Oral health (health and wellbeing needs in South Tyneside)

• The World Health Organization (WHO) emphasises the importance of good oral health, stating that 'the psychosocial impact of oral diseases often significantly diminishes quality of life'.
• Oral health is important for general health and wellbeing. Poor oral health can affect someone's ability to eat, speak, smile and socialise normally, for example due to pain or social embarrassment. Children may miss school and parents have to take time off work for their child to attend the dentist or be admitted to hospital. Other impacts include pain, infections, poor diet, and impaired nutrition and growth.
• Oral health problems include gum (periodontal) disease, tooth decay, tooth loss and oral cancers.
• Tooth decay is largely preventable, yet it is the most common oral disease affecting children and young people in England and is now the most common reason for 5 - 9 year olds to be admitted to hospital in England.
• Children with severe dental decay tend to experience lower growth, weigh less and have a lower quality of life. These improve after treatment of decayed teeth. This 'failure to thrive' is thought to extend beyond reasons of poor nutrition due to difficulty eating because of painful teeth.
• Dental access is good in South Tyneside when compared with the elsewhere in the North East. 81% of child (0 - 17) population seen in previous 12 months compared with 54 % in County Durham. 83% of adult (18+) population seen in the previous 24 months compared with 53 % in County Durham.
• Local authorities became responsible for improving the oral health of their population in April 2013. They are responsible for commissioning oral health promotion programmes and oral health surveys as part of the Public Health England (PHE) dental public health intelligence programme which aid the planning and evaluation of oral health programmes and monitoring of water fluoridation schemes.

• Whilst children's oral health has improved over the last 20 years, over a quarter of 5 year olds and 12 per cent of three year olds in South Tyneside have experienced tooth decay.
• Despite recent improvements, more deprived groups have poorer dental health and are more likely to be hospitalised for dental health problems. 72.5% of children in East Shields and Whitburn have healthy teeth compared with 87.9% of children in West Shields, Cleadon and Boldon.
• When comparing South Tyneside with the rest of the North East inequalities exist and approaches to prevention differ.
• 15.4% of children in Hartlepool, 18.3% in North Tyneside, 22.5% in Newcastle have decay experience compared to 26% in South Tyneside. 40.1 % of children in Sunderland have tooth decay. 

• The large variability in decay rates in the North East is likely to be heavily influenced by the variability of availability of fluoridated water. Hartlepool, Newcastle, Gateshead and Northumberland all have a higher proportion of decay-free five year olds than the national average and these are all areas with fluoridated water. This highlights the possibilities that exist through a population approach to improving health.
• As well as population approaches, targeted efforts into our vulnerable communities could help to narrow the gap in oral health inequalities. Consideration should be given to Public Health England advocated interventions such as tooth brushing schemes, utilising the workforce to promote good oral health, and a common risk factor approach which address key risk factors such as tobacco and alcohol and especially sugar reduction.

Dental access

• Dental access is good in South Tyneside when compared with the elsewhere in the North East. Though national trends around deprivation suggest that those at risk groups locally, may not be attending. Efforts should continue to promote visiting the dentists in all settings.
  • 81% of child (0-17) population seen in previous 12 months compared with 54 % in County Durham
  • 83% of adult (18+) population seen in the previous 24 months compared with 53 % in County Durham

Older people

• Long-term conditions can limit older people's ability to carry out their usual daily activities, which may impact on their oral hygiene routine and diet. This can leave older people at higher risk of both dental caries and periodontal disease
• Given the projected growth in the older population and the increase in some long term conditions, the future increased oral health needs of our older residents need to be catered for. The local system needs to ensure that oral health policies, oral health needs assessments, staff training on oral health care and a system to ensure oral hygiene support are all provided in residential, nursing care homes, 'care in your home' services and hospitals with inpatient facilities.

1. Reduce the population prevalence of dental disease - and especially levels of dental decay in young children and vulnerable groups
2. Reduce the inequalities in dental disease
3. Ensure oral health promotion programmes are evidence informed and delivered according to identified need.
4. Adopt a common risk factor approach to improving oral health and embed in local services.

• Public Health England recommends commissioning a range of upstream, midstream and downstream interventions based on the local oral health needs of the population. Some of these programmes may involve a universal approach whilst others may be targeted to areas of identified oral health inequalities following the Marmot principles of "proportionate universalism"
• For further information on levels of intervention see Figure 1 of the Appendices

1. Reduce prevalence of dental disease

• The effectiveness of fluoride in reducing levels of tooth decay at an individual level and at a community level is well documented. As advocated by PHE, local authorities should consider the case for water fluoridation in the context of local needs.

2. Reduce inequalities in dental disease

• Consideration should also be given to more targeted approaches in deprived communities such as tooth brushing programmes. The local oral health promotion team may be able to develop such an initiative with support from the children's integrated teams.
• Whilst the majority of oral health improvement programmes are directed towards children, service specification for care homes should include a responsibility for oral health that incorporates an oral health assessment on entry, daily mouth care in care plans for residents and regular access to an NHS dentist.
• Dental services for older people must be more integrated within the wider health and social care landscape. Developments in training, information sharing and referral pathways are necessary to achieve this. Formal and informal carers across all settings require appropriate training and support in ensuring adequate oral hygiene, recognising urgent dental conditions, and when and where to seek both routine and emergency dental treatment.

3. Ensure evidence informed oral health promotion

• Locally a review of oral health improvement programmes in line with national guidance, and the consideration integrating oral health improvement into existing commissioned programmes, would be beneficial.
• Nationally oral health policies, oral health needs assessments, staff training on oral health care and a system to ensure oral hygiene support is received are all more common in residential and nursing care homes than in 'care in your home' services and hospitals with inpatient facilities. Local efforts are needed to address this.

4. The common risk factor approach

• The common risk factor approach, integrates general health promotion by focusing on a small number of shared risk factors that can potentially impact a large number of chronic diseases. Reducing the sugar content of local food choices will have an impact obesity levels, especially childhood obesity, as well as reducing the impact upon oral health.
• Actions that could improve oral health through the environment include developing healthier children's centres and preschool settings, safe recreational areas (preventing dental trauma), removing high sugar food and drinks from public settings and introducing planning policies that promote healthier food outlets near schools.
• Efforts should be made to ensure that strategic approaches to tobacco, alcohol and obesity reflect the need to protect and promote oral health especially within deprived communities.  

Dental caries

• Dental caries (tooth decay) is the most common disease of the dental tissues and affects the majority of the population. It is caused by bacteria in the mouth utilising sugars in the diet as a source of food and producing acids as a by-product. The acids dissolve away the tooth substance leading to dental decay, abscess formation and eventually tooth loss.
• Every time sugar is consumed (in food and drink); bacteria in plaque in the mouth react with the sugar to produce acid. This creates holes in the teeth or 'tooth decay' (also known as 'dental caries').

Children

• Nationally, dental caries are the top cause of childhood hospital admission for five to nine-year-olds, with just under 26,000 admitted 2013 / 14 making 8.7 per cent of all admissions at an estimated cost of £14.5 million. In 2014 / 15 English hospital trusts spent £35 million on extraction of multiple teeth for under 18s).
• Whilst children's oral health has improved over the last 20 years, almost a third of five-year-olds and 12 per cent of three year olds in England have experienced tooth decay.

Periodontal disease

• Periodontal disease affects the structures which support the teeth; these are the tissues and ligaments which secure the teeth to the jaw bones. This disease is caused by a build-up of plaque around the teeth leading to the development of inflammation. In susceptible individuals the disease progresses by destroying the supporting structures of the teeth, the teeth become loose and if unchecked the disease results in tooth loss.

Trauma

• Teeth may be traumatised as a result of accidents and participation in contact sports. The upper incisor teeth are at greatest risk and experience most damage. The most recent data for England was published in March 2015 using a survey of 15 year olds which found the proportion of 15 year olds affected is very similar across the three countries (England, Wales, Northern Ireland), at around 4% of the population and there are no significant differences related to sex, free school meals, brushing or school attendance.

Mouth cancer

• Mouth cancer is the major fatal condition which affects the oral tissues. There is a high risk of developing mouth cancer in people who smoke and those who consume excessive amounts of alcohol.

Vulnerable groups

• Vulnerable groups in society are also more likely to suffer from poor oral health. NICE guidance 55 identifies a list of vulnerable groups who require specific support to improve their oral health. These include those who are:
  • From lower socio economic groups
  • Live in disadvantaged areas
  • Older and frail
  • Physical or mental disabilities
  • Who are, or who have been in care
  • Socially isolated
  • Have a poor diet
  • Smoke or misuse substances (including alcohol)
  • Some Black, Asian and minority ethnic groups

Lower socio economic groups

• Significant inequalities in oral health continue to exist with children in deprived communities having poorer oral health than those living in more affluent communities. For example across England there is huge variation ranging from 13 per cent to 53 per cent of five-year-olds having experience of tooth decay, these children have an average of three teeth affected. People from the most deprived backgrounds were twice as likely (14%) to be hospitalised for dental work than those that were better off (7%) in 2015. School-age children from the poorest backgrounds are up to three times more likely to be admitted to hospital for tooth extraction.

Older people

• The WHO noted that 'the interrelationship between oral health and general health is particularly pronounced among older people. Poor oral health can increase the risks to general health and, with compromised chewing and eating abilities, affect nutritional intake.'
• Maintaining good oral health can be difficult for elderly people. Moreover, the increasing numbers of older people with more teeth needing restoration has meant increasingly complex work for dentists. People living in residential care face additional challenges: oral health tends to be worse among elderly people residing in care homes. They also face particular difficulties accessing dental treatment and education regarding oral hygiene.

Physical or mental disabilities

• There are no national and local data on the oral health needs of people with mental health problems. There is a need for dental commissioners to tie oral health into any local commissioning arrangements that are set to improve the physical health of these vulnerable people.

Looked after children

• Although there are some national data to describe the health needs of looked after children, their oral health needs are routinely monitored. There is a requirement that all looked after children should have a health and dental check and this requirement from Ofsted requires Local Authority Fostering Services and its health partners to work together to achieve this. There is evidence to suggest that the oral health of looked after children and those entering care is poor.

Socially isolated

• Socially excluded people are accommodated in prisons, young offenders' institutes, secure children's homes, police custody suites or courts. They often have chaotic lifestyles and low aspirations for health, making it difficult for them to navigate systems and access healthcare. South Tyneside's blue light community are an appropriate example of this group.

Severely obese

• Severely obese people are in a high risk category for tooth decay due to diets high in refined sugars. They often have co-morbidities such as diabetes that can affect their oral health. However, severely obese people are unlikely to be able to access routine dental care within conventional dental practices due to the lack of suitable facilities.

Risk Factors

Teeth brushing

• Not brushing teeth at least twice a day is a key risk factor for poor oral health. 68 % of adults in routine and manual occupations have the lowest levels of reported brushing twice a day or more, compared with 79% of adults in managerial and professional occupations.

Lifestyle risk factors

• The risk factors for many general health conditions are common to those that affect oral health, namely a poor diet, smoking and alcohol misuse.

Diet

• The Scientific Advisory Committee on Nutrition found that high levels of sugar consumption are associated with a greater risk of tooth decay.
• PHE estimate that school-aged children consume around three times more sugar than the recommended maximum amount. Adults consume around twice the recommended maximum amount.
• Furthermore, high sugar consumption is associated with deprivation. Findings from the National Diet and Nutrition Survey reveal higher sugar intakes in adults in the lowest income group compared with other income groups.

Tobacco

• Smoking has a negative impact upon oral health. Seven per cent of current smokers have excellent oral health, compared with 11% of those who have never smoked.

Alcohol

• Guidelines on alcohol consumption produced by the Chief Medical Officer warns that drinking any level of alcohol increases the risk of a range of cancers including mouth cancer.  This is supported by a new review from the Committee on Carcinogenicity (CoC) on alcohol and cancer risk.

Children's oral health

• The proportion of five year olds free from dental decay is the only dental indicator in the key Public Health Outcomes Framework presented by Public Health England. 'dmft' is the number of 'decayed, missing and filled teeth'. This therefore includes teeth both with active, untreated decay (often seen as orange or brown 'holes' in the teeth), and teeth which have been treated by a dentist.
• The most recent dmft for three and 12 year olds can be found on Table 1 of the Appendices.
• The prevalence of decay is not equal across South Tyneside. Variation both geographically and by deprivation can be found in Figures 2 & 3 of the Appendices.

Oral cancer

• South Tyneside has the highest oral cancer registrations in the North East (Age standardised rates per 100,000 of the population).
• Oral cancer generally develops later in life, and can develop long after known risk factors are stopped. Based on a range of other indicators South Tyneside has a high proportion of people who smoke and drink alcohol beyond low risk levels which increases the risk of cancer of the mouth and throat.
• Oral cancer registrations 2012 - 2014 (Age standardised rates per 100,000 of the population) can be found in Table 2 of the Appendices.

Access to dental care

• Patients may access primary care NHS dental services anywhere in England although most will choose to secure a service close to where they live. In the North East NHS dental care is the service through which the vast majority of people secure dental services and purely private practice has not been identified as a significant part of the North East health care economy. The North East had the highest level of access to NHS dental services of any former Strategic Health Authority Area in March 2013.
• Early attendance at a dentist allows professional advice on diet, brushing and other key preventative factors to be given. Primary care dental services are services which can be accessed by any patient without the need for a referral from another healthcare professional.
• Access to dental services for school aged children is good with over 70% or more of children aged 5-13 accessing NHS dental services in the 12 month period. This declines amongst young adults but there is significant gender gap of around 15% between males and females. Young females in their 20s have a better health seeking behaviour than males. In the middle age 50% or more of the population access dental services, with a decline in the retired population.
• In 2009, 92% of adults were able to successfully make an appointment at a dentist for treatment1 and 74% of adults attended regular dental check-ups in the past three years.

• South Tyneside patients seen by an NHS dentist as a percentage of the population, by local authority, in the period ending December 2016:
  • 81% of child (0 - 17) population seen in previous 12 months
  • 83% of adult (18+) population seen in the previous 24 months

Low income families

• Nationally 45% of patients paid for their NHS dental care, 27% paid for private care, 25% received free NHS dental care and just 1% received a combination of both NHS and private dental care.
• In general, more free NHS care is provided in the north of England than the south. The second largest proportion of patients receiving free NHS dental care is the North East (29%).
• Using free school meals as a proxy for low income households - those eligible have worse overall dental health and reported poorer attendance for dental check-ups than ineligible children.

Wider unmet need

• There are a number of factors that impact upon oral health as identified in the Public Health Outcomes Framework (PHOF). Consideration should be given to both the levels of unmet need in these domains, and the implications for local oral health.
• Recent PHOF indicators which identify factors impacting on oral health can be found on Table 3 of the Appendices.

Children's oral health

• It is important to ensure that oral health promotion is targeted at those at greatest risk. The child population in South Tyneside is expected to remain the same but risk factors (Office for National Statistics:  Population projections), which will further increase demand for services, may be increasing.
• Whilst not a health related behaviour, being overweight or obese reflects an unhealthy diet. The trend in South Tyneside suggests that poor oral health will remain a risk.
• Consumption of 5 portions of fruit a day is seen as indication of the quality of a person's diet. 46% of 15 year olds in South Tyneside consume 5-a-day which is below the England average of 52.4%.
• Recent statistics on the level of excess weight in 10 - 11 year-olds can be found on Figure 4 of the Appendices.

Older people

• There are currently 11 million people in the UK over the age of 65, a figure that is set to increase to 14 million by 2032. In South Tyneside that is estimated to rise from 29,522 people in 2016 to 41,795 people in 2035.
• Good oral health is an essential component of active ageing. Social participation, communication and dietary diversity are all impacted when oral health is impaired.
• Household resident older people may not be able to easily access routine dental services due to functional limitations, transport difficulties and multiple long-term conditions. Coupled with this, as more people are keeping their teeth for longer the range of dental treatment required will be more complex than in the past and is more likely to demand the facilities of a dental surgery. This changing demographic picture makes identifying and accessing those who need preventive services and treatment more complex.
• Long-term conditions can limit older people's ability to carry out their usual daily activities, which may impact on their oral hygiene routine and diet. This can leave older people at higher risk of both dental caries and periodontal disease. The majority of adults aged over 75 are limited in their daily activities and the proportion who experience limitations has increased through the 1991, 2001 and 2011 censuses. Manual dexterity and tooth-brushing ability may be compromised by arthritis, Parkinson's disease and dementia, which can exacerbate periodontal disease and lead to tooth loss. Diabetes is also known to increase the risk of periodontal disease and hasten its progression.

• Under the terms of the Health and Social Care Act (2012) upper tier and unitary authorities became responsible for improving the health, including the oral health, of their populations from April 2013. From 1 October 2015 commissioning responsibility for the Healthy Child Programme for zero to five-year-olds transferred from NHS England to local government. This included the commissioning of health visitors, who lead and support delivery of preventive programmes for infants and children, including providing advice on oral health, weaning and advice on breastfeeding reducing the risk of tooth decay.
• NICE public health guidance (PH55) makes a number of recommendations aimed at improving oral health, many of which are underway in South Tyneside.
• One of the most effective ways to improve oral health is to embed it in all children's services at strategic and operational levels. Health visitors and school nurses are well integrated with the oral health promotion lead. The service specification for the oral health promotion lead may have a heavier focus on work with health visitors and school nurses. Oral health should be one of the priorities as the 0-19s service and the children and family integrated teams are developed. Health visitors should be trained both in oral health promotion and in how to access primary care dental services and first time dental examinations should be encouraged as early as possible.
• In South Tyneside, maternity staff, health visiting, neonatal unit and children's centre staff have received training to implement the UNICEF Baby Friendly Initiative standards. There is also ongoing training of breastfeeding peer supporters (women who have breastfed their own children and wish to support other women who chose to breastfeed). Breastfeeding support groups and infant feeding workshops are also held in the Children's Centres across the borough.
• A whole school approach to improving oral health is already underway through the Healthy Schools programme.
• Adults may be targeted within workplace settings through the 'Better Health At Work' award and adults in care settings could receive oral health advice. 
• Many public service environments promote oral health through the provision of drinking water and planning approaches to tackle the availability of poor quality food from takeaway outlets will also have a positive impact upon diet. Efforts will continue to ensure that oral health is promoted where practical and the food environment is supportive of making the healthy choice easier to make.

Community dental service

• The community dental services (salaried dental services) are the main providers of special care dentistry and specialist paediatric dental services. The services provide primary care for people who cannot be treated in the general dental services.

• NICE public health guidance (PH55) is aimed at public health and wider social and educational bodies as well as personnel within them and makes recommendations on how to assess oral health needs, develop local strategies and deliver community-based interventions in England.

Fluoride use

• Fluoride acts in several ways to slow and prevent the decay process and also to reverse decay in its early stages. The most important modes of action are to reduce demineralisation and promote re-mineralisation so that minerals are deposited back into the tooth surface. The effectiveness of fluoride reducing levels of tooth decay at an individual level and at a community level is well documented.

Key interventions to consider are:

• Targeted delivery of toothbrushes and toothpaste by health visitors
  • This has a high return on investment. The evidence for this is from studies which followed this approach with postal delivery of toothbrushes and toothpaste but this is likely to require additional staff and resources.
• Introduce supervised brushing in targeted areas
  • In the North East a small number of nurseries have developed schemes which they now sustain without extra funding. Supervised brushing schemes would likely require resource from the oral health promotion workforce in addition to start-up and continuing costs materials.  This could give an estimated £3.06 returned per £1 spent after 5 years (£3.66 after 10 years).
• Water fluoridation
  • Water fluoridation is one of a range of interventions available to improve oral health, and the only one that does not require behaviour change by individuals.
  • All water contains small amounts of naturally occurring fluoride. Fluoride in water at the optimal concentration (one part per million or 1mg fluoride per litre of water [1mg/l]) can reduce the likelihood of tooth decay and minimise its severity. Where the naturally occurring fluoride level is too low to provide these benefits, a water fluoridation scheme raises it to one part per million.
  • Reviews of studies conducted around the world confirm that water fluoridation is an effective, safe public health measure suitable for consideration in localities where tooth decay levels are of concern.
  • Local authorities also have the power to make proposals regarding water fluoridation schemes, a duty to conduct public consultations in relation to such proposals and powers to make decisions about such proposals.
• Adopt a common risk factor approach
  • Continue current evidence based interventions in smoking cessation and alcohol control services. Adopt best practice guidelines around tackling obesity and ensure that the activity from the childhood healthy weight group, the tobacco alliance and the alcohol harm reduction group reflect current oral health needs
  • Seek to ensure oral health promotion is included in training and education of health and social care staff so 'high risk' individuals are encouraged to see a dentist regularly for early detection of oral cancer.
• Sugar reduction
  • Tooth decay is linked with sugar consumption. Reducing sugar consumption should be part of the wider nutrition / food plan and PHE's sugar reduction work highlights a number of approaches to consider.
• Return on investment for oral health improvement
  • PHE's ROI highlights the difference in return over 5 and 10 years for health improvement programmes. Further information the potential return on investment on oral health interventions can be found on Figure 5 of the Appendices.

• Oral conditions can have an impact on children's quality of life in different ways, not just functionally, but also psychologically and socially. Nationally 58% of children aged 12 and 45% of those aged 15 reported that their daily life had been affected by problems with their teeth and mouth in the last three months. Children who were eligible for free school meals were more likely than other children to report problems in their daily life caused by their oral health.

Local picture

• The health related behavior questionnaire (HRBQ) targets year 4, 5, and 6 and years 8 and 10 for the mainstream provision in South Tyneside. The survey was also offered to alternative education.
• Key findings include:
  • Over three quarters of Year 4 - 6 children report brushing their teeth twice a day.
  • 1 in 5 children in Year 4 - 6 have not visited a dentist in the last six months. 
  • 1 in 5 children in Year 8 and 10 have not visited a dentist in the last six months. 
  • Further HRBQ findings can be found on Tables 4, 5 & 6 of the Appendices

National Picture

• Nationally more than three quarters of older children (12 - 15 years old), 77% of 12 year olds and 81% of 15 year olds, reported brushing their teeth twice a day or more often. Girls were more likely to do so than boys. Brushing at least twice a day was more common among children not eligible for free school meals than those who were eligible.
• Nationally the learning indicates that dental attendance, brushing, diet and smoking were all strongly associated with subjective oral health outcomes. Children who attend a dentist for check-ups reported better oral health, lower prevalence of toothache and better oral health related quality of life, with lower prevalence of oral impacts. Those who brushed twice a day or more often had better perceptions about their dental health and reported lower prevalence of oral impacts than those that brushed less often.

Adult dental access

• The number of patients seen during the recommended time frame is relatively high in South Tyneside compared to the England average.
• The GP patient survey asks patients [last time you tried] "Were you successful in getting an NHS dental appointment?"
• 95% of respondents in South Tyneside report being successful in getting an NHS dental appointment which is above the England average of 93%. 
• Table 7 of the Appendices provides further information on the responses for the GP Patient Survey.

• Diabetes
• Homelessness
• Substance misuse / treatment
• Poverty
• Gypsy, Roma, Travellers

Last Updated: December 2023