Adult Oral Health

Introduction

Good oral health is integral to general health as it contributes to general well being and allows people to eat, speak, and socialise without active disease, discomfort or embarrassment (see footnote 1).

Oral diseases are important public health issues as they are among the most commonly found chronic diseases. Although we have seen considerable reductions in dental disease since the 1970s, there are still substantial reductions to be made. Dental decay, for example, is commonly found despite being entirely preventable.

Oral diseases reduce quality of life and have multiple impacts on physical and psychological well-being. The dental health of adults and children in the UK has improved significantly in recent years, however, population averages mask oral health inequalities. Socially deprived and/or vulnerable groups in society tend to have poor health and less access to oral health care services. These groups tend to be symptomatic, irregular dental attendees.

Oral health varies by gender, age, socio-economic status and ethnic group and there is a well established association between poor oral health and socio-economic deprivation (see footnote 2). It is therefore an important public health issue for Haringey, as an ethnically diverse and in some areas deprived part of London.

Certain health damaging behaviours will increase the risk of oral disease; particularly poor dietary choices, using tobacco and alcohol, poor oral hygiene and low use of dental services.

An unhealthy diet is a risk factor for oral cancer and dental decay as well as systemic diseases such as obesity and diabetes. Frequent sugar consumption is a key risk factor for dental caries and is more prevalent in low-income groups.

Smoking or chewing tobacco are risk factors for oral cancers and periodontal disease.

There is a well recognised relationship between alcohol misuse and oral disease. Research suggests that patients suffering from alcohol use disorders experience poor oral health (see footnote 3). This includes significant levels of dental caries and an increased risk of developing gum disease. Of particular concern in the synergistic action of excessive alcohol consumption with tobacco, which when used together will substantially increase the risk of developing oral cancer. Evidence is also beginning to emerge of a link between oral cancer and the human papilloma virus (see footnote 4).

This chapter focuses only on adult oral health. Details on diet and nutrition, smoking, and dental health in children are covered in other sections.

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Key issues and gaps

Although the average level of oral health in Haringey is relatively good, compared to both England and London, there are enormous variations consistent with the patterns of deprivation that exist.

Despite an extremely varied population with some pockets of serious deprivation, the overall oral health picture in Haringey is above both the national and London average. However, this is not consistent across the borough and there are areas where dental disease levels give cause for serious concern. Poor oral health is also connected to deprivation due to diet. A detailed review of Haringey dental need can be found in the oral health needs assessment (PDF, 732KB).

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Who is at risk and why

Vulnerable groups within society often experience poorer oral health and can have more difficulty in gaining access to primary dental care services:

Adults with impairment or disability that makes diagnosis, experience or treatment of dental disease challenging are a special group at risk. People with a mental illness tend to have fewer teeth, more untreated decay and more periodontal disease than the general population.
Those in long term institutional care (including older people, people with a learning disability or mental health problem, those who are physically or medically compromised and those in secure units) are often dependant on others for their diet, personal care and access to health services.
Other vulnerable groups include those with drug and alcohol addiction, those with lack of educational attainment, people in poverty, those seeking asylum and the homeless.

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The level of need in the population

Poor oral health is closely associated with socio-economic deprivation and social exclusion. In general, caries (tooth decay) levels are higher amongst disadvantaged people. The British Association for the Study of Community Dentistry Services (cited in 'Equality and Inequalities in Health and Social Care in Northern Ireland: A Statistical Overview (DHSSPS, 2004:99-100)') found that prior to the introduction of the new dental contract when a system of registration was in place, a greater number of unskilled manual workers than professionals were not registered with a dentist. Haringey has a mixed population in relation to levels of deprivation. The Index of Multiple Deprivation (IMD) 2010 shows that Haringey is the 13^th most deprived borough in England in 2010.

Local data on adult oral health are not routinely collected in the UK. Our best local estimates come from decennial national surveys that collect data to regional level. These can be used to determine broad trends, but are likely to be an inaccurate estimate of disease levels at a PCT level. This is because poor oral health is strongly associated with levels of social deprivation and the social deprivation across NCL and London is not uniform.

The most recent adult dental health survey was carried out in 2009.

The results from the adult decennial surveys show that oral health in adults has improved considerably in the last 40 years largely due to the widespread use of fluoride toothpaste (see footnote 5). In 1968 37% of the population in England had no natural teeth. In 2009 this figure had fallen to 6%.

Figure 1: Proportion of the population with no natural teeth. ADHS 2009

The 2009 Adult Dental Health survey found that in England 94% of the population had some natural teeth. In the London Strategic Health Authority area the proportion of the population was slightly higher at 96%. However, the survey also found that the proportion of the population with natural teeth was not uniform across social groups. Adults who had routine and manual occupations had the lowest proportion of the population with natural teeth (90%) and those with managerial and professional occupations the highest (98%). In the London SHA area 91% of dentate (those with some natural teeth) adults had 21 or more teeth.

Figure 2: Proportion of the population with some natural teeth. ADHS 2009

From these data we can infer that in Haringey the population in the more deprived areas of the borough are more likely to have fewer natural teeth.

Despite the fact the adult oral health has improved in recent years the 2009 adult dental health survey found that a considerable proportion of the survey population had dental problems. This is shown in figure 3 below.

Figure 3: Dental problems in London and England AHDS 2009

Access to General Dental Services

The proportion of the population attending a dentist in the previous 24 months is generally taken to have been at its greatest in March 2006, when patients were registered with a dentist and dentists received a payment for each patient registered.

The population of Haringey has excellent access to General Dental Services. The data in figure 4 shows that in North Central London only Haringey has a greater proportion of the population attending a dentist than the England average. Haringey has increased the proportion of the population attending a dentist since 2006, despite the added challenge of an increasing population.

Figure 4: The proportion of the population accessing a dentist in the previous 24 months.

Uptake and Deprivation

A rapid appraisal in 2008 looked at a sample of 14,599 dental treatment forms (FP17s) forms for patients with a Haringey residential postcode visiting an NHS dentist in January and February 2008. The number of claims was looked at in relation to the postcode of the patient and the level of deprivation of that area as measured by the Index of Multiple Deprivation.

The results showed a complex relationship between deprivation and demand, where demand was measured by the attendance at a dentist for dental care. Generally there was a correlation between deprivation and demand such that the greater the level of deprivation the greater the demand. However at the more extreme ends of the scale, the relationship appeared to be an inverse one. The areas of highest deprivation showed a reduced demand for NHS dental care while the demand for NHS dentistry appeared to increases slightly in the areas of least deprivation.

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Current services in relation to need

Haringey commissions a variety of dental services to meet the needs of its population. This includes:

48 General (high street) dental practices
Specialist minor oral surgery
Orthodontics
Children’s dental service
Sedation service
Dental service for adults and children with additional needs
Endodontic (root treatment) specialist service

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Service users and carers opinion

As part of the Haringey Oral Needs Assessment in 2009, the Patient Advice and Liaison Service (PALS) reported that there was much uncertainty about how to go about finding an NHS dentist both in-hours and out-of-hours and that patients reported problems of getting an urgent appointment. Many stakeholders commented that they did not know where to go to get information about services, treatments, charges and location. Stakeholders emphasised the need for a 24-hour helpline. It was noted, by stakeholders, that some boroughs had introduced a mobile service to improve access. There was a widely expressed view that many people did not understand NHS charges nor the system of exemptions. It was also felt that people on low incomes could not meet the costs of dental care. PALS reported that patient concern over charging was one of the most frequent reasons for calls concerning dentistry and that many patients felt they had insufficient information on charges or felt they had been coerced into private treatment.

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Expert opinion and evidence base

Choosing better oral health: An oral health plan for England, 2005 (external link)
Delivering better oral health: an evidence-based tool kit for prevention. 2^nd edition, DH 2009
Valuing Peoples Oral Health: A good practice guide for improving the oral health of disabled children and adults, 2007 (external link)
Smoke free and smiling: helping dental patients to quit tobacco. DH 2007
One in a million – the facts about water fluoridation
Commissioning Tool for Special Care Dentistry: BSDH, 2006
Tobacco and oral health: A survey of dental education and training in tobacco issues – NICE 2007 (external link)
Improving oral health and dental outcomes: developing the dental public health workforce in England , 2010 (external link)

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Unmet needs and service gaps

Haringey is keen to improve access to specialist dental services. A pilot project in the borough that offers minor oral survey services in local clinics has demonstrated that by offering these services in the community it reduces the number of patients who need to attend hospital.

Following the pilot a community-based minor oral surgery service is being commissioned and will start seeing patients in Autumn 2012.

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Recommendations for commissioning

Oral health promotion in Haringey should:
1. Tackle the social determinants of oral disease
2. Implement the common risk factor approach
3. Target adults and children with additional needs (vulnerable)
4. Actively prevent oral disease through community and practice-based prevention
To increase awareness of the translation services available to dentists
To improve the commissioning of dental services in Haringey
Ensure all Haringey residents are aware of how to access to an NHS dentist
Improve the quality of oral health services
Continue to participate in the NHS dental epidemiology programme

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Recommendations for further needs assessments

Update the 2009 Oral Health Needs Assessment

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Key contact

Anna Ireland, Consultant in Dental Public Health, NHS North Central London,

anna.ireland@nclondon.nhs.uk

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Footnotes

1. Department of Health. An Oral Health Strategy for England. London: Department of Health; 1994. (external link)

2. Kelly M, Steele J, Nuttall N, Bradnock G, Morris J, Nunn J, Pine C, Pitts N, Treasure E, White D. Adult Dental Health Survey. Oral Health in the United Kingdom 1998

3. Gelbier S, Harris C. Oral and dental health in the alcohol misuse. Addictive Biology 1996; 1(2):165-9

4. Human Papilloma viruses in oral carcinoma and oral potentially malignant disorders: a systematic review. Syrjanen et al. Oral Diseases 2001; 17:58-72

5. Sheiham A. Oral health, general health and quality of life. Bull World Health Organ website 2005;83(9):644. (PDF, 59KB)

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