Oral Health JSNA | Boltons Health Matters
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Oral Health JSNA

Abstract

 This is the JSNA chapter on Oral Health. Theme chapters summarises implications for commissioning, who is at risk and why, the level of need in the population, service provision and use, unmet needs, what works in terms of evidence, community views and priorities, any related equality impact assessments, unmet service needs/gaps and recommendations for further needs assessment work. 

Introduction

The term oral health includes not only the health of people's teeth and gums but also the supporting bone and soft tissues of the mouth, tongue and lips.  Oral health is an important part of health and wellbeing.  Whilst good oral health can enable an individual to enjoy a range of foods and to communicate with others, it is also important for self-esteem and social confidence.  Poor oral health can impact upon individuals and their families in terms of tooth pain and infection which may result in sleep loss and disruption to family and working life.

Whilst significant strides have been made in dental/oral health in the UK over the last 40 years, many people still suffer with pain as a consequence of poor oral health.  Inequalities in dental health exist with populations living in relatively deprived circumstances being the most at risk of poor dental health.  It is these populations who are most likely not to have a dentist or not to visit the dentist regularly.  These groups are also more likely to have poorer diets, to consume alcohol in quantities above recommended limits and to smoke, and this is why they are known to be at particular risk.

Oral diseases (such as gum disease and tooth decay) are largely preventable and controllable but some sections of population such as the vulnerable, disadvantaged and socially excluded face greater risk of poor oral health.  Again this is generally as a result of poorer material circumstances but, in some cases, other factors come into play such as low usage of toothpaste, particularly fluoride toothpaste and ineffective or inconsistent tooth brushing techniques and routines.

The oral health of children living in the borough is a major concern for NHS Bolton.  Levels of oral health are still quite poor in Bolton especially in children aged under 5 years and poor oral health is associated strongly with social deprivation in the child population.  Although improvements have been made, tooth decay remains one of the most common diseases of childhood affecting physical and psychological wellbeing and quality of life.

NHS Bolton spends £20million per year on dental problems.  The majority of this spend is in primary care (£16million) (dentists etc.) dealing with pain relief and treating dental decay.  More children in Bolton have teeth extracted under General Anesthetic than most other large towns in England; in addition, £300,000 is spent on prevention and health promotion around dental problems.  As a percentage of expenditure across all programmes, NHS Bolton spends a slightly lower proportion on dental problems than the national average and has worse dental outcomes, but not significantly so .

Implications for Commissioning

From Bolton’s Strategic Plan the key issues regarding commissioning are :

  1. Improve oral health:
    Consider water fluoridation;
    Commission effective, evidence-based, needs-led programmes to improve oral health in guidance with the Department of Health’s ‘Delivering Better Oral Health: an evidence-based toolkit for prevention’
    Develop evidence-based and effective preventive interventions for children and young people in primary care and other settings (e.g. nurseries, schools and Children’s Centre’s)
    Develop dental Public Health capacity
    Support, advise, and work with other agencies to promote oral health
    Ensure people have access to information to support good oral health, self-care, and healthy choices
    Improve prevention in relation to dental caries (decay), periodontal (gum) disease, and oral cancer
  2. Reduce oral health inequalities:
    Collect and analyse data to better understand oral health needs and demands, oral health inequalities, access to services, and inequity in access
    Identify communities and vulnerable groups affected by oral health inequalities and/or inequitable access
    Action to tackle inequalities and inequitable access
  3. Commission high quality, evidence-based, preventively focused dental services to meet local needs:
    Maintain/increase access to dental services to meet local needs
    Integrated and joined up dental services
    Clinical governance
    Evidence-based, preventively-focused practice
    Funding for dentistry
    Public and patient involvement
    Communication and information
    Workforce planning, support, and development
Who's at Risk and Why

All age groups and populations are at risk of poor oral health even though it is largely preventable.  The main modifiable risk factors for oral disease include having a diet high in sugar, smoking or chewing of tobacco, excessive drinking of alcohol, poor oral hygiene, trauma, and less frequent use of dental care services.  Smoking and alcohol have also been implicated in the presence of mouth cancers.

Certain communities are more likely to have poor oral health and are less likely to use dental services.  These include the more deprived, socially excluded population along with those with learning disabilities, and those in long-term and short-term residential and institutional care.  The link between poor dental health and deprivation has long been evidenced.  Those areas with the worst dental health statistics are generally the most deprived parts of the country.  Poor oral health is strongly linked with deprivation and high levels of dispossession exist in inner Bolton with seven of Bolton's wards falling into the lowest 10% in the country.

Older people are generally more likely to have worse oral health and fewer teeth due to the ageing process and a lower likelihood to see the need for dental treatment.  Women during pregnancy face increased risk of oral disease and tooth loss.

The Level of Need in the Population
Adults

In Bolton around 57,000 adults and 23,000 children visit a dentist each year.  A greater proportion of Bolton’s adult, child, and total population have visited a dentist in the last two years compared to the average for England, but fewer than the North West region as a whole.  However, over recent years there has been a minor reduction in the proportion of Bolton’s population who have visited the dentist – in contrast the North West and England trends show a slight increase.

There persists a strong inequality gradient for access to a dentist in Bolton, with more than a third of the most deprived fifth of Bolton’s population not having visited a dentist in over two years.  There is a great deal of evidence that suggests worse dental and oral health in more deprived population and lower social classes.

BME groups are less likely to have visited a dentist in the last two years than the general population, as are Bolton’s disabled and LGB groups.
Geographically, the areas of Bolton with highest rates of people having not visited the dentist for over two years cluster around the town centre and in the South East of the borough – areas of particular interest include Farnworth, Kearsley, Rumworth, Halliwell, Crompton, and Breightmet.

National evidence suggests that women are more likely to have fewer teeth than men due to a greater risk of problems during pregnancy.

Children

In Bolton, a greater proportion of all children (72.2%) have visited a dentist in the previous two years than adults (56.4%).  This is consistent with the regional and national picture.  This is around average for Bolton's peers and is above the national average of approximately 70%, however the top decile of areas achieve 81%.

The most recent dental surveys of children were taken of 5 year olds and 12 year olds.  Children aged 5 years old in Bolton have on average 1.9 number of dentinally decayed, missing (due to decay), and filled teeth (dmft); Bolton children aged 12 years old have an average 0.9 dmft.  The figure for 12 year olds is better than the North West region whilst being lower than England.  However, the figure for 5 year olds is considerably worse than both the region and nation.

Over 45% of 5 year olds and just under 40% of 12 year olds in Bolton have decay experience.  In both cases this proportion is higher than England and higher than is average for our statistical peer group.

In addition, 2.9% of 5 year olds in Bolton have evidence of sepsis which is again higher than both the England average and our peers.  St Helens and Tameside have higher proportions of sepsis in 5 year olds, making Bolton the third highest of our ten peers.

In sum, Bolton is one of the poorer performing districts in the Greater Manchester conurbation for the dental health of its 5 year olds.  Bolton currently ranks as the 12th worst area in England for dmft in 5 year olds.  However, despite this poor picture data does show an improving trend; the number of dmft in 5 year olds in 2003/04 was 3.2 (now 1.9), and the rate of improvement is greater than that seen nationally.

Key JSNA Indicator Sheets
BEHAVIOUR AND ACCESS TO SERVICES: Access to dentist
CHILD HEALTH: Decayed, missing, and filled teeth (dmft)

Current Services in Relation to Need

The majority of dental services are provided by independent practitioners in local dental practices working under either General Dental Service (GDS) or Personal Dental Service (PDS) arrangements.  There are 35 dental practices in Bolton (21 GDS and 14 PDS) with almost 100 dentists.  Of these practices 12 are currently accepting NHS patients.  All practices are required to follow current guidance and evidence based practice in relation to oral disease and the promotion of oral health as outlined by the Department of Health .  In addition, there are 3 orthodontic practices, a community dental service focusing on provision to vulnerable groups and patients with special needs, and out-of-hours (evening and weekend) emergency dental service, a daytime urgent dental care service, as well as hospital based specialist services for orthodontics and oral surgery.

Bolton's Oral Health Promotion Improvement Team is actively involved in a range of evidence based programmes identified within ‘Delivering Better Oral Health: an evidence-based toolkit for prevention’.  Most of the interventions aim to increase the availability and/or use of fluoride using a variety of methods in guidance with ‘Brushing for Life, Brush Bus and a Curriculum Linked Schools Toothbrushing programme for 7–8 year olds’.

Also, a dental voucher scheme is available which aims to ensure that vulnerable 0-5 year olds are able to gain access to care with a local dentist.
Child oral/dental health is worse in Bolton than it is both regionally and nationally.  However, in recent years it has improving at a faster rate than nationally.

Cost-Effectiveness

The Department of Health accept that it is difficult to quantify the cost effectiveness of oral health programmes and little evidence has so far been published.  Traditional oral health education by health professionals is deemed to be relatively costly .  However, in general prevention is more cost-effective than cure - in Bolton we spend approximately £60,000 alone on General Anesthetic a month.  The Department of Health conclude that this reinforces the need to consider and plan activity carefully in order to maximise the long-term impact of any interventions .

Projected Service Use and Outcomes
  • There is now a greater availability of NHS dental care in the UK than there has been over the last 10-15 years. This should hopefully lead to greater numbers registering and hence impact upon services.
  • The population of Bolton is ageing and hence the type of dental work that accompanies the older population will increase over time.
Evidence of What Works

Bolton’s Health Matters has created a collection of evidence and intelligence to ensure best practice in decision within this area. To view this collection, please click here 

Community Views and Priorities

NHS Bolton receives a high number of enquiries about local dental services.  Each year around 70% of all enquiries to the Patient Advice and Liaison Service (PALS) are about dental care – an average of around 46 enquiries per day.

The results of a survey on patient satisfaction answered by members of the local Citizen's Panel in 2009 showed that 62% of respondents were registered with a NHS dentist.  A further 21% had a private dentist and 17% did not currently have a dentist.  Overall, 76% of respondents were satisfied with their dental service.  However, 'access to NHS dentists' was listed as the service that was most in need of improvement by 45% of respondents but this had fallen from 75% in the previous year.

Equality Impact Assessments

No recent local equality impact assessments have been carried out that we are aware of.  If you are aware of any such work locally please let us know at Bolton Health Matters

Unmet Needs and Service Gaps

Dental practices in Bolton currently have spaces for NHS patients.  However, there is still a significant proportion of the Bolton population who are either not registered with a dentist or who do not visit regularly enough for a check-up.  This would suggest that there is sufficient capacity but more work is needed to encourage those not already registered with a dentist.

Bolton generally scores favourably in terms of the proportion of people accessing dental services when compared nationally.  However, there is still a significant proportion of the population who have not seen a dentist in the last two years.

Those living in the most deprived parts of the borough are much less likely to have visited their dentist in the last two years than those living in more affluent areas.  Recent additions to address gaps in service include a new dental access service, and a new practice to serve a targeted area of deprivation.
Fluoride in drinking water provides a protective factor against dental decay but this is not included in waters of the North West.

Improvements are necessary in the following areas;

  1. Dental health improvement activity with BME communities particularly focusing on the use of chewing tobacco and the use of shisha pipes in relation to increased risk of mouth cancers
  2. Alcohol health improvement interventions aimed at raising the awareness of the links between oral cancer and excessive alcohol use
  3. Smoking cessation and prevention health improvement interventions aimed at raising the awareness of the link between smoking and cancers of the throat and mouth
  4. Dietary health improvement interventions aimed at raising awareness of the link between tooth decay and sugary drinks, sweets and foods.  However, the evidence of this making any difference to dental decay is small compared to getting fluoride on teeth.  Consideration should perhaps be given to introducing more fluoride programmes, see for example the Childsmile fluoride varnish programme in Scotland
  5. Promotion of healthy infant feeding and weaning practices, especially in deprived communities.
Recommendations for Further Needs Assessment Work
  • Assessment and regular monitoring/analysis of the Public Health Outcomes Framework indicators linked to dental health are necessary.  These are: 4.2 Tooth decay in children aged 5.
  • Analyse the current dental registration status across Bolton and target improved uptake in key under represented populations.
  • There is a lack of information about the level of decay in the teeth of adults in Bolton.
Key Contacts

Jean Holgate – Oral Health Promotion Manager, NHS Bolton.

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