1.  EXECUTIVE SUMMARY

  1.1  An unacceptable and growing chasm exists in the UK between those with good and poor dental health. The Secretary of State for Health has recognised the disparity between the oral health of those living in poorer communities compared to those in more affluent areas.

  1.2  The dental team has a vital role to play in maintaining the oral health of the nation. Its role, and that of the dentist as team leader, must not be underestimated when developing strategies to tackle oral health inequalities.

  1.3  More emphasis is needed on health promotion and preventive approaches in conjunction with attempts to treat the damage caused by dental disease. It is essential that funding and remuneration systems recognise the resource needed to ensure that this preventive approach can be adopted.

  1.4  The Adult Dental Health Survey (ADHS) and the Child Dental Health Survey (CDHS), are invaluable means of identifying and tracking oral health inequalities, providing information to inform the development of services that are tailored to the needs of the community.

  1.5  The promotion of measures that would bring teeth into contact with fluoride would make a radical difference to the standard of oral health in the UK. These measures must be appropriate to the community.

  1.6  Health promotion materials and information provided must be accessible, and gender and culturally sensitive.

  1.7  Dentists are ideally positioned to offer advice to patients about a range of topics including smoking cessation, and the BDA supports smoking cessation activities including tobacco education programmes and the ban on tobacco advertising and promotion.

  1.8  Activities that control alcohol consumption have the potential to have a positive impact on combating inequalities in oral health.

  1.9  Dentists have been actively involved in the Healthy Schools programme and other local and national initiatives to improve nutritional status of children.

  1.10  New food legislation such as the new minimum nutrition standards for schools, proposals for new labelling schemes for food, and restrictions on television advertising of high sugar have potential to have a strong impact on oral health inequalities through improving the diet of the wider population.

  1.11  The BDA welcomes schemes such as Sure Start, and hopes to see an expansion in such programmes. More multi-agency collaboration is needed between the various health organisations to tackle health inequalities.

  1.12  Community schemes have good potential for combating oral health inequalities. Further evaluation would be beneficial to assess long-term benefits and behaviour change.

2  INTRODUCTION AND BACKGROUND

  2.1  The British Dental Association (BDA) is the professional association and trade union for dentists practising in the UK. Its 23,000-strong membership is engaged in all aspects of dentistry including general practice, salaried services, the armed forces, hospitals, academia and research, and includes students.

  2.2  An unacceptable and growing chasm exists in the UK between those with good and poor dental health. There is a seven-fold difference between the populations of primary care trusts (PCTs) in England with the best dental health and those with the worst[183]. By the age of five, more than a third of British children have suffered tooth decay, missing teeth or fillings; in some parts of the country as many as three-quarters of children are affected[184].

  2.3  The Secretary of State for Health has recognised the disparity between the oral health of those living in poorer communities compared to those in more affluent areas[185]. Yet his commitment to elevating public health to the top of the national agenda, and his recognition that this is "pivotal" to reducing health inequalities, is being undermined by the NHS dental system he has inherited.

3.   The extent to which the NHS can contribute to reducing health inequalities, given that many of the causes of inequalities relate to other policy areas eg taxation, employment, housing, education and local government

  3.1  The dental team has a vital role to play in maintaining the oral health of the nation and their role, and that of the dentist as team leader, must not be underestimated when developing strategies to tackle oral health inequalities.

  3.2  The opportunity for a dentist or member of the dental team to sit and explain to children and their parents how to care for their teeth is the most effective way of establishing good dental habits at a young age. As these children grow into adults, they may want to discuss other areas of concern with their dentist, such as their drinking and smoking habits.

  3.3  The BDA supports the measures outlined in "Choosing Better Oral Health"[186]. It is essential that funding and remuneration systems recognise the resource needed to ensure that this preventive approach can be adopted. New contract reforms have introduced a target for the number of units of dental activity (UDAs) a dentist or practice must perform annually. This system of performance measurement fails to promote a more preventive approach to care because of the pressures on time it creates.

  3.4  Current dental contracts mean that PCTs' dental budgets reflect the historic level of spending on NHS dentistry in that area, and so do not always reflect the oral health needs of their local population. As a result, PCTs which have been under-funded historically continue to suffer from under-funding, causing them difficulty in commissioning services to meet patient need. This includes (but isn't limited to) steps to address particular inequalities. Increased funding should be focused on meeting these needs of the local populations, and supplemented by PCTs having the expertise to commission appropriate services.

  3.5  There is evidence that adults and children with disabilities have poorer oral health and receive less dental care than the rest of the population. The Salaried Primary Dental Care Service (SPDCS) has traditionally provided care for people with disabilities. Resources need to be provided to ensure the service continues to carry out this very important role.

  3.6  SPDCS carries out work in addition to the valuable work of treating patients such as health promotion and health education. They are involved in working with Sure Start, visiting schools to promote dentistry as well as oral health, meeting with local authorities to discuss school meals and working with health visitors and school nurses. The salaried services also work with other vulnerable members of society, elderly housebound people, who are often living in near poverty situations and adults with learning disabilities or mental health problems, conditions which can also exacerbate existing inequalities.

  3.7  Consultants in Dental Public Health (CsDPH) play a vital role in ensuring the commissioning of preventive services, and providing a public health input at local level. Although never published, the Dental Public Health Workforce in England status report (January 2005) identified a shortage of CsDPH. The recent reorganisation of PCTs in England has impacted upon the staffing and workload of dental public health staff and it is essential that this is not allowed to adversely impact upon public health initiatives.

  3.8  The Adult Dental Health Survey (ADHS) and the Child Dental Health Survey (CDHS) are invaluable means of identifying and tracking oral health inequalities. From this information strategies can be developed to tailor services to the needs of the community. This survey underpins effective planning for improvements to nationwide oral health.

4.   The effectiveness of public health services at reducing inequalities by targeting key causes such as smoking and obesity, including whether some public health interventions may lead to increases in health inequalities; and which interventions are most cost-effective

  4.1  More emphasis is needed on health promotion and preventive approaches in conjunction with treatment of the damage caused by dental disease. Patients should be provided with the appropriate information in order to make informed decisions about their oral health, and information on dental services must be made available and in an accessible format to the public. To help achieve national targets, there needs to be increased appreciation of cultural differences in relation to oral care. For example, leaflets on oral health should be available in languages other than English. Cultural and gender sensitivities need to be respected.

  4.2  The promotion of measures that would bring teeth into contact with fluoride would make a radical difference to the standard of oral health in the UK. Fluoride—through targeted water fluoridation, tooth brushing campaigns, fluoride rinses, or being added to milk—has a proven track record of reducing caries. Fluoridation measures must be appropriate to the needs of the community. Ideally, a reduction in sugar consumption/healthier diet should be combined with appropriate use of fluoride.

  4.3  The BDA supports initiatives on smoking cessation including tobacco education programmes and the ban on tobacco advertising and promotion. Further education programmes are needed to further reduce smoking rates amongst groups with high smoking prevalence, but as part of a targeted campaign with multi-agency collaboration.

  4.4  Dentists are ideally positioned to offer advice to patients about a range of topics including smoking cessation. Improving the referral rate to smoking cessation programmes is an important first step. However, it is essential that funding and remuneration systems are appropriate to ensure that this preventive approach can be adopted.

  4.5  The BDA supports Smokefree and Smiling, smoking cessation guidance for primary care dental teams.[187]

  4.6  Along with tobacco, alcohol is one of the main risk factors for oral cancer. Activities that control alcohol consumption therefore have the potential to have a positive impact on combating inequalities in oral health.

  4.7  Nutrition is also an important contributing factor to oral health. There is strong evidence to link frequency of sugar consumption and dental decay. There is a high consumption of sugary sweets and drinks among children and young people in lower income groups. Children have access to sugary drinks and foods through school tuck shops, canteens and dispensing machines. Activities that limit the amount of sugary food and drink in schools are supported, and cold water machines should be available in every school. There is a strong case for encouraging local education authorities and schools to reassess their policies on these facilities.

  4.8  Dentists have been actively involved in the Healthy Schools programme and other local and national initiatives to improve children's nutritional intake. In particular, many breakfast clubs have been set up and tooth brushing schemes have been built into these services in many disadvantaged areas. The BDA supports these nutritional programmes, including the Healthy Schools Programme and the School Fruit and Vegetable Scheme.

  4.9  New legislation such as the minimum nutrition standards for schools, proposals for new labelling schemes for food, and restrictions on television advertising of high sugar have potential to have a strong impact on oral health inequalities through improving the diet of the wider population.

5.   Whether specific interventions designed to tackle health inequalities, such as Sure Start and Health Action Zones, have proved effective and cost-effective

  5.1  Dental health is an important part of general health and should not be considered in isolation. More multi-agency collaboration is needed to ensure joined up thinking between the various health organisations to tackle health inequalities. The BDA welcomes initiatives such as Sure Start and hopes to see an expansion in such programmes.

  5.2  In many areas Sure Start has involved oral health initiatives, typically focusing on oral health promotion and fluoride toothpaste. There should be a comprehensive approach with every Sure Start Scheme having a dental care professional in the team. Dental care professionals can offer advice on all aspects of oral health including brushing teeth, use of fluoride toothpaste, advice to parents on bottle-feeding (to help reduce the incidence of bottle caries caused by sugary drinks fed to babies/young children in a bottle especially at bedtime) and advice on the advantages of offering drinks such as milk and water between meals rather than acidic or sugary alternatives.

  5.3  The BDA supports schemes such as Brushing for Life, a scheme intended to promote regular brushing of children's teeth with fluoride toothpaste. The programme is delivered by health visitors who provide toothbrushes, toothpaste and dental health education material at children's eight, 18, and 36 month development checks.

  5.4  Some Health Action Zones have been involved in oral health promotion. A successful example is the Plymouth HAZ that gave out packs including a toothbrush and toothpaste to every child at their six-nine month check-up. Community schemes such as these have the potential to combat oral health inequalities. Further evaluation would be beneficial to assess long-term benefits and behaviour change.

January 2008

184   British Association for the Study of Community Dentistry, 2005-06 survey of five-year-olds. Back

185   "The Healthy Society", Speech in the House of Commons, by Rt Hon Alan Johnson MP, Secretary of State for Health, 12 September 2007. Back

186   Choosing better oral health: An oral health plan for England, The Department of Health, 14 November 2005. Back

187   Smokefree and Smiling: Helping dental patients to quit tobacco, The Department of Health, 25 May 2007. Back