choosing better oral health - the national...

Choosing Better Oral HealthAn Oral Health Plan for England

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DH INFORMATION READER BOX

Policy EstatesHR/Workforce PerformanceManagement IM & TPlanning FinanceClinical Partnership Working

Document Purpose Best Practice Guidance

ROCR Ref: Gateway Ref: 4790

Title Choosing Better Oral Health: An Oral Health Planfor England

Author Department of Health: Dental and OphthalmicServices Division

Publication Date 14 Nov 2005

Target Audience PCT CEs, SHA CEs, Care Trust CEs, Directors ofPH, SHA Dental Leads, Consultants in DentalPublic Health, General Dental Practitioners,Community Dental officers, Salaried DentalPractitioners, Dental Care Professionals

Circulation List NHS Trust CEs, Foundation Trust CEs, MedicalDirectors, PCT PEC Chairs, Special HA CEs, AlliedHealth Professionals, GPs, Communications Leads,Local Authority CEs

Description Choosing Better Oral Health: an Oral Health Planfor England provides support for PCTs in assessingoral health needs and commissioning appropriateservices to reduce oral health inequalities. It alsoprovides dental practices with evidence basedguidance on preventive care

Cross Ref Choosing Health; making healthier choices easier(Gateway ref 4135), Choosing a better diet: a foodand health action plan (Gateway ref 4618),Delivering Choosing Health: making healthierchoices easier (Gateway ref 4516)

Superseded Docs An Oral Health Strategy for England 1994

Action Required

Timing

Contact Details Tony JennerDental and Ophthalmic Services DivisionDepartment of Health, New King’s Beam House22 Upper GroundLondon SE1 9BW020 7633 4247http://www.dh.gov.uk/AboutUs/HeadsOfProfession/ChiefDentalOfficer/fs/en

For Recipient Use

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CONTENTS 1

FOREWORD 3

EXECUTIVE SUMMARY 5

INTRODUCTION 9National context 9Oral health as part of public health improvement 9Improving Oral Health – the challenge 10Reducing inequalities and achieving sustained improvements 10Aim of the Oral Health Plan 10

ORAL HEALTH in ENGLAND – an overview 11Adult oral health 11Child oral health 12Periodontal (gum) disease 14Oral cancer 14Impacts of poor oral health 15

Social impacts 16General health impacts 16Financial impacts 17At-risk groups 17

CAUSES OF POOR ORAL HEALTH 19Diet and nutrition 19Oral hygiene 20Exposure to fluorides 20Tobacco and alcohol use 21Injury 21Other medical conditions 21

CONTENTS

CONTENTS

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2 CHOOSING BETTER ORAL HEALTH: AN ORAL HEALTH PLAN FOR ENGLAND

IMPROVING ORAL HEALTH – PRINCIPLES OF GOOD PRACTICE 23Community support 23Integrated working – common risk approach 23Evidence based practice 24The targeted population approach 24Complementary actions 25Partnerships 25Evaluation 25

IMPROVING ORAL HEALTH – MAKING IT HAPPEN 27A system for delivery 27Implementation 28Key roles and responsibilities 29

Primary Care Trusts 29Strategic Health Authorities 29Regional Public Health Groups 29Local Authorities and the Voluntary Sector 30Public Health Teams 30Oral Health Professionals 30Freeing up capacity 31The local health community 31Individuals 32

GOOD PRACTICE 33Improving diet and reducing sugar intake 33Improving oral hygiene 35Optimising exposure to fluorides 36Tobacco control and promoting sensible alcohol use 37Reducing dento-facial injuries 38Professional training and support 39Research and development 40

WORKFORCE 41Requirements 41Oral health promoters 41Training and development 42

Appendix I Oral health and cross-cutting public health initiatives 43

Appendix II What works? The evidence 45

Appendix III Further information 49

Appendix IV References 53

Appendix V Glossary of terms 55

Appendix VI Members of Steering Group and Reference Group 57


With the White Paper Choosing Health: MakingHealthier Choices, the Government initiated aprogramme to help people adopt healthierlifestyles. Subsequently, the delivery plan DeliveringChoosing Health identified the support andservices people need to make healthier choices.

Good oral health is central to healthy living andthis oral health action plan identifies theinformation and services that will enable people totake control of their oral health. Reducing sugarconsumption and giving up smoking, as advocatedin the documents referred to above, will bringdirect benefits to oral health. Additionally, theadvice and support that dentists and othermembers of the dental team give their patientsregarding risks such as these can contribute to theGovernment’s prime objectives on healthier living.In particular, the regular access that the dentalteam has to people – who may have no othercontact with health professionals – offers newopportunities for building partnerships.

This plan draws on current evidence on the maincauses and consequences of poor oral health andthe measures by which improvements can bemade within an integrated Primary Care Trust(PCT) led health promotion programme.

At the core of the plan is the need to integrateoral health into the wider public health agenda.Oral health should be considered part of generalhealth, addressed through evidence-based

interventions focusing on the underlyingfactors that put people at risk of disease. Healtheducation helps, but is not enough to make a realdifference by itself. I believe that it is importantthat we work together, across agencies andsectors, to develop a range of complementaryapproaches. We have included in the documentsome case studies from around the country thatdemonstrate this intersectorial working.

One reason we have developed this plan now asan important part of the Government’s deliveryplan for public health in England, is to helpPCTs prepare for their new responsibilities forcommissioning NHS primary care dental services.

Moving away from the traditional approach, withits emphasis on treating people when they’vealready developed oral health problems to apreventive approach involving fewer interventions,is a major step towards providing better dentalcare in the 21st Century.

I would like to put on record my appreciation andthanks to the team led by Tony Jenner for thework they have put into preparation of this plan.

Barry CockcroftActing Chief Dental Officer

FOREWORD 3

FOREWORD


1. INTRODUCTIONThis action plan sets out to inform and providesupport for dental practices as they focus moreon preventive care under the new contractualarrangements which will be in place from 1st April2006. Designed to improve oral health bothnationally and locally, this plan also sets out toassist and support PCTs in meeting their newresponsibilities for dental services under the Healthand Social Care (Community Health and Standards)Act 2003. This legislation extends their remit toassessing local oral health needs andcommissioning the appropriate services to tacklelong standing oral health inequalities. For the firsttime since the foundation of the NHS, primary caredentists will be given the opportunity to focus onprevention and health promotion, as well astreatment within their contracts with the NHS

2. ORAL HEALTH – THE CURRENT PICTUREAdult oral health in England has been and still issteadily improving. Today, more adults keep theirteeth for life – although many still suffer fromtooth decay – and the number of adults aged 65with no teeth is high compared to some of theother EU countries. This presents challenges fordentistry in supporting people with an ageingdentition. (Para 14-16)

Child oral health has also been improving and farfewer children experience tooth decay than theydid 30 years ago. Older children in England nowhave the best oral health in Europe. However, inspite of this overall improvement, national surveysstill highlight inequalities which are stronglyassociated with social background. There are alsovariations according to other factors, such as waterfluoridation. (Para 17-20)

Periodontal (gum) disease affects a largeproportion of the population, especially inadulthood. It can result in teeth becoming looseand having to be extracted. (Para 21 -22)

Oral cancer incidence is rising, accounting forapproximately 800 deaths each year. Survival ratesincrease dramatically if the disease is diagnosed inits early stages, but low awareness and the painlessnature of early oral cancer means people generallyonly seek treatment when the cancer is moreadvanced and difficult to treat. (Para 23-25)

Impacts of Poor Oral Health

Improving oral health is part of the Government’swider public health strategy and many of the keyfactors that lead to poor oral health are risk factorsfor other diseases. People living in areas of materialand social deprivation and other vulnerable groupsin society have poorer oral health and they oftenaccess dental services less frequently. Poor oral

EXECUTIVE SUMMARY 5

EXECUTIVE SUMMARY


health has a major financial impact on both theindividual and society at large. (Paras 26-32)

3. CAUSES OF POOR ORAL HEALTH Diet and Nutrition

The majority of the English population consumesmore sugar than is recommended. There isparticular concern about high levels of consumptionamongst pre-school children, adolescents, andolder people particularly those living in institutions.Children who consume excessive amounts of fizzydrinks risk tooth erosion. (Paras 37-39)

Poor Oral Hygiene

Regular brushing of the teeth and gums from anearly age with a fluoride toothpaste will help preventtooth decay and periodontal disease. (Para 40)

Fluoride

Lack of exposure to fluoride can increase the riskof tooth decay occurring every time sugary foodsand drinks are consumed. Fluoride tips the balance

in favour of the ‘repair’ of teeth damaged by acidsfrom the consumption of sugar in food or drinks.(Para 42)

Tobacco and Alcohol

Smoking increases the severity of periodontaldisease and is one of the main risk factors fororal cancer. Smoking combined with excessiveconsumption of alcohol can lead to a 30 timesgreater risk of oral cancer. (Paras 43-44)

Injury

The health of teeth can be compromised bytraumatic injury. Children and people who playcontact sports are at particular risk. (Para 45)

4. KEY ROLES AND RESPONSIBILITIES FORIMPROVING ORAL HEALTH

Primary Care Trusts (PCTs) – are responsible forthe effective implementation of the newcontractual arrangements for dentistry. To achievethis and meet the oral health needs of theirpopulation PCTs should consider:



n ensuring that improving oral health is an integralpart of their Local Delivery Plans (LDPs)

n liaising with other organisations, especially localauthorities, to ensure that improving oral healthis included in joint planning objectives

n ensuring that the dental services thatthey commission have an evidence basedpreventive focus

n ensuring that they are able to obtain appropriatehealth needs information and advice indeveloping local programmes forimplementation (Para 60)

Strategic Health Authorities (SHAs) – have aresponsibility for:

n monitoring the progress of PCTs implementationof the new contractual arrangements fordentistry.

n undertaking local consultation on new waterfluoridation schemes and implementing new

schemes providing there is local support(Para 61)

Regional Public Health Groups (RPHGs) – as partof their overall responsibility for reducing healthinequalities, RPHGs will need to promote oralhealth. (Para 62)

Local Authorities – educational establishmentscan give out oral health messages. For example,schools can provide staff training on oral health,including procedures to follow with dental traumacases. (Para 63-64)

Voluntary Sector – voluntary groups can make avery worthwhile contribution. For example theycan help develop healthy eating guidelines forresidential homes and other institutions, and traincarers of vulnerable people in the care of mouths,teeth and gums. (Para 65)

Oral Health Professionals – Consultants in DentalPublic Health act as advisers and advocates for oralhealth improvement. They can support strategiesto address inequalities, and ensure that oral health

EXECUTIVE SUMMARY 7


is included in local health-related initiatives.Individually, primary care dentists can ensure thattheir teams have the skills and knowledge topromote oral health effectively to patients andrecognise problems that need referral. (Para 67-68)

The Local Health Community – GPs, HealthVisitors, Midwives, District, Community and SchoolNurse Advisers can also help to promote good oralhealth, and should be able to recognise when it isappropriate to refer patients to a dentist. Whereverpossible they should prescribe sugar-free medicines.Health visitors and midwives in particular have akey role in advising families with young childrenon good oral hygiene. (Paras 71-73)

Pharmacists – can offer advice on customers’specific problems, and promote the use of sugar-free medicines, toothbrushes and fluoridetoothpastes. (Para 72)

Commercial organisations and industry canimprove oral health through promoting andproducing sugar-free food and drinks, and enablingthe public to make informed choices throughclearer labelling. (Para 76)

5. IMPROVING ORAL HEALTH – KEY AREASFOR ACTION

Sustainable improvements in oral health areobtained through:

n Fluoride – increasing the use of fluoride will helpprevent tooth decay. The almost universal use offluoride toothpaste is one of the main reasonsfor improvement in oral health over the last30 years. Only one in ten of the population inEngland receives fluoridated water. SHAsworking with PCTs now have a realistic optionof implementing water fluoridation where thereis local support. (Paras 41, 78)

n Improving diet and reducing sugar intake –reducing the frequency and amount of addedsugars consumed in line with the Government’starget of 11% of food energy. Increasing theconsumption of fruit and vegetables to at least

five portions a day and promoting the use ofsugar free medicines. (Paras 37-39, 75-76)

n Encouraging preventive dental care – oral diseasesare preventable; the new commissioningarrangements and contractual framework for NHSdentistry will promote an approach that involvesfewer interventions and generates additional timeand capacity that can be used to adopt a morepreventive approach to dental care. (Paras 4, 67)

n Reducing smoking – in addition to the contractfor dental care, PCTs may additionally wishto contract with dental practices to providesmoking cessation advice for patients as part oftheir smoking cessation programmes. Smoking isa significant risk factor for periodontal diseaseand oral cancer. (Paras 43-44, 79)

n Increasing early detection of mouth cancer –measures to raise awareness of mouth cancershould lead to early detection and a reductionin the high mortality rate. (Paras 23-25, 79)

n Reducing dental injuries – a safer playenvironment should be established and peopleplaying contact sports should be advised to wearmouth shields. (Paras 45, 80)

6. WORKFORCE REQUIREMENTSImplementing the oral health plan will need a skilledand diverse workforce as indicated by the roles andresponsibilities detailed in section 4 of thisdocument. Oral health promotion staff have oftenbeen drawn from a wide range of backgrounds andhave been largely focused within the salaried dentalservices. They are becoming increasingly involved inwork on general health promotion which, in thelight of this plan’s focus on the common risk factorapproach, is to be welcomed and endorsed.

PCTs will want to ensure that such staff haveappropriate training and qualifications and area resource that can be used across the wholeof primary care dental services supporting dentalpractices as they move in a preventive directionand take on wider public health roles.(Paras 83-89)



NATIONAL CONTEXT1 Published by the Department of Health in 1994,the last National Oral Health Strategy incorporatedtargets for the oral health of 5 and 12-year-oldchildren and also adults in England by 2003.

2 Modernising NHS Dentistry: Implementing theNHS Plan published in 2000 flagged up theimportance of developing a preventive focus withindentistry and gave a commitment to tackle oralhealth inequalities. NHS Dentistry – Options forChange published in 2002 identified prevention asa key function for a modernised NHS dental serviceallowing General Dental Practitioners “for the firsttime, to focus on preventive measures to combatdental disease and to tackle the serious oral healthinequalities particularly in children”.

3 The Health and Social Care (Community Healthand Standards) Act 2003 legislated for far-reachingreform of NHS dental services to deliver theOptions for Change objectives. To meet their newresponsibilities for dental services under the Act,PCTs will assess local oral health needs in orderto tackle long standing oral health inequalities.Moreover, for the first time since the foundationof the NHS, primary care dentists will be given theopportunity to focus on prevention and healthpromotion, as well as treatment within theircontracts with the NHS. A significant part of theoverall reform is a new system of dental charges.

Draft regulations for general dental servicescontracts and personal dental services agreementsand for a new system of dental charges havenow been published. For the first time since thefoundation of the NHS, all primary care dentistswill be given the opportunity to work in ways thatinvolve fewer interventions and promote a greaterfocus on prevention and health promotion – in linewith evidence-based practice

ORAL HEALTH AS PART OF PUBLIC HEALTHIMPROVEMENT4 With the Public Health White Paper, ChoosingHealth, the Government initiated a majorprogramme to provide appropriate choices forpeople wishing to adopt healthier lifestyles. Oralhealth was referred to in the light of the proposednew contractual changes for dentistry, whichwill give a new focus to advice on the preventionof disease, lifestyle advice and discussing theappropriate options for care. The delivery planfor the White Paper, Delivering Choosing Health,identified the support and services needed toenable people to make healthier choices. Thepublication of this Oral Health Plan as part ofDelivering Choosing Health will be reinforcedby implementation of the new contractualarrangements for dentistry, for which PCTs willbe accountable to SHAs.

INTRODUCTION 9

INTRODUCTION


5 The importance of the common risk approachto improving oral health was demonstrated by thepublication of the food and health action plan,Choosing a Better Diet, which set out to reducethe average sugar intake to 11% of food energy(currently 12.7%). Since sugar is the main riskfactor in dental decay, there are already closesynergies in action.

IMPROVING ORAL HEALTH – THE CHALLENGE6 People living in England should continue toenjoy a standard of oral health which is amongstthe best in the world. Within this context the aimsof Government policy are to reduce inequalities byenabling people to take control of their own oralhealth. The challenge is to create the opportunityand conditions to enable individuals andcommunities to enjoy good oral health as animportant part of overall good health.

REDUCING INEQUALITIES AND ACHIEVINGSUSTAINED ORAL HEALTH IMPROVEMENTS7 Action is needed to reduce oral healthinequalities across the population. It isunacceptable and unjust that disadvantagedsections of society experience the highest levelsof oral diseases. Oral health initiatives need tolink with the government’s broader inequalitiesprogramme to ensure that the causes of thedifferentials are addressed.

8 Oral diseases are largely preventable but noeasy or quick fixes exist to promote oral health.Interventions need to be developed that willachieve sustained long term improvements in oralhealth. Action is needed to create conditions thatsupport and encourage good oral health. Forexample, policy changes which promote healthierfood and drink choices in schools help to create aschool environment conducive to good oral health.

AIM OF THE ORAL HEALTH PLAN9 This action plan is designed to complement thenew contractual arrangements for NHS Dentistry.It sets out a framework for action which PCTscould take into account in the coverage they give

to dentistry in their Local Delivery Plans (LDPs)in connection with the statutory duty theywill assume from April 2006 with regard tocommissioning primary care dental services.It should therefore be a useful resource forcommissioning managers and professional advisersfor evidence based commissioning. It will alsoinform and provide support for dental practicesas they focus more on preventive care under thenew contractual arrangements.

10 The plan encourages a range of organisationsto work together to improve oral health and alsocomplements and supports the important workbeing undertaken in terms of oral health andgeneral health improvement.

11 The key aim of the action plan is therefore toreduce both the prevalence of oral disease and oralhealth inequalities across all age groups in Englandby providing the NHS, dental practices and otherorganisations with the information and guidanceneeded to improve oral health.



12 Although we have seen significantimprovements in oral health in the last 30 years,many people still suffer unnecessarily from painand discomfort because of oral diseases, which arestill a major public health problem in this country.

13 When we refer to oral health we are talkingabout the health of people’s teeth, gums andsupporting bone, and the soft tissues of themouth, tongue and lips. Oral diseases are largelypreventable. Indeed many sections of our societynow experience very good levels of oral health butvulnerable, disadvantaged and socially excluded

groups still face particular problems. We need totackle these inequalities and improve oral healthacross the whole population.

ADULT ORAL HEALTH14 National surveys conducted in the UK every10 years have shown considerable improvementsin oral health. Nowadays more adults keep theirteeth for life. In 1968 as many as 37% of adultsin England and Wales had no natural teeth; by1998 in England this figure had fallen to 11%(Figure 1). However, the number of adults with

ORAL HEALTH IN ENGLAND – AN OVERVIEW 11

ORAL HEALTH IN ENGLAND – AN OVERVIEW

Figure 1 Proportion of adults with no teeth in England, 1968 to 1998

Source: National Adult Dental Health Survey, 1968 to 1998 (Kelly M, Steele J, Nuttall N, Bradnock G, Morris J, Nunn J, Pine C, Pitts N, Treasure E and White D(2000). Adult Dental Health Survey 1998

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no teeth is still high compared to some otherEuropean countries.

15 Tooth decay still affects a large proportion ofthe population and a significant proportion ofpeople over the age of 75 are still without anynatural teeth. Although more middle-aged peoplehave their own teeth, many of these teeth havebeen filled and these fillings need maintenanceand repeated repair. This changing pattern in thedemand for dental services needs to be taken intoaccount in future workforce planning.

16 There is a strong association between oralhealth and social disadvantage with people insocial classes III, IV and V being three timesmore likely to have lost all their teeth than thosein I & II (Figure 2)

CHILD ORAL HEALTH17 The oral health of children in England isthe best since records began. National surveysof children’s oral health are undertaken every10 years together with more frequent local NHSsurveys. In the early 1970s, around 30% of


Figure 2: Variations in the numbers of adults with no teeth

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Figure 3 Average DMFT/dmft per child in England, 1973 to 2003

Source: National Children’s Dental Health Surveys 1973 to 2003. Harker R and Morris J (2005). Office for National Statistics, London.

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children started school with no experience oftooth decay; by 2003 this figure had risen to 59%.The proportion of older children with decayed,missing, or filled (DMFT) permanent teeth has alsodropped. In 1973, 93% of 12-year-old childrenhad tooth decay in England; by 2003 this hadfallen to a historic low of 38%.

18 The average number of decayed, missing orfilled teeth in all children has fallen since 1973 inall age groups. The most significant change hasbeen in older children. In 12-year-old childrenin this period the fall has been from 5.0 to 0.7affected teeth (Figure 3), which means that thisage group now has the best oral health in Europeas measured by the World Health Organization(WHO) global database (Figure 4). In 5-year-oldchildren, improvements have been achieved since1973. However, since 1983, these have nowlevelled out. Further action is needed in respectof oral health in young children

19 In spite of this overall improvement, a gapbetween the oral health status of children in lowersocio-economic groups and children in higher socio-economic groups still exists (Figure 5). The 2003National Survey of Child Dental Health highlights

inequalities by social background, for example, theprobability of having obvious decay experience ofthe primary teeth was about 50% higher in thelowest social group than in the highest socialgroup. Among 15 year olds from managerial andprofessional backgrounds, 47% had obvious decayexperience compared with 65% from routine andmanual socio-economic backgrounds.

20 Regular NHS surveys of children’s oral healthhave been nationally co-ordinated by the BritishAssociation for the Study of Community Dentistry(BASCD: www.BASCD.org). These surveys haveproved invaluable in monitoring progress towardstargets. The latest survey of 5 year old childrencarried out in 2003/04 continues to demonstratedisparities in oral health across and within regionsin England with a seven-fold difference betweenPCTs with the best dental health and those withthe worst. Figure 6 shows the regional variations inoral health taken from the results of this survey.


Figure 4 Average levels of tooth decay in 12 year old children in Europe

Source: WHO Oral Health Country/Area Profile programme, 2005

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PERIODONTAL (GUM) DISEASE21 Diseases of the periodontal tissues andsupporting structures of the teeth affect a largeproportion of the population and become morecommon with increasing age. The most recentnational adult dental health survey found that54% of adults aged over 16 had moderate signsof periodontal disease in one or more teeth (pocket

depth > 3.5mm). More severe periodontal disease(pocket depth > 5.5mm) was found in 5% of thepopulation, the majority of whom were aged over65 years.

22 Periodontal disease can lead to a loss of thesupporting structures holding the teeth in position.This ‘loss of attachment’ becomes more prevalent


Figure 5 Social class inequalities in 5 year old children’s oral health in Britain 1937-1993

Source: National Children’s Dental Health Surveys 1973 to 1993

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Figure 6 Dental caries experience (dmft) of 5-year-old children in Great Britain. BASCD co-ordinatedNHS Dental Epidemiology Programme surveys 2002/2003 Scotland and 2003/2004 England and Wales

Source: The dental caries experience of 5-year-old children in England and Wales (2003/2004) and in Scotland (2002/2003). Surveys co-ordinated by the BritishAssociation for the Study of Community Dentistry N.B. Pitts(1), J. Boyles(2), Z.J. Nugent(1), N. Thomas(3), and C.M. Pine(4).

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in older people. The prevalence and severity ofperiodontal disease is greater in smokers.

ORAL CANCER23 Oral cancer is a malignant tumour of the mouthand accounts for 4% of all cancer cases in the UK.In 2000, there were nearly 2,300 new cases ofcancer of the oral cavity. Approximately 800 deathsare attributed to oral cancer each year. Oral canceris more common in males, with a male to femaleratio of 1.6 to 1. More than nine out of 10 patientswith oral cancer are aged over 40 years when theyare diagnosed, the average age at diagnosis being64 years for males and 61 years for females.

24 After a steady decline over the past fewdecades, the incidence of oral cancers is now rising,particularly in women, and there is evidence of anincreasing minority of younger people beingaffected. Despite recent improvements in theprevention and survival rates of many cancers, therehas been no similar improvement for oral cancer.The painless nature of early oral cancer that is eitherinvisible or appears as a seemingly harmless mouthulcer makes detection difficult, Low awarenessamong the public leads to people seeking treatment

only when the cancer has reached an advanced andmore difficult to treat stage.

25 Oral cancer has a high death rate, similar tothat of cancer of the cervix. The survival rate fororal cancer in England is about 50% at five years.Survival rates increase dramatically if the disease isdiagnosed in its early stages. The five-year survivalrate is over 80% when the cancer is diagnosed atan early stage, but falls to below 20% for thosewho have distant metastatic disease (spread toother parts of the body).

IMPACTS OF POOR ORAL HEALTH26 Oral health is an integral element of generalhealth and well-being. Good oral health enablesindividuals to communicate effectively, to eat andenjoy a variety of foods, and is important in overallquality of life, self-esteem and social confidence.However oral diseases are very common and theirimpact on both society and the individual aresignificant (Figure 7). Pain, discomfort, sleeplessnights, limitation in eating function leading to poornutrition, and time off school or work due to dentalproblems are all common impacts of oral diseases.


Figure 7: Impact of oral diseases

Source: Modified from Department of Human Services (1999)

Poor educationalperformance

Time offSchool

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SOCIAL IMPACTS27 Improving oral health is part of theGovernment’s wider public health strategy. Oralhealth is central to healthy living and a key markerof the health of a community. Good oral healthmakes an important contribution to an attractiveappearance, self-esteem and quality of life. Missingor decayed teeth and ill-fitting dentures can makepeople feel self-conscious and lead to loss ofconfidence and social isolation.

28 The most common oral diseases, tooth decayand periodontal disease, can both cause painand infection as well as eventual tooth loss. Thisdiscomfort often results in lost sleep and disruptionto family life, leading to time off work and/orschool. Acute dental infection can cause swellingand severe pain and in extreme cases can be life-threatening. Chronic infection also tastes and smellsunpleasant. It also results in loss of working daysand days of schooling. Poor oral health can alsoaffect food choices and lack of teeth can impactadversely on nutritional status and socialising.

29 Dental treatment has become much moreacceptable due to advances in technology andbehaviour management techniques. However,

extensive treatment can still be stressful, especiallyfor the very young. Many children still have teethextracted under general anaesthetic, a distressingexperience and an avoidable, albeit small, riskto life.

GENERAL HEALTH IMPACTS30 Many of the principal factors that can leadto poor oral health are also risk factors for otherdiseases, emphasising the need to include oralhealth in initiatives designed to promote healthin general.

31 The common risk factors are:

n diets high in sugary foods and drinks, including‘hidden’ added sugars in foods that would notbe expected to contain sugars;

n inappropriate infant feeding practices;

n poor oral hygiene;

n dry mouth (xerostomia);

n smoking/use of tobacco and other carcinogenicsubstances; and

n excessive alcohol consumption



FINANCIAL IMPACTS32 Dental treatment is expensive for the individual,for the NHS and for society as a whole. The totalspend on dental care in England in 2003/04 wasapproximately £3.8 billion including private dentaltreatment. Indirect costs, such as time off work toattend for dental treatment, are also a significantfinancial burden to society.

AT-RISK GROUPS33 Despite the general improvement in oralhealth there remain very marked inequalities inoral health. People living in areas of material andsocial deprivation have much higher levels of toothdecay. They are more likely to have diets high insugary foods and drinks and they brush their teethless often. Vulnerable groups of society also havepoorer oral health and less access to oral healthcare services. For example, children and adultswith a learning disability and people with mentalillness tend to have fewer teeth, more untreateddecay and more periodontal disease than thegeneral population.

34 Other groups at risk of poor oral healthinclude people with disability, those in long-terminstitutional care (such as residential homes,psychiatric hospitals and prisons), homeless peopleand some refugee and asylum seeker groups. Someminority ethnic groups may face an increased riskof oral disease because they are more likely to beliving in areas of disadvantage, and some groupsmay encounter language and cultural barriers toaccessing care and advice.

35 Elderly people living in residential care tend tohave a poorer diet than those living in their ownhomes. Adolescents, especially young men fromsemi-skilled or unskilled manual backgrounds, havebeen identified as a group in which there is adramatic reduction in dental visits in the transitionfrom childhood to adult life. Children, expectantmothers and women of childbearing age requirespecial consideration. Other vulnerable groupsinclude people requiring palliative care and peopleundergoing chemotherapy, radiotherapy or a bonemarrow transplant.



36 To achieve sustainable oral healthimprovements and reduce inequalities, action isneeded to tackle the underlying causes of oraldiseases. Contemporary public health research andpolicy recognises a spectrum of determiningfactors. These range from decisions takennationally on economic and social policy throughthe impact that these have on the socialenvironment matched with health behavioursadopted by individuals in the population. (Figure8). Focusing on these ‘upstream’ factors that causepoor oral health and create inequalities isfundamentally important. Actions that only seek tochange individual behaviour and lifestyles will havea limited long term effect.

DIET AND NUTRITION37 The frequent and high consumption of sugarsis the major cause of dental decay. The majorityof the English population consumes more sugarthan the recommended 60g per day. Soft drinks,confectionery and biscuits are the main sources ofsugars in the diet. There is particular concern aboutthe high levels of consumption among pre-schoolchildren, adolescents and older people particularlythose living in institutions. A range of factorsinfluence what people eat and drink but costs,availability, access and clear information areall important.

CAUSES OF POOR ORAL HEALTH 19

CAUSES OF POOR ORAL HEALTH

Figure 8 Underlying causes of oral health

Source: Modified from Watt (2005)

Political, economic& Policy Context

SocialEnvironment

Oral HealthBehaviours

BiologicalFactors

Oral Health


38 Tooth wear occurs naturally with time butexcessive wear at any age may lead to pain andthe need for treatment. In children and youngpeople, tooth wear is more commonly seen aserosion (chemical dissolution of teeth). Childrenand young people who consume excessiveamounts of acidic fizzy drinks, including diet andsugar free varieties, are more likely to be affected.

39 Eating a healthy balanced diet which containsplenty of fruit and vegetables and is low in fat,salt and sugar and, based on whole grain products,is important for promoting good health. All agegroups of the population consume less than thecurrent recommendation of at least five portionsof fruit and vegetables a day. Snacking on fruitand vegetables rather than snacks high in sugarcan help to promote oral health and particularlyhelp to reduce the risk of dental caries.

ORAL HYGIENE40 The health of periodontal tissues, the mucousmembrane lining the mouth, and the bonesupporting the teeth can be compromised when

teeth and gums are not brushed regularly anddental plaque accumulates. Oral hygiene practicesare best learnt in early childhood as part of bodyhygiene and cleanliness.

EXPOSURE TO FLUORIDES41 Tooth decay occurs when acid is producedby bacteria found in the plaque on the surfaceof the teeth. This results in the loss of some ofthe tooth calcium and phosphate minerals. Thisdemineralisation happens every time sugary foodsand drinks are consumed. Once the plaque acidhas been neutralised some of the minerals can bedeposited back into the teeth – a process known asremineralisation. Fluoride tips the balance in favourof this ‘repair’. Increasing the availability of fluoridecan therefore help prevent tooth decay.

42 Since the 1970s, fluoride has been added tomost toothpastes and this is the main reason forthe improvement in oral health seen in the UKand Europe. Effective, twice-daily toothbrushinghas the additional benefit of improving periodontalhealth. In areas with high levels of disease, water



fluoridation is an effective and safe public healthmeasure to reduce decay and more beneficial thanthe use of just fluoride toothpaste alone.

TOBACCO AND ALCOHOL USE43 Tobacco use, especially smoking, increasesthe prevalence and severity of periodontal disease.It is by far the greatest risk factor for oral cancer.Smoking 20 or more cigarettes a day increases therisk to six times that of non-smokers. Although lessharmful than smoking, the chewing of tobaccoproducts, common in some Asian communities,is also associated with an increased risk of oralcancer. So too is chewing betel. Tobacco use is alsolinked to a range of other oral health problems andreduces the success rates of dental treatments suchas implant surgery.

44 Excessive alcohol consumption, particularlyspirits, is a further risk factor for oral cancer,especially when combined with smoking and a poordiet. Heavy drinkers and smokers are 30 times morelikely to develop oral cancer than non-smokers andnon-drinkers (Blot et al (1998)).

INJURY 45 Broken (traumatised) teeth are a commonproblem amongst certain groups such as adolescentboys. Broken teeth can adversely affect people’sappearance and self-confidence, and are expensiveand difficult to treat. Dental injuries may occur for avariety of reasons including playing contact sports,violence and falls. Binge drinking, violence and non-accidental injury are also causes of facial injury andbroken teeth.

OTHER MEDICAL CONDITIONS46 A range of medical conditions may adverselyaffect oral health. For example people with eatingdisorders, particularly bulimia may have problemswith excessive tooth wear due to the acidic pH ofthe mouth. Also, people with chronic diseases onmultiple long-term medications may have problemswith dry mouth.

CAUSES OF POOR ORAL HEALTH 21

Case study 1: Incentivising smoking cessation pays off in Sheffield

A pilot to encourage dental teams’ involvement in smoking cessation in Sheffield was establishedin August 2002. Dental practices received a one-off payment for every client referred to the StopSmoking Service who set a quit date. There was no requirement for dental team members to deliversmoking cessation advice themselves beyond identifying those who were ready to quit.

A formal evaluation of the pilot revealed that clients referred by dental teams were less likely toset quit dates than those referred by other healthcare workers. Also, although there was an initialincrease in referral rate from dental teams, after one year it had returned to that existing prior topilot commencement.

As a consequence, through continuing collaborative work with the Stop Smoking Service, dental teamshave now been offered smoking cessation training and given the opportunity to become accreditedstop smoking practices – and eligible to receive the same payments as accredited medical practices.Currently there are 15 practices looking to work towards accreditation status. Successful practices willbe able to offer smoking cessation counselling services on a one-to-one or group basis and will be anintegral part of the citywide Stop Smoking Service.


COMMUNITY SUPPORT47 In the past, traditional preventive interventions,rather than decreasing inequalities, may have hadthe reverse effect of widening the health gapbetween the rich and poor. Improving oral healthis a shared responsibility between government,education, health professions, the public and thewider society. Community involvement is essentialfor achieving sustainable oral health improvements.This is a time consuming process. Healthprofessionals have an important role to play inenabling and encouraging community action.

INTEGRATED WORKING – COMMON RISKAPPROACH48 A major criticism of preventive and educationalprogrammes has been the narrow and isolatedapproach adopted. This uncoordinated approachcan at best lead to a duplication of effort, butoften in fact results in conflicting and contradictorymessages being delivered to the public. Thecommon risk approach recognises that chronicnon-communicable diseases and conditions suchas obesity, heart disease, stroke, cancers, diabetes,and oral diseases share a set of common risk

IMPROVING ORAL HEALTH – PRICIPLES OF GOOD PRACTICE 23

IMPROVING ORAL HEALTH –PRINCIPLES OF GOOD PRACTICE

Figure 9 Common risk factor approach

Sheiham & Watt, 2000

Diet

Stress

Control

Hygiene

Smoking

Alcohol

Exercise

Injuries

Obesity

Cancers

Heart disease

Respiratory disease

Dental caries

Periodontaldiseases

Trauma


conditions and factors (Figure 9). For example apoor quality diet, smoking, inadequate hygiene,excessive alcohol intake and trauma are factorslinked to the development of several chronicconditions including oral diseases.

49 The key concept of the integrated commonrisk approach is that by directing action onthese common risks and their underlying socialdeterminants, improvements in a range of chronicconditions will be achieved more efficiently andwith greater effectiveness. The common riskapproach provides a rationale for partnershipworking. A wide range of government healthinitiatives exists, which provide an idealopportunity to integrate oral and generalhealth actions (Appendix I).

EVIDENCE BASED PRACTICE50 In recent years, in line with the evidence basedmovement in clinical medicine and dentistry, theeffectiveness of preventive interventions has beenscrutinised to determine what interventions are

effective, and identify those that produce minimalbenefit or even cause harm. A collection ofeffectiveness reviews of the oral health literaturehas been published in recent years. These provideuseful indications for developing effective practice.(Kay and Locker 1996, Sprod et al 1996) Asummary of the evidence base for oral healthinterventions is outlined in Appendix II.

THE TARGETED POPULATION APPROACH51 There are two complementary approachesto improving oral health

n the population approach, in which the aim isto lower the average level of risk factor in thepopulation; and

n the high-risk approach, in which people atparticularly high risk are identified throughscreening, and offered appropriate adviceand treatment

Both are important, but initiatives designed toreduce inequalities in health can be structured in



another way, the targeted population approach.This involves identifying communities at greater riskof disease and using population strategies withinthese targeted groups. Such an approach is used ina range of health and social policy initiatives such asthe neighbourhood renewal strategy.

COMPLEMENTARY ACTIONS52 Public health research has shown thatimplementing educational interventions alone doesnot produce sustained improvements in healthand has a limited effect on reducing the healthgap. The WHO and other internationalorganisations recommend the need forimplementing a complementary range of actions topromote health. Based upon the Ottawa Charter(WHO, 1986), these include

n promoting oral health through public policy: byfocusing attention on the impact on health ofpublic policies from all sectors, and not just thehealth sector

n creating supportive environments: by assessingthe impact of the environment and clarifyingopportunities to make changes conducive tooral health

n developing personal skills: by moving beyondthe transmission of information, to promoteunderstanding, and to support the developmentof personal, social and political skills that enableindividuals to take action to promote theiroral health

n strengthening community action: by supportingconcrete and effective community action indefining priorities, making decisions, planningstrategies and implementing them to achievebetter oral health

n reorienting oral health services: by refocusingattention away from the responsibility to providecurative and clinical services, towards the goalof achieving improvements in oral health

PARTNERSHIPS53 A core theme of government public healthpolicy is to promote partnership working acrossthe NHS and beyond. The adoption of anintegrated common risk approach forms the basisof joint working. Oral health professionals need tocollaborate with the relevant agencies and sectorsto place oral health upon a wider agenda forchange. In sections that follow, details are providedof possible partners and their roles in promotingoral health.

EVALUATION54 Evaluation is a very important area of practice.Sufficient resources and appropriate methodsshould be directed to the evaluation andmonitoring of oral health strategies. Both processand outcome evaluation measures should be used.Better training and more support are needed todevelop the capacity of oral health professionalsto evaluate their activities fully.

IMPROVING ORAL HEALTH – PRICIPLES OF GOOD PRACTICE 25


55 As previously stated, this plan outlines the keysteps that can be taken to improve oral health andsupports Delivering Choosing Health: MakingHealthier Choices Easier.

A SYSTEM FOR DELIVERY

At the same time, local authorities and PCTsshare a responsibility to improve oral health by:

n Leading partnerships to improve oral health;n Identifying local oral health needs and targets

to reduce inequalities; andn Commissioning and delivering preventive

dental services.

Progress against its objectives can be measuredthrough:

n Improvements in the oral health of thepopulation; and

n Increased delivery of high quality preventivedental services.

IMPROVING ORAL HEALTH – MAKING IT HAPPEN 27

IMPROVING ORAL HEALTH – MAKING IT HAPPEN

Case study 2: LPSA drives child oral health initiative in Blackburn

Blackburn with Darwin Borough Council and the Primary Care Trust are starting a borough wide secondgeneration Local Public Service Agreement (LPSA) aimed at improving oral health in children, which willbe available to all 2-3 year olds. State and private nurseries, playgroups, Sure Start centres and primaryschools will be used for targeting and accessing children whose parents will be engaged by a mail shotand encouraged to take part. An experienced oral health promotion project worker will track thiscohort of children throughout their nursery years and on to reception.

A dental health culture will be encouraged through regular education sessions and by distributingtoothpaste and toothbrush packs every four months. Furthermore, a dentist and dental nurse will bemade available for those children who are not already registered with a dentist. The project worker willhelp to identify those children who need access to dental treatment, whilst posters and leaflets will helpto advertise the service to parents. A preventive dental health routine and culture will be instilled at thisyoung age, and improve the dental health of all children who feed into the borough’s primary schools.A common risk approach will be adopted. When the children enter primary school, the project workerwill focus specifically on those in the 25 schools with the worst dental health (56% of 5 year olds).These children will benefit from intensive educational sessions and further toothpaste and toothbrushpacks. In addition, they will continue to have access to the dentist. The project aims to reduce themean dmft of 5 year olds by 40%.


56 Partnership working and a common riskapproach provide a range of opportunities for thepromotion of oral health. This is the responsibilityof regional public health groups, strategic healthauthorities and primary care trusts. It involvesdental leads (public health, clinical and primarycare) and oral health promotion teams withinprimary care trusts. Through references to oralhealth and dentistry in their local delivery plans,PCTs can drive this agenda forward with theprimary care dental and medical care teams workingtogether and with other partner organisations.

57 Improvements in oral health will not beachieved by doing ‘more of the same’. Progress willonly come through change in the way the publicare ‘engaged’ in improving and maintaining theirown oral health. New contractual arrangements forNHS dentistry will also give dentists and the widerteam a new focus to advise on general publichealth issues and lifestyle.

IMPLEMENTATION58 The good practices which PCTs could adopt toimplement this action plan include:

n coverage of oral health and dentistry in localdelivery plans;

n planned local information surveys to identifylocal oral health inequalities and priorities;

n oral health information linked and integral topublic health information; and

n any planned oral health and well-beingequity audits.

59 PCTs may wish to consider setting local targetsthat focus on disadvantaged communities wherethe prevalence of disease is above the nationalaverage. PCTs will also need to consider how theycan commit resources (staff, time and funding) toimprove the oral health of their population.


Case study 3: ‘Start Smiling’ – Oral Health Promotion within Sure Start

In 2001, Shropshire Oral Health Promotion started working with the Sure Start schemes in Telford andOswestry to help improve the oral health of children living in the Sure Start areas. A project team withmembers from oral health promotion, health visitors and Sure Start staff was formed and the ‘StartSmiling’ project was born.

To encourage the use of fluoride toothpaste and help children to develop effective oral hygienepractices, Sure Start funding was used to purchase toothbrush and fluoride toothpaste packs andparents received packs for their children on a regular basis. To encourage the early transition to a cup,parents were also given a first drinking cup for their child. An information pack and recipe cards forparents were produced to encourage good weaning practices and healthy eating for young children.Cooking, shopping and budget management sessions were held for parents and grandparents. To helpchildren reduce their sugar consumption and increase their intake of fruit and vegetables the Sure Startsetting adopted a healthy eating policy devised by the project team.

After small beginnings with funding from both Primary Care Trusts the ‘Start Smiling’ projectbroadened to encompass the whole of Telford & Wrekin and Shropshire County. Sure Start schemes inboth areas provided funding for dental services to help improve access for Sure Start children. Oralhealth promoters, health visitors and Sure Start workers throughout the county work in partnership toincrease awareness of the value of good oral health both to children and the community and helpchange the focus from treatment of disease to the prevention of oral health problems.

The 2004 survey showed a marked improvement in the oral health of 5 year olds in Shropshire Countyand Telford & Wrekin proving that partnership working is not only enjoyable but can result in asignificant oral health gain for children!


KEY ROLES AND RESPONSIBILITIESPrimary Care Trusts

60 PCTs are responsible for the effectiveimplementation of the new contractualarrangements for dentistry. To achieve this andmeet the oral health needs of their populationPCTs should consider

n ensuring that improving oral health is an integralpart of their Local Delivery Plans (LDPs);

n liaising with other organisations, especially localauthorities, to ensure that improving oral healthis included in joint planning objectives;

n ensuring that the dental services that theycommission have an evidence based preventivefocus;

n ensuring that they are able to obtain appropriatehealth needs information and advice indeveloping local programmes forimplementation;

n whether water fluoridation might be appropriatefor improving oral health locally.

Strategic Health Authorities (SHAs)

61 SHAs will have responsibility for monitoringand managing the progress of PCTs’implementation of the new commissioningarrangements, including the promotion of goodoral health. SHAs also have primary responsibilityfor fluoridation schemes. When requested to do soby PCTs, they may undertake a public consultationon water fluoridation. If there is local support, theSHA can make arrangements with the local watercompany to fluoridate its water. CDO’s letter ofSeptember 2005 (Gateway ref: 5136) providesguidance on implementation of the changes tothe legislative framework governing fluoridation.

Regional Public Health Groups (RPHGs)

62 Reducing inequalities in health, including oralhealth, is now a key policy objective for the ninegovernment offices for the regions in England. Itfollows that Regional Directors of Public Health will



wish to ensure that this oral health action planinforms their general health policy and that oralhealth initiatives link with government schemestargeted at deprived areas, such as Sure Start.Regional Public Health Groups will therefore needto promote oral health

Local Authorities and the Voluntary Sector

63 Local authority and the voluntary sector’spolicies and guidance need to include an oralhealth component.

64 In the education sector for example, pupils, headteachers, school nurses, teachers, other staff andschool governors can all contribute to promotingoral health. For example, schools can provide:

n healthy snack foods and drinks in tuck shopsand vending machines;

n safe recreation areas to reduce the risk of dentaltrauma; and

n staff training on oral health, particularlyprocedures to follow with dental trauma cases.

65 There is a wide range of voluntary groups thatcan be involved and with whom links should bedeveloped to ensure protocols to protect andimprove oral health are in place in residentialhomes and other institutions. The protocols shouldinclude training for carers of children, people withdisabilities and older people, in the care of mouths,teeth and gums.

Public Health Team

66 The public health team can support strategiesto address inequalities, and ensure that oral healthis included in local health-related initiatives,programmes and reports.

Oral Health Professionals

67 Under the new contractual arrangements beingimplemented for NHS dentistry, the dental teamwill have the opportunity to give a strengthenedfocus on the prevention of disease, lifestyle andoptions for care. General Dental Practitioners, theSalaried Primary Care Dental Service, dental careprofessionals (DCPs), Consultants in Dental PublicHealth and other dental specialists have a key roleto play in improving oral health, whether working


Case study 4: Motivating success with the Adopt-a-school campaign

The Dental Public Health Department at Ipswich PCT in partnership with the local Community DentalService developed a proposal for a scheme to reduce the high referral rate of children with dentaldecay for dental treatment. The “Adopt a School” scheme has been initiated mainly by the DentalHealth Education Team of the CDS, which as its name suggests ‘adopts’ a whole school for one termand year 6 of the school for the entire year.

The process involves 3 stages:

1. Brush In: Each child is provided with a toothbrush to be kept at school and also a toothbrush to betaken home. There will be supervised tooth brushing session every week for a whole term for thewhole school.

2. Sweets out: Each child is given a diet record sheet, which is checked every week for the whole yearby a dental health educator – lessons are also given on ‘hidden sugars’ and alternative snacks.

3. Fluoride: Year 6 is given weekly-supervised fluoride mouth rinses for the duration of a year.

The children’s dental health cleanliness status is recorded at the commencement of the programme andrecorded again at the completion of the programme. ‘Motivators’ by way of stickers and certificates areissued throughout the programme and a prize is on offer for the best achievement of a child in eachyear group at the end of the programme.


in primary or secondary care settings. This mayinclude acting as advisers and advocates toinfluence decision-makers, PCTs, healthcarecolleagues, community leaders and others,and generally giving out consistent oralhealth messages.

68 Individually, dentists can ensure that their teamhas the skills and up to date knowledge to promoteoral health effectively to patients, including at-riskgroups, and recognise problems that need referralto the wider primary healthcare team.

Freeing up capacity

69 This plan has been prepared in anticipation ofthe delegation of the commissioning of primarycare dental services to PCTs from April 2006.The present item of service remuneration system,which offers dentists little incentive to undertakeoral health promotion, will be replaced by localcontractual arrangements. In negotiating localcontracts, PCTs will be required to take accountof recent guidance from the National Instituteof Clinical Excellence (NICE) on the intervals atwhich patients should be recalled for routine dentalexaminations. NICE has advised that the intervalbetween oral health reviews should be determinedon the basis of an assessment of disease levels anddisease risk in individual patients. Having regard tothe improvement in oral health, NICE has indicatedthat the shortest interval for oral health reviews forall patients should be 3 months although this is notnormally needed for a routine dental recall. Thelongest interval for patients younger than 18 yearsshould be 12 months and the longest interval foradults should be 24 months for people who arenot at risk of oral disease. (NICE, 2004)

70 Observance of the NICE guidelines, supportedby the changed balance of incentives within thenew contractual framework, should free upcapacity that can be used to support a morepreventive approach and to improve access to NHSdentistry. The new arrangements are also designedto improve the quality of dentists’ working livesby removing the ‘treadmill’ effect, for which the

current item of service remuneration system hasoften been criticised, and by allowing more timefor prevention and health promotion.

The local health community

71 Other health professionals can help promotegood oral health, and should also be able torecognise when it is appropriate to refer patientsto a dentist.

72 GPs, pharmacists and district, community andspecialist nurses can include oral health within theirpromotion of health and well-being. Specifically,they can:

n integrate oral health within health promotionprogrammes and projects whenever possible;

n ensure oral health messages and interventionsare consistent and effective;

n ensure medicines are sugar-free whereverpossible, particularly for people on long-termmedication

n be alert to the signs of oral disease in vulnerablepeople.

73 There is a need to equip better the widerhealthcare workforce to deliver improved oralhealth:

n health visitors and midwives have a key role inadvising parents on oral health particularly onreducing sugar in their child’s diet. They canencourage good oral hygiene practice bydemonstrating the use of a toothbrush andfluoride toothpaste in infants so that parentscommence brushing as soon as the first teetherupt. They can also encourage night timesupervised brushing with fluoride toothpastein young children as part of developing abedtime routine;

n health promotion staff and other membersof public health teams can help develop oralhealth promotion policies and provide adviceand training in health promotion skills to dentalteams;



n pharmacists and their staff are in a position bothto offer advice on customers’ specific problems,which may need referral to a dentist, forexample, a persistent mouth ulcer, and topromote the use of sugar-free medicines,toothbrushes and fluoride toothpastes.

Individuals

74 To have the best chance of good oral health,individuals are recommended to adopt thefollowing behaviours:

n reduce the consumption and especially thefrequency of sugary foods and drinks withinthe context of a healthy diet;

n clean teeth effectively twice a day with afluoride toothpaste;

n do not smoke or chew tobacco;

n follow safe limits on alcohol consumption; and

n have a dental check-up at appropriate intervals,as agreed with their dentist, in line withguidelines published by NICE.



75 This section documents a range of goodpractices which can improve oral health. Details arepresented for each of the underlying risk factorsfor oral disease. The target populations and keypartners are listed for each action point. In additionactions on professional training and support, andresearch and development are outlined.

76 Improving diet and reducing sugars intake

n Promoting breastfeeding and recommendedweaning practices;

n Reducing both the frequency and amountof added sugars consumed in line withDepartment of Health target (11% of energyfrom added sugars);

n Increasing the consumption of fruit andvegetables to at least 5 portions per day;

n Reducing consumption of acidic soft drinks; and

n Promoting use of sugar free medicines.

GOOD PRACTICE 33

GOOD PRACTICE

Topic Good Practice Target Group Participants

Infant feeding

Preschools and nurseriesSchools and collegesHospitalsPrisonsLocal authoritiesPCTsPublic Health PractitionersDentists and DCPs

Pre-schoolchildrenSchoolchildrenStudentsPatientsPrisonersOlder peoplein care andnursinghomes

Promote the development andadoption of nutrition and healthyeating guidelines which include actionon sugars in organisations where foodand/or drinks are prepared and/orsold.

Policyguidelines

Midwives, health visitorsand GPsSure Start Community groupsPCTsChildren’s CentresPublic Health PractitionersDentists and DCPs

Nursingmothers andbabies

Promote breastfeeding in line with DHrecommendations.Ensure weaning advice conforms toCOMA/SACN recommendations.Ensure oral health input into localinfant feeding strategies andguidelines.



Topic Good Practice Target Group Partners

Midwives, health visitorsand GPsPCTsChildren’s CentresTeachersPublic health practitionersDentists and DCPs

Wholepopulation

Children andadults at highrisk

Improve the consistency of all dietarymessages, and in particular stress theimportance of reducing the frequencyof sugary drinks and foods.Ensure effective dietary education forthose at risk of dental caries anderosion.Restriction of promotion of food anddrink high in sugar particularly tochildren.

Publicinformationand support

Food Industry and Parents

Food Industry

Caterers

Schools, Leisure facilitiesetc.

Infants andyoungchildrenWholepopulation

WholepopulationWholepopulation

Discourage addition of sugars toweaning foods, drinks and vitaminsupplements.Encourage reduction in sugars contentof soft drinks, breakfast cereals,confectionery and other sugary foodsand drinks.Encourage caterers to reduce sugarscontent of prepared foods.Encourage vending machine providersto include sugar free choices.

Sugar content

GPs and hospital doctorsPharmacistsPharmaceutical IndustryDentists and DCPs

Wholepopulation,especiallychildren andchronically illon long termmedication

Increase proportion of sugar freemedicines prescribed and sold.

Sugar basedmedicines

IndustryGovernment

Wholepopulation

Improve labelling information on foodsand drinks to specify percent sugarsand pH levels of drinks.

Labelling


77 Improving oral hygiene

n encouraging the early adoption of oral hygienepractices in young children;

n promoting effective oral hygiene self carepractices across the population; and

n supporting parents, health professionals andcarers of people who need help in maintainingtheir oral hygiene.

GOOD PRACTICE 35


Nurses, midwives andhealth visitorsCarersDentists and DCPs

Wholepopulation

Improve the effectiveness of oralhygiene instruction provided by oraland other health professionals.

Training andsupport

TeachersDentists and DCPs

Local authorities

Schoolchildren

People inresidential care

Incorporate oral hygiene teachingwithin general body cleanliness inPersonal and Social Educationteaching.Ensure individuals in residentialand care settings have access totoothbrushing facilities and adviceon oral hygiene.

Body and oralhygiene

Health visitors and GPsSure StartCommunity groupsChildren’s CentresDentists and DCPs

Parents andinfants

Encourage parents and carers tostart toothbrushing with fluoridetoothpaste within the first year ofchild’s life.

Earlytoothbrushing


78 Optimising exposure to fluorides

n Promoting water fluoridation in areas with poororal health and where local communities supportthis action; and

n Encouraging the use of fluoride toothpastesacross the population, especially young childrenin disadvantaged areas.



PCTsEducation Local authoritiesDentists and DCPs

High riskpopulations

Development of other options todeliver fluorides where required e.g.varnishes with special needs groups,fluoride milk in schools etc.

Other fluorides

Health visitors and GPsSure StartCommunity groupsPCTsChildren’s CentresPublic health practitionersDentists and DCPs Toothpaste manufacturers

Wholepopulation,especiallyyoungchildren indisadvantagedareas

Increase the use of fluoride toothpaste,especially by young children indisadvantaged communities.Ensure recommendations onappropriate use of toothpastes aregiven by health professionals andother care staff.Assess the feasibility of distributingfluoride toothpastes and brushes toyoung children in disadvantagedcommunities.

Fluoridetoothpastes

PCTsSHAsWater IndustryDentists and DCPsPublic health

Wholepopulation

In line with government legislation, inareas with high caries levels PCTsshould explore the need and feasibilityof water fluoridation. When requested by PCTs, SHAs shouldundertake a public consultation toassess local support.

Waterfluoridation


79 Tobacco control and promoting sensiblealcohol use

n Supporting smokers to stop;

n Referring motivated smokers who wish helpin stopping to NHS Stop Smoking Services;

n Improving early detection of early stagemalignant lesions and referral to specialistcare; and

n Encouraging sensible patterns of alcoholconsumption.

GOOD PRACTICE 37


Dentists and DCPsGPsPharmacistsPCTs

Wholepopulation

Smokers,heavy drinksand olderpeopleWholepopulation

Train and support dentists to examineroutinely the oral mucosa of allpatients.Encourage and train GPs to undertakeexamination of the oral mucosa oftobacco users, heavy drinks and olderpeople.Encourage and train pharmacists torecognise oral health problems thatneed referral to dentists or specialistcare.

Early detection

Dentists and DCPs Public health practitionersPCTs and SHAsProfessional Associationse.g. BDAIndustry/Employers

Wholepopulation

Support broader tobacco controlagenda.

Tobaccocontrol

Dentists and DCPs Public health practitionersCommunity groups

Users ofsmokelesstobacco

Encourage dental teams to provideadvice and support to individuals tostop the use of smokeless tobacco.Support community wide initiatives ontobacco use.

Smokelesstobacco

Dentists and DCPsNHS Stop SmokingServicesPCTsPublic health practitioners

SmokersEncourage dental teams routinely toenquire about their patients’ use oftobacco and to give advice andsupport on stopping.When appropriate refer smokers tolocal NHS Stop Smoking Services.

Smokingcessation


80 Reducing dento-facial injuries

n Creating a safer environment for play, recreationand travel;

n Reducing trauma caused by violence and bingedrinking; and

n Implementing guidelines on first aid for dentalinjuries.



Dentists and DCPs SchoolsSports and leisureorganisationsLocal authoritiesPublic healthPCTs

Children andyoung people

Ensure schools, colleges and othersettings are aware and adoptguidelines on first aid for dentalinjuries.

First aidguidelines

Dentists and DCPs Local authoritiesPoliceDrinks IndustryPublic healthPCTs

Young peopleand heavydrinkersChildren

Support policies on reducing bingedrinking amongst young people.Train and support dental teams in therecognition of children at risk of non-accidental injuries.

Reducingviolent trauma

Dentists and DCPsSchoolsSports and leisureorganisationsLocal authoritiesPublic health practitionersPCTs

Children andyoung people

Promote improvements in the qualityof the environment e.g. safer playareas, leisure facilities, schools andcolleges.Advocate guidelines on the use ofprotective head wear and gum shieldsduring contact sports.Encourage availability of affordablegum shields.

Safeenvironment


81 Professional training and support

n Developing the health promoting knowledgeand skills of the dental team;

n Incorporating oral health input into the trainingof other health professionals;

n Providing support if implementing andevaluating the oral health component ofthe LDPs; and

n Developing oral health links with other areas ofhealth improvement.

GOOD PRACTICE 39


Dentists and DCPs PCTs

Public healthReview common risks for oral andgeneral health and develop sharedagenda for action.

Links

PCTsUniversities and collegesNICE

Dentists andDCPs

Improve provision of health promotionresources and materials.Provide evidence-based guidelines forfuture interventions.

On-goingsupport

Dentists and DCPsUniversities and collegesTrainers

Midwives andhealth visitorsGPs andpractice nursesPharmacistsSure Start staffTeachersCarers

Expand and develop oral health inputinto professional training of relevanthealth workers.

Training

Dentists and DCPsUniversities and collegesTrainersNHS WorkforceConfederationGDC

DentalstudentsDentistsDCPs

Provide high quality training todevelop dental teams’ healthpromoting knowledge and skills.Expand health promotion input intoBDS and other training programmes.Develop role of DCPs in deliveringhigh quality health promotion.

Capacitybuilding


82 Research and development

n Assessing the effectiveness and costeffectiveness of oral health interventions,particularly in relation to reducing inequalities;

n Determining the impact on oral health of otherareas of health improvement; and

n Developing evaluation and monitoring systems.



Universities and collegesNICEPostgraduate deansPrimary care researchnetworks

Dentists andDCPs

Improve the quality of the evaluationand monitoring of oral healthinterventions.

Evaluation andmonitoring

Universities and collegesNICE

Dentists andDCPs

Improve the evidence base for oralhealth interventions, especially inrelation to inequalities.Assess the cost effectiveness ofdifferent interventions.Encourage involvement of the dentalteam in the research agenda.

Effectivenessof oral healthinterventions


REQUIREMENTS83 A diverse and skilled workforce is needed toimplement this plan. PCTs will firstly wish toconsider the advice that they receive on meetingthe oral health needs of their residents. Consultantsin Dental Public Health are trained specifically toassess oral health needs and provide advice onhow these needs should be met. They are able toprovide advice either individually or by headingup an advisory network covering a number oforganisations. Oral health promotion is currentlyprovided by a wide range of health professionalsincluding dentists, other members of the dentalteam, oral health promoters, health visitors, schoolnurses, midwives and district nurses in a widevariety of settings. These can range from individualadvice in a dental practice to child health clinics,children’s centres, schools and other communitydevelopment locations. The focus may be directlyon oral health or as a contribution to otherprogrammes like Sure Start or smoking cessation.However, there is a lack of information on the sizeof the wider oral health promotion workforce, therange of activities that are being undertaken andthe extent to which they match need.

84 The Primary Care Dental Workforce Review(DH, 2004) estimated the future demands for,supply of, and training needs for the dentalworkforce. The review predicted an undersupply

in clinical time in the range of 16% to 21% by2011. However, the impacts of the new contractualarrangements for the provision of primary careNHS dentistry and the push towards a servicethat is focused on prevention have yet to betaken fully into consideration. The review maderecommendations for the development of thedental workforce concentrating mainly on dentalattendance and dental treatment provided bydentists, dental therapists and dental hygienists.The review did not include information on numbersof oral health promoters and their training needs.Consideration will be given to including this staffgroup in any updating of the review.

85 “Shaping the Future of Public Health:Promoting Health in the NHS” published in July2005 is for and about all those who recognisethemselves as the specialised health promotionworkforce in the NHS in Primary Care and definesroles, functions and development needs and makesrecommendations to improve the fitness forpurpose of this workforce.

ORAL HEALTH PROMOTERS 86 Although dental teams will be more involvedin health promotion, oral health promoters willcontinue to have a key role. They come from awide range of backgrounds including that of adental care professional or generic health promoter.

WORKFORCE 41

WORKFORCE


They are usually based within the salaried primarycare dental services, but are becoming increasinglyinvolved in the work of general health promotiondepartments. This is to be welcomed in the light ofthe plan’s advocacy of joint working in line withthe common risk approach. But the specialist skillsof oral health promoters should be maintained andPCTs need to review career pathways to encouragerecruitment and retention.

TRAINING AND DEVELOPMENT87 Current oral health promotion training isprovided as a diploma, a Certificate in Oral HealthEducation, open to and available at a numberof colleges.

88 It is recommended that SHAs/NHS WorkforceDevelopment Confederations should work withPostgraduate Dental Deans to:

n train members of the dental team in healthpromotion interventions such as level I and levelII smoking cessation interventions incollaboration with smoking cessation co-ordinators, as suggested in NHS Dentistry:Options for Change (DH, 2004);

n provide continuing professional development fororal health promoters, and consideration shouldbe given to the inclusion of an oral healthpromotion element in both basic and masters’degrees in health promotion;.

n ensure oral health promoters have the necessaryskills to train other members of the dental teamand the wider public health workforce andinform managers and policy makers of therelevance of these skills to improving oralhealth; and

n provide training in health promotion evaluationmethods. In this context academic establishmentswill be able to contribute to the updating of theevidence base for oral health promotion and itswider dissemination.

89 The Department of Health will work with theGeneral Dental Council and Deans of DentalSchools to ensure that dental public health andpreventive dentistry underpins dental educationand the underlying principles are coveredsatisfactorily in undergraduate and other pre-qualification training courses.



APPENDIX I: ORAL HEALTH AND CROSS-CUTTING PUBLIC HEALTH INITIATIVES 43

APPENDIX I: ORAL HEALTH AND CROSS-CUTTINGPUBLIC HEALTH INITIATIVES

Aims

n Our fundamental aim must be to create a society where more people (especially disadvantaged)are encouraged and enabled to make healthier choices. Choosing Health

n Important that people can act on messages about health – communicate consistent messageswith partnership working and ensure that people can follow them up easily. Choosing Health

Targets

n Reduce the average intake of added sugar to 11% of food energy (currently 12.7%) Food andHealth Action Plan

n Reduce adult smoking rates (from 26% in 2002) to 21% or less by 2010, with a reductionin prevalence among routine manual groups (from 31% in 2002) to 21% or less.Delivering Choosing Health

Delivery

n Defra to facilitate industry action to reduce sugar, fat and salt levels through jointly sponsoredscientific scoping studies and research by March 2006. Food and Health Action Plan

n PCT Directors of Public Health are already expected to produce annual public health reports. Localpartners should respond formally and set out actions they intend to take and progress against theprevious years’ recommendations. Choosing Health

n Standard set health information that can be linked to other local data sets for publication.Public health observatory reports for local communities at local authority level that will supportDirectors of Public Health. Choosing Health

n Local services can/will be delivered by:– Primary care and hospital trusts and other NHS organisations– Children’s services, including schools– Other local authority services, such as housing, social care, leisure and recreation– The voluntary sector and community based organisations– Private businesses

Delivering Choosing Health


SUPPORTING INFORMATIONA. Main source of non-milk extrinsic sugars isfrom beverages, including soft drinks and alcoholicdrinks, with a majority from carbonated drinks.Food and Health Action Plan

B. 34% of consumers in the IGD’s ConsumerWatch report of June 2003 identified clearer foodlabelling as the main way the food industry couldhelp them make healthier food choices. Food andHealth Action Plan

C. A quarter of children under 16 drink alcohol –on average around 10 units per week. DeliveringChoosing Health

D. 22% of 15 year-olds smoke regularly.Delivering Choosing Health

E. Strongest predictors of dietary change are:

n knowledge of the recommendation to eat five ormore servings of a variety of fruitand vegetables per day

n taste preferences

n self-efficacy (in particular confidence in foodpreparation). Food and Health Action Plan

F. DEFRA to facilitate industry action to reducesugar, fat and salt levels through jointly sponsoredscientific scoping studies and research by March2006. Food and Health Action Plan

H. More accessible and responsive ‘stop smoking’services, wider availability of nicotine replacementtherapy Delivering Choosing Health



Oral health interventions should be evidence-based. Common findings from effectivenessreviews of oral health promotion initiatives areoutlined here and may be helpful in planning localinterventions.

ORAL HEALTH EDUCATIONImproving individuals’ knowledge of oral healthcan be achieved through oral health education butthe clinical, behavioural and health significance ofthis is unknown.

Oral hygiene education on an individual level iseffective for reducing plaque levels. However theseproduce only short-term changes. Recent evidenceshows that school-based tooth brushing campaignscan be effective if toothbrushes and fluoridatedtoothpaste are supplied over a period of time andhome and long-term school support is provided.

Oral health messages should be simple, appropriateand build on existing beliefs. Simple teachingmethods and materials can be used effectively forcomplex scientific messages.

Preventive and clinical approaches to oral healthpromotion can be effective in preventing toothdecay. However those in greatest need are leastable to benefit from this.

Mass media campaigns are ineffective atpromoting either knowledge or behaviour change.

They may have some value in raising awarenessand agenda setting.

JOINT WORKINGInformation alone does not produce long-termbehaviour changes. Focusing action on commonrisk/health factors provides an opportunity for jointworking with other health professionals andagencies. Such an approach reduces duplication ofeffort.

Personnel from non-health sectors, such as schoolsand workplaces, have effectively conducted severaloral health promotion activities focusing onimproving oral health knowledge. There is evidenceof spread of effect to other family members fromthese settings.

SUGAR CONSUMPTIONVery few studies have assessed the effect of oralhealth promotion on sugar consumption. Thosestudies that have attempted to alter sugarconsumption have used self-reported outcomemeasures that have limited validity. More recentevidence shows that policies which reduce sugarconsumption may be a useful way of preventingtooth decay.

APPENDIX II: WHAT WORKS? THE EVIDENCE 45

APPENDIX II: WHAT WORKS? THE EVIDENCE


FLUORIDATIONWater fluoridation is effective at preventing dentalcaries particularly in areas of poor oral health.Epidemiological studies and independent reviews ofthe relevant literature have consistently failed tofind evidence that fluoride in water, at or aroundone part per million, has any effect on the healthof the body other than reducing tooth decay.Fluoride toothpaste is another effective method ofdelivering fluoride. The use of fluoride supplementsin schools has been shown to be effective in cariesprevention but regular use is unlikely to besustained at home by those most in need.

TRAUMARegulating and encouraging the use of properlyfitted mouth-guards by players in high contactteam and field sports can reduce oral trauma.

CANCER SCREENINGLimited evidence exists on the effectiveness ofscreening for the early detection of oral cancersand cannot be recommended for a wholepopulation strategy.

OLDER PEOPLEMost interventions have focused upon schoolchildren. Older people can however benefit fromoral health promotion provided the appropriatesupport is given. For example, programmesproviding oral health education and oral hygieneskills training for the carers of older people.

BEHAVIOURAL CHANGEProgrammes using more innovative approachesthan the medical/behavioural model have morepotential for achieving longer-term behaviourchanges. Additionally, tailored approaches basedupon active participation and addressing social,cultural and personal norms offer longer-termchanges in behaviour compared with simple one-off interventions.

Environmental factors influence the ability tochange behaviours. Interventions need to focusupon creating supportive environments for oral

health. For example, programmes that seek to alterthe availability, cost and appeal of food and drinkchoices in schools are altering the socialenvironment to facilitate healthier actions e.g. byincreasing the consumption of water in schoolsthroughout the day.

COST It is difficult to quantify the cost effectiveness oforal health promotion programmes and littleevidence has been published to date. Traditionaloral health education using health professionals isrelatively costly and this therefore highlights theneed to consider and plan activity carefully in orderto maximise long term impact.

DEVELOPING INTERVENTIONS TO IMPROVEORAL HEALTHThese are some of the main recommendationsfrom oral health promotion effectiveness reviews.

n Researchers and practitioners need to improvethe quality of the design of interventions.

n There is also a need to improve the quality ofthe evaluation used. Both quantitative andqualitative approaches are needed.

n A set of standardised and validated outcomemeasures is required to evaluate interventions.

n There should be wider use of appropriate,theoretical models that adopt a more progressiveapproach.

n Practitioners should adopt a combination ofstrategies in addition to educational approaches– using other public health strategies beyond thedevelopment of personal skills and the re-orientation of health services.

n It is essential to conduct full and detailed needsassessments. Developing appropriateinterventions based on the needs of the targetpopulation is more likely to produce an effectiveoutcome.



n Decision-makers should be targeted morethrough advocacy and lobbying for policychanges.

n Ways of integrating oral health into generalhealth promotion need to be explored.

n Community development approaches focusingon oral health issues need to be implementedand fully evaluated.

Based upon these findings, the followingrecommendations can be made for thedevelopment, implementation and evaluation oforal health promotion interventions.

n Place emphasis on addressing inequalities toachieve sustainable long-term improvements inoral health;

n Adopt a common risk factor approach in whichoral health interventions focus upon alteringconditions and risks common to other chronicconditions and diseases;

n Recognise the importance of addressing theunderlying social, economic and environmentaldeterminants of oral health, thus, working‘upstream’;

n Develop locally sensitive interventions thataddress local needs and priorities by jointworking between health professionals and localcommunities;

n Adopt a range of complementary public healthstrategies in addition to oral health educationactivities;

n Work in collaborative partnerships acrosssectors, agencies and organisations to promoteoral health;

n Use appropriate evaluation methods andoutcome measures to assess the effects ofinterventions.

APPENDIX II: WHAT WORKS? THE EVIDENCE 47


CURRENT INITIATIVESIn Saving Lives: Our Healthier Nation, theGovernment first set out a national strategy forimproving health. To underpin this, a new healthpoverty index is being developed that combinesdata about health status, access to health services,uptake of preventive services, and opportunities topursue and maintain good health. Oral health andthe determinants of oral health should form anintegral part of this drawing on existing datasources like those referred to in paragraphs 9-15.

The Government has launched a range ofinitiatives to tackle health inequalities and thewider problems associated with social exclusion,with an emphasis on tackling the root causes ofill health to improve the health of all and reduceinequalities. The aim is to address social exclusionthrough community participation, joint workingacross agencies, a recognition of the need for earlyinterventions to prevent lifetime disadvantage, andtrying out innovative solutions which if successfulcan be adopted as mainstream working practices.

The Public Health White Paper Choosing Health:Making Health Choices Easier, published inNovember 2004, sets out key principles forproviding the support that people need in makingtheir own choices to improve health. The aim is foreveryone to achieve better health and wellbeingthrough healthier choices and for people in

disadvantaged areas to have the opportunities ofliving healthier lives. The White Paper recognisedthat many of the issues affecting people’s generalhealth are important for oral health too.

http://www.dh.gov.uk/PublicationsAndStatistics

Delivering Choosing Health: Making HealthierChoices Easier was published in March 2005 and isthe delivery plan for Choosing Health. It recognisesthat in order to help people make healthier choices,support and services for people need to beprovided at a local level. It recognises the vitalimportance of co-delivery between the NHS andlocal government and other partners in localcommunities, business and the voluntary andcommunity sectors. National , Regional, sub-regional and local responsibilities are identifiedfor the new focus on prevention and lifestyleadvice within NHS dentistry.


Modernising NHS Dentistry: Implementing theNHS Plan highlighted that oral health promotioncan be worked into other initiatives supportingchildren, older people, black and ethnic minorityethnic groups and deprived populations. TheGovernment is currently working with theTranscultural Oral Health Centre to fund a trainingpackage for health promoters and the dentalprofession on ethnicity and oral health issues.

APPENDIX III: FURTHER INFORMATION 49

APPENDIX III: FURTHER INFORMATION


More information on Modernising NHS Dentistry:Implementing the NHS Plan can be found on theDepartment of Health website at


Modernising Dentistry: Delivering Change pointsout that while oral health for both adults andchildren in England is the best that it has ever been,inequalities still exist between and within regions inthe country. Better access to NHS dentistry must beassured. To this end, by 2006 investment in NHSdentistry will be running at £250 million a year extracompared with 2003-04. The equivalent of 1,000more dentists will be recruited by October 2005 andthere will be a 25% increase in training places fordentists from 2005. Local commissioning of dentistrywill be implemented from April 2006, and PCTs willbe required to provide the appropriate services tomeet the local population’s reasonable oralhealth needs.

More information on Modernising Dentistry:Delivering Change can be found on theDepartment of Health website at


The National Service Framework (NSF) for Children,Young People and Maternity Services identifies thatoral health is an integral part of general health. Theoral health needs of children and young people,particularly those who are vulnerable, should beidentified in local health promotion programmes.PCTs should ensure adequate service provision forall children. Sugar-free medicines should beprescribed wherever possible.

More information on the NSF can be found on the Department of Health website athttp://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/ChildrenServices/ChildrenServicesInformation/fs/en

A number of ongoing initiatives related to oralhealth are outlined below.

Brushing for Life schemes involve the distributionof toothbrushes and toothpaste to parents ofyoung children by health visitors.

The national healthy school standard requires thata school presents consistent, informed messagesabout healthy eating through the food on offer invending machines, tuck shops and school meals,provides, promotes and monitors healthier food atlunch, breaktime and breakfast clubs, and includeseducation on healthier eating on its curriculum.

More information on the healthy schoolsprogramme can be found athttp://www.wiredforhealth.gov.uk

Under the school fruit and vegetable scheme,every child aged four to six in LEA maintainedinfant and primary schools is entitled to a freepiece of fruit each school day.

More information on the School Fruit andVegetable Scheme can be found athttp://www.5ADAY.nhs.uk

Health action zones (HAZs) bring together a rangeof organisations to tackle health inequalities insome of the most deprived areas in England.The 26 health action zones cover approximately13 million people.

More information on health action zones can befound at http://www.haznet.org.uk

The healthy living centre initiative has a budget of£300 million through the New Opportunities Fund.The programme promotes health in its broadestsense. Priority is given to projects that focus onareas of deprivation and the needs of people whoexperience worse than average health. There is noone model for a project – many are not based in abuilding but are outreach.

More information on healthy living centres can befound on the Department of Health website athttp://www.dh.gov.uk



More than 500 Sure Start local programmes workwith parents and parents-to-be to improvechildren’s life chances through better access tofamily support, advice on nurturing, health servicesand early learning. Sure Start programmes areconcentrated in neighbourhoods where a highproportion of children are living in poverty. Theyaim to improve local services for families withchildren under four, and spread good practiceto everyone involved in providing services foryoung children.

More information on Sure Start can be found athttp://www.surestart.gov.uk

The neighbourhood renewal strategy aims tonarrow the gap between the most deprivedneighbourhoods and the rest of England, andmake a real impact in poorer neighbourhoodsthrough better health, skills, housing and physicalenvironment, and lowering unemployment andcrime. Local strategic partnerships bring togetherthe different parts of the public sector and theprivate, business, community and voluntary sectorsat local level. A local neighbourhood renewalstrategy sets out the key issues in that particulararea, including health and oral health where itis considered a local priority, and the action tobe taken.

More information on neighbourhood renewal canbe found at http://www.neighbourhood.gov.uk

The 5 A DAY programme aims to promote theconsumption of fruit and vegetables to reduce therisk of heart disease and some cancers. Communityinitiatives to reduce inequalities in consumption andincrease access to fruit and vegetables are currentlyunderway funded by the Big Lottery Fund. Moreinformation on the 5 A DAY programme can befound at http://www.5ADAY.nhs.uk

Details of other relevant initiatives can be foundon the following websites.

Children and Young People’s Unithttp://www.cypu.gov.uk

Food Standards Agency http://www.food.gov.uk

Health Development Agency http://www.hda-online.org.uk (now merged withNICE)

Social Exclusion Unithttp://www.socialexclusion.gov.uk

There are details of the national cancer plan andthe national service frameworks for coronary heartdisease, mental health, children, diabetes and olderpeople on the Department of Health website athttp://www.dh.gov.uk

GUIDANCE Guidelines for oral health care for a number ofvulnerable groups have been produced by:

n The British Society for Disability and Oral Health(for people with learning disability, physicaldisability, mental illness, living in residentialcare, requiring palliative care), available athttp://www.bsdh.org.uk/guidelines.html;

n The Royal College of Surgeons ofEngland (people with a learning disability,undergoing chemotherapy/radiotherapy/bone marrow transplant), available athttp://www.rcseng.ac.uk/dental/fds/clinical_guidelines; and

n The British Dental Association (older people,homeless people), available at http://www.bda-dentistry.org.uk.

A simple oral health assessment proforma isavailable as an appendix to the British Societyfor Disability and Oral Health guidelines on oralhealth care for long-stay patients and residents, athttp://www.bsdh.org.uk/guidelines/longstay.pdf.This can be used to identify the oral health careneeds of vulnerable people entering long-stayinstitutions such as residential homes, psychiatrichospitals and prisons.

APPENDIX III: FURTHER INFORMATION 51


Blot WJ, McLaughlin JK, Winn DM. et al. (1988)Smoking and drinking in relation to oral andpharyngeal cancer. Cancer Res 1988 48: 3282-87

Department of Health (1998). Our HealthierNation. The Stationery Office. London.

Department of Health (2000). Modernising NHSDentistry. The Stationery Office. London.

Department of Health (2002). NHS Dentistry –Options for Change. Department of Health,London.

Department of Health (2003). Health and SocialCare (Community Health and Standards) Act 2003.Department of Health, London.

Department of Health (2004). Choosing Health:Making Healthier Choices Easier. Department ofHealth, London.

Department of Health (2004). Report of thePrimary Care Dental Workforce Review.Department of Health, London.

Department of Health (2005). Delivering ChoosingHealth: Making Healthier Choices Easier.Department of Health, London.

Department of Health (2005). Choosing a BetterDiet: a Food and Health Action Plan. Departmentof Health, London.

Department of Human Services (1999). Promotingoral health 2000-2004: Strategic directions andframework for action. Health DevelopmentSection. Melbourne.

Harker R and Morris J (2005). Children’s DentalHealth in England 2003. Office for NationalStatistics, London.

Kay, E and Locker, D (1996). Is dental healtheducation effective? A systematic review ofcurrent evidence. Community Dentistry and OralEpidemiology, 24, 231-235.

Kelly M, Steele J, Nuttall N, Bradnock G, Morris J,Nunn J, Pine C, Pitts N, Treasure E and White D(2000). Adult Dental Health Survey 1998. TheStationery Office, London.

National Institute for Clinical Excellence (2004):Dental Recall - Recall interval between routinedental examinations. London, NICE.

Pitts NB, Nugent ZJ, Thomas N, and Pine CM.(2005) BASCD Survey Report: The dental cariesexperience of 5-year-old children in England andWales (2003/4) and in Scotland (2002/3). Surveysco-ordinated by the British Association for theStudy of Community Dentistry Community DentalHealth 22:46-56.

APPENDIX IV: REFERENCES 53

APPENDIX IV: REFERENCES


Sheiham A and Watt R. (2000). The common riskfactor approach: a rational basis for promoting oralhealth. Community Dentistry and OralEpidemiology, 28, 399-406.

Sprod A, Anderson R and Treasure L (1996).Effective oral health promotion. Health PromotionWales. Cardiff.

Watt R (2005). Strategies and approaches in oraldisease prevention and health promotion. Bulletinof the World Health Organization, 83, 1-7.

World Health Organization (1986). The OttawaCharter for Health Promotion. World HealthOrganization, Geneva.

WHO Oral Health Country/Area ProfileProgramme website (2005).http://www.whocollab.od.mah.se/countriesalphab.html



Oral health: A standard of health of the oral andrelated tissues which enables an individual to eat,speak and socialise without active disease,discomfort or embarrassment and whichcontributes to general well-being (Department ofHealth, 1994).

Oral mucosa: The mucous membrane lining themouth.

DMFT/dmft: An indicator of the level of dentaldecay obtained by calculating the number ofdecayed, missing and filled teeth (dmft score).DMFT refers to decay experience in the permanentor secondary dentition and dmft to the decayexperience in the primary dentition. The averagescore is reported for a population.

Oral cancer: Malignant tumour of the mouth.

Dental caries: The material remaining after toothsubstance has been destroyed as a result of attackby acids produced by plaque bacteria from sugarsin the diet. Commonly referred to as tooth decay.

Periodontal disease: Disease of the gums andsupporting structures of the teeth. Commonlyreferred to as gum disease.

Erosion: Chemical dissolution of teeth.

Fluoride: A chemical compound that helps toprevent dental caries.

Water fluoridation: Addition of fluoride to apopulation's drinking water to reduce tooth decay.Fluoride may be added to other substances e.g.milk, toothpaste.

Dental trauma: Tooth loss or damage caused byphysical injury.

Fissure sealants: A plastic-like material placed inthe grooves and pits of the biting surfaces of theback teeth to prevent decay starting in thesesusceptible sites.

Common risk factor approach (CRFA): Anapproach to promoting general health bycontrolling a small number of risk factors which canhave a major impact on a large number of diseases.This is a cost-effective alternative to disease-specific approaches.

Dental Care Professionsals (DCPs): This termcommonly refers to members of the wider dentalteam, such as dental therapists, hygienists, anddental nurses.

APPENDIX V: GLOSSARY OF TERMS 55

APPENDIX V: GLOSSARY OF TERMS


STEERING GROUPTony Jenner (Chair), Acting Deputy Chief DentalOfficer – Department of Health

John Beal, Regional Dental Advisor, GovernmentOffice for Yorkshire and the Humber

Colette Bridgman, Consultant in Dental PublicHealth, Oldham & Salford PCTs

Kate Jones Specialist Registrar in Dental PublicHealth, Guy’s Kings St Thomas’ Dental Institute

Jerry Read, Project Leader, Oral Health and DentalEducation – Department of Health

Nigel Thomas, Director of Dental Public Health,Rotheram PCT & British Association for the Studyof Community Dentistry

Richard Watt, Professor of Epidemiology andPublic Health, University College London

REFERENCE GROUPIan Cooper, Senior Dental Officer, Departmentof Health (until 2002)

Jeff French, Health Development Agency

Sue Fuller, Specialist in Dental Public Health,Tameside and Glossop PCT

David Gibbons, Professor of Dental Public Health,GKT Dental Institute (until 2002)

Elizabeth Kay, Professor of Dental Health ServicesResearch, Turner Dental School, Manchester

Polly Munday, Oral Health Promotion Manager,Community Dental Health, Guy’s, Kings andSt Thomas’ Dental Institute

Cynthia Pine, Dean & Professor of Dental PublicHealth, Liverpool University School of Dentistry

Elizabeth Treasure, Professor of Dental PublicHealth, University of Wales College of Medicine

APPENDIX VI: MEMBERS OF THE STEERING & REFERENCE GROUPS 57

APPENDIX VI:MEMBERS OF THE STEERING& REFERENCE GROUPS


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