Oral health
1. Summary
2. Introduction
Tooth decay is the most common oral disease affecting children and young people in England, yet it is largely preventable. Poor oral health can affect children and young people’s ability to sleep, eat, speak, play and socialise with other children.
The financial costs of tooth decay are high and there is also a considerable social impact: with children missing school and parents/carers needing to take time off work to take their children to the dentist or for a hospital visit.
Health inequality is a common feature in dental disease; high levels of dental disease tend to affect those in low income families and those living in socially deprived conditions.
The oral health of older people has improved in England since the late 1960s, with more adults keeping their teeth into old age. However, many of these teeth will have fillings and other restorations which need continued good oral hygiene practices and regular check-ups, otherwise new decay will develop very quickly. This rapid deterioration in oral health is sometimes seen in older people that enter residential care who have lost the ability to care for their own mouths.
Oral cancer is a disease for which the outcome and prognosis can be significantly improved if it is detected early. Risk factors for oral cancer are smoking, excessive alcohol consumption and the Human Papilloma Virus (HPV) infection.
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Other JSNA topics this topic closely linked to: |
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3. Data and Intelligence
Oral health inequalities
In 2016/17, the children who had the highest levels of decayed, missing or filled teeth was significantly higher in the most deprived wards compared with the least deprived wards.
In 2016/17, the proportion of children with tooth decay was significantly higher in the most deprived wards compared with the least deprived wards.
In 2016/17, the most deprived wards in Hartlepool (where the water is naturally fluoridated) had a much lower disease experience (children with decayed, missing or filled teeth) than the most deprived wards in Stockton-on-Tees. Water fluoridation is clearly reducing the severity of dental disease for children in Hartlepool.
In 2016/17, children living in the most deprived wards in Hartlepool had a similar severity of dental decay as children living in the least deprived wards in Stockton-on-Tees. In addition, the gap in disease severity was greater between the most affluent and most deprived wards in Stockton-on-Tees compared to that in Hartlepool wards. It can be clearly seen, water fluoridation significantly reduces inequalities in oral health.
Early intervention
It can take 18 months or more from the start of the decay process to continue to a stage that a filling is required. This decay process can be reversed if caught early so that a filling is not required. In Stockton-on-Tees, there is an increase of 247% in decay from 3 year olds to 5 year olds. Early fluoride interventions could reduce these significant increases in disease rates in very young children.
Dental access
Low dental attendance rates (40% of one-year-olds and 58% of two-year-olds) result in missed early intervention opportunities to give prevention advice and start fluoride applications for high risk children. Between the ages of 0-4 and 5-9, there is a 55.2% increase in dental take-up in Stockton-on-Tees. However, for many children attending for the first time at age five is too late, decay has already started. More needs to be done to promote the national campaign “Dental check by one” to raise dental attendance rates at the earliest possible opportunity. It is worth noting that in 2018 adult dental attendance rates in Stockton-on-Tees (56.5%) was higher than the national average (50.6%).
General anaesthetic
Recent figures have shown that in 2017/18, there were over 500 operations in Teesside hospitals costing over £423,000 to remove decayed teeth in children, of which 175 were for Stockton-on-Tees school children.
In Stockton-on-Tees, the rate of dental treatment under GA is almost 3 times higher than that of fluoridated Hartlepool. GA rates increased between 2016/17 and 2017/18 to meet increased demand and to address long waiting times. Although, it would appear that the GA rates in Stockton-on-Tees are lower than the England average, this is because many children are treated with sedation rather than with a GA.
Oral hygiene for care home residents
In a 2013 survey of care home residents in Teesside 80% of residents cleaned their own teeth, however, 22% did this less than once a day. The results also stated that 55% of residents had poor oral hygiene which would suggest that many residents would benefit from support in brushing their teeth.
Oral cancer
From 2012-16, oral cancer registrations were statistically significantly higher in Stockton-on-Tees than the national average.
From 2012-17, deaths from oral cancer were statistically significantly higher in Stockton-on-Tees than the national average.
4. Which population groups are at risk and why?
5. Consultation and engagement
6. Strategic issues
7. Evidence base
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Issue number 1 = highest priority |
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1 |
Source |
Public Health England (2018) |
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Title incl. web link |
Water Fluoridation. Health Monitoring Report for England 2018 |
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Summary
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- The evidence presented confirms that water fluoridation is an effective and safe public health measure to reduce the prevalence and severity of dental decay, and reduce inequalities. - The odds of experiencing decay in five-year-olds were reduced by 23% in the least deprived areas and 52% (95% CI 47%-56%) for those living in the most deprived area. - Hospital admissions for removal of decayed teeth in 0-19yr olds were 59% lower. |
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Source |
Public Health England (2016) |
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Title incl. web link |
Improving oral health: community water fluoridation toolkit |
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Summary |
This toolkit will help local authorities make informed decisions on water fluoridation and the process to follow should they wish to implement, vary or terminate a scheme. |
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Source |
National Institute for Health and Care Excellence (NICE, 2014) |
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Title incl. web link |
Oral health: local authorities and partners |
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Summary |
This guideline makes recommendations on undertaking oral health needs assessments, developing a local strategy on oral health and delivering community-based interventions and activities. The recommendations in this guideline aim to: - promote and protect oral health by improving diet and reducing consumption of sugary food and drinks, alcohol and tobacco (and so improve general health too) - improve oral hygiene - increase the availability of fluoride - encourage people to go to the dentist regularly - increase access to dental services. |
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1 & 2 |
Source |
Public Health England (2014) |
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Title incl. web link |
Local authorities improving oral health: commissioning better oral health for children and young people. An evidence-informed toolkit for local authorities |
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Summary |
This document provides guidance for local authorities to effectively commission services that will improve oral health. It makes the following recommendations - Put children and young people (CYP) and their families at the heart of commissioning. - Adopt an integrated approach with partners for oral health improvement, including NHS England, Public Health England and Clinical Commissioning Groups. Ensuring all local authority services for CYP have oral health improvement embedded at a strategic and operational level. - Commission for oral health improvement across the life course, giving every child the best start in life and adopting the principle of proportionate universalism. - Address the underlying causes of health inequalities and the causes of poor general and oral health though upstream evidence informed actions. - Sustain and develop the CYP workforce. - Support CYP through their families, early years, schools and community settings to maintain good oral health, adopting a place based approach. - Lead and advocate a clear local vision for oral health improvement and addressing oral health inequalities. - Provide access to quality local dental services focused on improving oral health. |
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Source |
Public Health England (2018) |
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Title incl. web link |
Commissioning better oral health for vulnerable older people - Resources to support commissioners in improving the oral health of vulnerable older people. Link |
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Summary |
The toolkit gives an overview of the impact of oral diseases in vulnerable older people and presents the evidence of what works to improve oral health to inform commissioning. - The toolkit is supported by a rapid review of the evidence and a resource compendium. |
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3 |
Source |
National Institute for Health and Care Excellence (NICE, 2016) |
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Title incl. web link |
Oral health for adults in care homes |
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Summary |
This guideline covers oral health, including dental health and daily mouth care, for adults in care homes. The aim is to maintain and improve their oral health and ensure timely access to dental treatment and includes recommendations on: - care home policies on oral health and providing residents with support to access dental services - oral health assessment and mouth care plans - care staff knowledge and skills - availability of local oral health services |
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Source |
Leeds Metropolitan University (2010) |
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Title incl. web link |
Community Health Champions: Evidence review |
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Summary |
This evidence review looks at the evidence base for community health champions and similar roles.Community members (either as volunteers or paid community health workers) undertake health promotion activities within the neighbourhoods and communities where they live and/or work. “Altogether Better” is based on an empowerment model. At the heart of this model is the concept that community health champions can be equipped with the knowledge, confidence and skills to make a difference in their communities. The evidence indicates that using Health Champions has improved access and increased uptake to services. |
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4 |
Source |
National Institute for Health and Care Excellence (NICE, 2015) |
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Title incl. web link |
Oral health promotion: general dental practice |
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Summary |
This guideline covers how general dental practice teams can convey advice about oral hygiene and the use of fluoride. It also covers diet, smoking, smokeless tobacco and alcohol intake. The recommendations cover: - oral health advice given by dentists and dental care professionals - how dentists and dental care professionals can adopt a patient-centred approach |
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8. What is being done and why?
Primary Dental Care is evenly distributed across the borough with some providing extra services such as sedation and orthodontics.
Map of dental practices in Stockton-on-Tees, 2019
Community Dental Services provide a specialised service to meet the additional oral health needs of the population. The Tees Community Dental Service, hosted by North Tees and Hartlepool Foundation trust, provide this service from Lawson Street Health Centre. Services provided include:
- Dental care for patients who need specialised equipment, facilities or expertise due to disability.
- Specialist referral service for general dental practitioners, hospital dental service general medical practitioners for special needs services.
- Sedation and domiciliary services.
- General anaesthetic services
- Oral health improvement programmes
- Dental epidemiology surveys and adult special needs screening.
Specialist services
Domiciliary oral healthcare has been defined as “a service that reaches out to care for those who cannot reach a service themselves”. There are dental practices across the borough that are commissioned to provide this service.
Sedation services are provided by some practices across the borough, one specialist advanced sedation service and the Community Dental Service.
Oral health improvement services (as of 2018/19)
Preschool daily toothbrushing programme: this programme is offered to all pre-school settings. Currently there are over 2,000 children brushing in the vast majority of settings. Supervised toothbrushing schemes are recommended by NICE and PHE as an effective intervention to improve oral health.
School Tooth Brushing Programme is offered to every primary school in the borough. Currently there are over 5,000 children (nursery, reception and into Year 1) brushing in the vast majority of settings. The schools identified as having the worst oral health are offered whole school brushing. School supervised toothbrushing schemes are recommended by NICE and PHE as an effective intervention to improve oral health.
School Fluoride Varnish Programme is running in a number of targeted primary schools across the borough. Currently there are approximately 3,000 children receiving fluoride applications in 10 schools. The programme is delivered by dental practices commissioned by the public health team and pupils receive 2 cycles of fluoride varnish per school year. Schools in this programme have been targeted based on high dental decay rates. Commissioning of fluoride varnish programmes are recommended by NICE and PHE to improve oral health in high risk children.
The Tees Oral Health Promotion Team commissioned by NHS England provide training to the health and social care workforce working with vulnerable groups. This includes Health Visitors, School Nurses, and staff in residential and care homes This is planned in partnership with public health team and the Public Health England Consultant in Dental Public Health. Both NICE and PHE recommend the provision of training for health and social care staff.
Specialist stop smoking services are provided by North Tees and Hartlepool NHS Foundation Trust. Stop smoking drop in clinics are accessible in a variety of locations and providing access to deprived communities. There are also community pharmacy stop smoking enhanced services commissioned. Dental practices are aware of these locations and sign-post patients appropriately.
9. What needs are unmet?
10. What needs to be done and why?
11. What additional needs assessment is required?
An oral health needs assessment for vulnerable older people is required to answer the following questions:
- Is there reasonable and equitable access to local dental services for the needs of vulnerable older people and their carers, which are focused on prevention?
- Are oral health requirements included in specifications for services for older people including care home and care at home services?
- Is there an integrated approach to oral health improvement across services for vulnerable older people and the older people’s workforce?
- What are the views of older adults and their carers on service provision?
12. Key contact
Name: Richard Gerrard
Job title: Health Improvement Specialist
Organisation: Public Health, SBC
Phone number: 01642 528361
Contributor/s:
Kamini Shah, Consultant in Dental Public Health, PHE
James O’Donnell, Public Health Intelligence Specialist, Public Health Team, SBC
13. References
1. Public Health England (2018) Water Fluoridation. Health Monitoring Report for England 2018
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/692754/Water_Fluoridation_Health_monitoring_report_for_England_2018_final.pdf
2. National Institute for Health and Care Excellence (NICE, 2014) Oral health: local authorities and partners
https://www.nice.org.uk/guidance/ph55
3. Public Health England (2014) Local authorities improving oral health: commissioning better oral health for children and young people. An evidence-informed toolkit for local authorities
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/321503/CBOHMaindocumentJUNE2014.pdf
4. Public Health England (2018) Commissioning better oral health for vulnerable older people
Resources to support commissioners in improving the oral health of vulnerable older people.
https://www.gov.uk/government/publications/commissioning-better-oral-health-for-vulnerable-older-people
5. National Institute for Health and Care Excellence (NICE, 2016) Oral health for adults in care homes https://www.nice.org.uk/Guidance/NG48
6. Leeds Metropolitan University (2010)Community Health Champions: Evidence review
https://www.researchgate.net/profile/J_Woodall/publication/267560858_Altogether_Better_Thematic_Evaluation__Community_Health_Champions_and_Empowerment/links/5527c22e0cf2e089a3a1c3f7/Altogether-Better-Thematic-Evaluation-Community-Health-Champions-and-Empowerment.pdf?origin=publication_detail
7. Public Health England (2019) Surveys and intelligence: children
https://www.gov.uk/government/collections/oral-health#surveys-and-intelligence:-children
8. Public Health England (2019) Public Health Profiles
e-mail: richard.gerrard@stockton.gov.uk