Oral health


Oral health is essential to general health and quality of life. The term encompasses both clinical conditions, for example oral cancer, periodontal (gum) disease and tooth decay along with disorders that limit an individual’s capacity to function. These include pain, ability to chew, willingness to smile, speaking and psychosocial wellbeing.

There are two major oral diseases: tooth decay and the periodontal diseases. Both are a major public health problem. Nearly all individuals suffer at some stage in their life and care is costly. Nearly 5% of all healthcare expenditure is spent on treating oral problems, despite them being largely preventable.

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

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

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

Improvements in oral health are most likely to be achieved by ensuring the adoption of the single most important measure in contributing to improvements in oral health over the last 30 years, namely the appropriate use of fluoride, especially fluoride-containing toothpastes.

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

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

Facts, figures and trends

The World Health Organisation (WHO) estimates that globally, 60-90% of children and nearly 100% of adults have suffered from dental decay. As part of a series on national dental epidemiological surveys, Public Health England has published the findings of both 3 and 5 year-old children. The surveys assess a sample of children by counting the number of teeth they have which are decayed, missing, or filled (dmf). The tables below summarise some key points from the survey.

Tables 1 and 2. Results of dental survey of 5 year-olds (2012)


5-year old population

Drawn Sample

Percentage Examined





Bracknell Forest






Percentage of children who had experienced tooth decay

Average number of decayed, missing or filled teeth per child in the whole sample

Average no. of decayed, missing or filled teeth per child in sample of patients with tooth decay





Bracknell Forest




Source: Public Health England

At 5 years of age, children are assessed as having fewer dmf teeth on average in Bracknell Forest than in England as a whole (figure 1). The data also highlight the variation in the distribution of dmf teeth. While the average number of affected teeth for Bracknell Forest 5-year-olds is 0.78, for those who have suffered from decay, the average number of teeth affected is almost 3. Data are available for other age groups and while somewhat of historical importance, all reinforce the patterns described previously.

Figure 1. Percentage of children with 2 or more dmf teethFigure 1 below shows the number of children with 2 or more dmf teeth as a percentage of the surveyed sample by Berkshire electoral ward. In the present survey sample, 273 children in Berkshire had two or more dmf teeth. 183 (67%) of these had teeth that had no indication of any care intervention.

Source: Berkshire Healthcare Foundation Trust

Figure 2 shows the percentage of the overall dmf total that was formed by the decayed component by Local Authority. The overall majority of disease experience was untreated at the time of the survey and while variation between the Local Authorities (LAs) exists, the confidence intervals would suggest that it is not statistically significant.

Figure 2.  Decayed teeth by local authority of school 2012

Source: Berkshire Healthcare Foundation Trust

Figure 3 shows the results for the Berkshire LAs of the national dental health survey of 3 year-old children undertaken in 2013. Bracknell Forest had a mean dmf score of 0.34 that is similar to that of England as a whole (0.36).

Figure 3. Mean number with 95% confidence intervals of decayed, missing and filled teeth for 3 year-old children by Berkshire Local Authority 2013.

Source: Public Health England

Identifying children in which 100% of the dmf total was formed by the decayed (d) component alone helps provide an insight into possible barriers to accessing care.

Figure 4 shows this analysis for children who had a dmf total of two or more. Again, while variation exists, the small sample size means that any interpretations need to be treated with caution. Nevertheless, there would appear to be pockets where children appear not to be accessing care and work is needed to understand why.

Figure 4. Percentage of children sampled with a dmf-t score of 2 or more in which the total score was decay alone.

Dental services have the key role in managing disease once it has occurred.  Figure 5 provides details of NHS service usage. The data show the number of residents who have attended for an NHS dental inspection within the past 24 months in Bracknell Forest broken down into age bands for 2008, 2013 and 2015.

While overall there has been an increase in uptake, the data highlight the considerable variation in the percentage of uptake within the age groups. Up to the age of 2, service uptake is very low, possibly with parents perceiving that there are few if any benefits of taking their child to a dental practice before teeth have erupted. The promotion of tooth brushing schemes in some of the Berkshire LAs has as one of their aims to increase uptake in the youngest age band. For the early teens, both parents and children are concerned about the development of their teeth, especially whether they need orthodontic treatment as the secondary (adult) dentition replaces the primary (baby) teeth which would suggest that availability of services is not a problem.

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

Figure 5. NHS dental service uptake for Bracknell Forest residents in 2008, 2013 and 2015.

Source: NHS Business Service Authority Information Services

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

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

As highlighted previously, the growing size of the elderly population have increasing dental need. Previous success in care arrangements has allowed this subgroup to retain more of their own teeth and for longer.  Many of the teeth are heavily restored and the care needed to address any problems arising is complicated by other factors including patient co-morbidities, not least those individuals suffering from dementia.

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

Programmes are being developed to help support dental personnel to provide care, for example dealing with issues of consent and complex medical histories. There is also an appreciation of the potential role of a wider audience can play in helping promote the contribution that good oral health can make and which recognises the multi-disciplinary nature of care. This would include helping care home staff to support the delivery of care and to increase their confidence when assisting with oral hygiene.

National and local strategies

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

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

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

What is this telling us?

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

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

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

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

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

What are the key inequalities?

While overall, oral health has seen significantly improvements in England over the last few decades, marked inequalities persist. Globally, nationally and locally, there is substantial evidence highlighting that people in the poorer and more deprived areas suffer worse oral health when compared to those living in more affluent areas.

The problems of inequalities in disease experience are further compounded by the inequalities in service uptake: those with greater clinical need tend to use services less.

These issues arise for a number of reasons including:

  • variation in perceived importance of good oral hygiene
  • low education and literacy levels
  • cultural differences and language barriers
  • financial restrictions
  • fear
  • low awareness of the risk factors for oral diseases

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

  • early years and parents
  • vulnerable adults
  • older people
  • prisoners
  • adults with learning difficulties

What are the unmet needs/ service gaps?

1. The prevalence of children with dental decay highlights that oral health issues have already arisen at 3 years of age. The ‘Brushing for Life’ programme in place in 3 of the Berkshire Local Authorities, is designed to help address this and lead to improvements in both overall levels of oral health and reduce inequalities. This programme could also be linked into programmes aimed at helping increase attendance for care.

2. The growing oral health needs of the elderly population will require appropriate solutions. Work has commenced on identifying the needs of this growing section of the population. While currently all new entrants to a care or nursing home have a medical assessment, dental assessments are not included.

3. The changing epidemiology of oral cancer and the growing evidence of an association with HPV exposure, suggests that there is good opportunities would arise through collaboration with the Sexual Health team. Work is also required to understand how patients with the oral health problems are initially accessing primary care services.

Recommendations for consideration by other key organisations

Recommendations for consideration are:

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