Oral health inequalities
In the UK we treat oral health (the health of our teeth and gums) separately from other types of health. It is the remit of dentists rather than doctors. However, might oral health influence our wider health – and might health inequalities be a useful indicator of probable health inequalities more generally? If so, should doctors and dentists be exploring ways of sharing information and working more closely together?
Although oral health and health generally are treated separately they both have something in common i.e. the bulk of the NHS time and resource available is committed to treating health problems rather than preventing them, which tends to perpetuate health inequalities rather than reducing them.
Why oral health matters
The mouth is a gateway to the rest of our body. With approximately 700 species, the oral cavity possesses the second largest and most varied microbiota after the gut (1). There is a link between oral health and overall body health. For example, smoking, alcohol and a poor diet can affect both our oral health and our health more generally. An association has also been found between gum disease and systemic disease (2)
Periodontitis (the advanced form of gum disease that can cause tooth loss) is linked to systemic disease such as diabetes, coronary artery disease, adverse pregnancy outcomes, and rheumatoid arthritis (RA) (3). A systematic review in 2013 found that pregnant women with periodontitis may be at increased risk of delivering preterm and/or low-birth-weight infants (4). On the other hand, Diabetes and gum disease have a clear two-way association, and there is substantial evidence that treating one illness improves the other (5). For example, periodontal (gum) therapy has been shown to improve glycaemic control in diabetic patients (6).
How dental disease causes systemic diseases
It has been suggested that the inflammatory pathway initiated by periodontal (gum) disease stimuli might allow oral bacteria, lipopolysaccharides (which are part of certain types of bacteria) and proinflammatory chemicals to enter other areas of the body, contributing to chronic systemic disorders and infectious illnesses. (7)
The cost of oral disease:
In England oral diseases place significant costs on society and the NHS for what are essentially preventable diseases. The NHS spent £3.6 billion on dental care in 2017 to 2018 in England. A similar amount is estimated to be spent on private sector dental care (8). In 2020, UK household expenditure on dental services was approximately £1.5 billion (9).
Dental inequalities and social inequalities:
Oral health inequalities are disparities in oral health that are preventable and both unfair and unjust. They are more than just inequalities in oral health status between rich and poor people. As with overall health, there is a continuous stepwise relationship across the whole social spectrum, with dental health deteriorating at each stage as people fall down the social ladder. (10).
Tooth decay is the most common oral disease affecting children and young people in England. Children from disadvantaged backgrounds are disproportionately more likely to be admitted to hospital to have teeth extracted. In England, almost one-fifth of such admissions were for children from the most deprived tenth of the population. In contrast, the least deprived 10% accounted for just 4% of admissions with a primary diagnosis of dental caries (tooth decay) (9). Sheffield has one of the highest rates in England for the extraction of children’s teeth under general anaesthesia (11). In 2017, 34% of five-year-old children in the Northwest experienced dental caries compared to just 16% in the Southeast of England (12) – a clear example of the North/South health divide.
This suggests that oral health inequalities may be a useful indicator or early warning of potential health inequalities more generally.
Initiatives to reduce oral health inequalities
There are a number of programmes and activities aimed at bridging oral health disparities. Unfortunately, there is often a lack of published monitoring and evaluation to determine the impact of these initiatives. For example, the oral health promotion strategy 2016-2021 works to reduce oral inequalities by improving oral health for people living in Bristol, Bath and Northeast Somerset, North Somerset and South Gloucestershire. The strategy aims to improve oral health through promoting healthy drink and food, improving levels of hygiene and improving exposure to fluoride. The strategy also aims to bridge inequalities through promoting oral health among vulnerable groups including children, elderly and those with disabilities in addition to those who smoke or consume high quantities of alcohol or use drugs (13) The strategy appears soundly based but, as yet, we haven’t found any reports of what results it has achieved i.e. has the strategy reduced oral health inequalities in practice?
However, here are some of the initiatives that have been reported to have had an impact:
- The prototype system consists of pilots and "waves" of dental contract reform. In addition to standard treatments, there is a greater emphasis on preventing dental illness (i.e., providing "complete oral health evaluations and self-care programmes"). An assessment of the first year of prototyping (2016-2017) found that 90% of patients had reduced or maintained levels of dental decay. 80% of patients had reduced or eliminated levels of gum disease. 97% of patients said they were satisfied with the dental care they received (14)
- A scheme ran in Teeside, aimed at improving the oral health of young children by providing materials for supervised toothbrushing in schools in socially deprived areas. Nursery and reception children in 58 schools joined the programme and school staff supervised tooth brushing daily. The data suggested a reduction in tooth decay levels in brushing schools compared to schools not participating in the scheme.
- The ‘Smile Award Plus’ programme was commissioned by Buckinghamshire County Council to improve the oral health of early years children and their families. The successful accredited settings are the ones that have food friendly, less sugar, healthy snacks and promote oral health messages. In 2016, 94 % of children’s centres achieved accreditation. Reported behaviour changes being made by families included dietary changes, appropriate bottle and dummy use, introduction of open cup drinking and improved compliance with tooth brushing (15)
To reduce oral health inequalities and help reduce health inequalities more widely:
- Recognise that prevention is better than cure, and allocate sustainable funding for prevention on that basis.
- Report on the effect of oral health initiatives, to assess their impact on oral health inequalities and identify which are most effective.
- Continue oral health promotion, to raise awareness..
- Check people at high risk (e.g. those with severe dental problems, to prevent them developing related non communicable diseases; and those with non-communicable diseases to screen for associated dental disease and provide appropriate treatment).
- Include oral health within Integrated Care Systems action plans, including greater collaboration between dentists, GPs and pharmacists.
Maysa Elsayedkarar August, 2021