenced on identifying the needs of this growing section of the population. While currently all new entrants to a care or nursing home have a medical assessment, dental assessments are not included.
  3. The changing epidemiology of oral cancer and the growing evidence of an association with HPV exposure, suggests that there is good opportunities would arise through collaboration with the Sexual Health team. Work is also required to understand how patients with the oral health problems are initially accessing primary care services.

Recommendations for consideration by other key organisations

The following are our recommendations for consideration:

  • The continuation of appropriate fluoride strategies, for example the adoption of an oral health promotion programme aimed at developing good hygiene practices from birth.
  • The promotion of oral health as part of a life course approach as part of healthy eating and the prevention of other medical conditions. This could include more ‘Early Years’ settings to obtain the ‘Smiling for Life’ accreditation.
  • Encouraging parents and children attendance for dental care, for example a ‘child friendly’ dentist scheme
  • To work with various agencies to help develop improved care arrangements for the elderly.
  • Collaborative working between professionals across the wider sectors to ensure that oral problems are identified as earlier as possible and managed efficiently and effectively.