Guidance

Context

Context

Introduction

Oral health is important to general health and wellbeing. Poor oral and dental health can affect a person's ability to eat, speak and socialise normally, for example, due to social embarrassment or pain (Department of Health Dental quality and outcomes framework). Oral diseases are also associated with coronary heart disease (Humphrey et al. 2008; Mathews 2008); diabetes complications (Grossi and Genco 1998; Stewart et al. 2001; Taylor 2001); rheumatoid arthritis (Ortiz et al. 2009); and adverse pregnancy outcomes (Xiong et al. 2006).

Tooth decay (dental caries) and gum disease (periodontal disease) are the most common dental problems in the UK. They can be painful, expensive to treat and can seriously damage health if left unchecked ('Dental quality and outcomes framework'). However, both problems are largely preventable (Levine and Stillman-Lowe 2009).

Oral health in England

While oral health in England has improved significantly across the population as a whole over recent decades, marked inequalities persist. The Health and Social Care Information Centre adult dental health survey 2009 reported that the proportion of adults in England without any natural teeth fell over the last 30 years from 28% to 6%. However, the survey also showed a clear socioeconomic gradient. For example, people from managerial and professional occupation households had better oral health (91%) compared with people from routine and manual occupation households (79%).

The NHS dental epidemiology programme for England oral health survey of children aged 12 showed that levels of dental disease among this group are decreasing, in line with previous survey years.However, from May 2006, data are collected about children only if written information and consent has been provided. Previously, consent was assumed if a letter was sent to the parents or guardians and no objection was received. These consent arrangements suggest a bias towards the participation of those who are less likely to have tooth decay (Davies et al. 2011).

Data collected between 2008 and 2009 show 66.6% of 12 year old children were free from visually obvious dental decay. However, 33.4% are reported as having dental caries (with 1 or more teeth severely decayed, extracted or filled). The same survey reported a higher prevalence and severity of oral disease among those living in Yorkshire and the Humber, the north west and north east compared to those in the midlands and south west; with the lowest levels of disease reported in the south and east (The NHS dental epidemiology programme for England: oral health survey of 12 year old children 2008/2009).

The National dental epidemiology programme for England oral health survey of 5 year old children 2012 indicates wide variations in dental health across the general population. A significant proportion of children (72.1%) are free from obvious dental decay, with 27.9% having at least 1 decayed, missing or filled tooth. However, at the local authority level, the prevalence of dental caries ranges greatly: from the lowest reported of 12.5% in Brighton and Hove to the highest of 53.2% in Leicester.

Improving the oral health of local populations

The risk factors for poor oral health – diet, smoking, alcohol use, hygiene, stress and trauma – are the same as those for many chronic conditions (Watt and Sheiham 2012).

Risk factors for severe dental caries in the UK include: living in a deprived area; being from a lower socioeconomic group or living with a family in receipt of income support; belonging to a family of Asian origin; or living with a Muslim family where the mother speaks little English (Rayner et al. 2003). Other risk factors include substance misuse or having a chronic medical condition (Department of Health valuing people's oral health: a good practice guide for improving the oral health of disabled children and adults).

The oral health of local communities is important for their general health and wellbeing and their quality of life. It may be improved by adopting a 'common risk factor' approach and by providing evidence-based oral health promotion programmes and interventions. The aim of the latter is to improve people's:

  • diet – this includes reducing the amount of sugar consumed and how frequently

  • oral hygiene

  • access to fluoride products

  • access to a dentist.

The role of local authorities in improving oral health

Since April 2013, NHS England (previously the NHS Commissioning Board) has been working with local authorities and Public Health England to develop and deliver oral health improvement strategies and commissioning plans specific to the needs of local populations (NHS Commissioning Board securing excellence in commissioning primary care; Public Health England commissioning better oral health for children and young people).

Oral health needs assessments are required to inform joint strategic needs assessments. Local authorities have the responsibility for commissioning surveys of dental health, dental screening and improving the oral health of their populations.

Delivering better oral health toolkit

Below (box 1) is an edited extract from Public Health England's delivering better oral health: an evidence-based toolkit for prevention. This toolkit provides practical, evidence‑based guidance to help dentists and their teams promote oral health and prevent oral disease among their patients.

Box 1 Summary guidance for primary care dental teams: Advice for patients

Prevention of caries in children aged 0–6 years

Children aged up to 3 years:

  • Breastfeeding provides the best nutrition for babies

  • From 6 months of age infants should be introduced to drinking from a free-flow cup, and from age 1 year feeding from a bottle should be discouraged

  • Sugar should not be added to weaning foods or drinks

  • Parents or carers should brush or supervise toothbrushing

  • As soon as teeth erupt in the mouth brush them twice daily with a fluoridated toothpaste

  • Brush last thing at night and on one other occasion

  • Use toothpaste containing no less than 1000 parts per million (ppm) fluoride

  • It is good practice to use only a smear of toothpaste

  • The frequency and amount of sugary food and drinks should be reduced

  • Sugar-free medicines should be recommended

All children aged 3–6 years:

  • Brush at least twice daily, with a fluoridated toothpaste

  • Brush last thing at night and at least on one other occasion

  • Brushing should be supervised by a parent or carer

  • Use fluoridated toothpaste containing more than 1000 ppm fluoride. It is good practice to use a pea-sized amount

  • Spit out after brushing and do not rinse, to maintain fluoride concentration levels

  • The frequency and amount of sugary food and drinks should be reduced

  • Sugar-free medicines should be recommended

Children aged 0–6 years giving concern (for example, those likely to develop caries, those with special needs). All advice as above, plus:

  • Use fluoridated toothpaste containing 1350–1500 ppm fluoride

  • It is good practice to use only a smear or pea-sized amount

  • Where medication is given frequently or long term, request that it is sugar free, or used to minimise cariogenic effects

Prevention of caries in children aged from 7 years and young adults

All children and young adults:

  • Brush at least twice daily, with a fluoridated toothpaste

  • Brush last thing at night and on at least 1 other occasion

  • Use fluoridated toothpaste (1350–1500 ppm fluoride)

  • Spit out after brushing and do not rinse, to maintain fluoride concentration levels

  • The frequency and amount of sugary food and drinks should be reduced

Those giving concern (for example, those with obvious current active caries, those with ortho appliances, dry mouth, other predisposing factors, those with special needs). All the above, plus:

  • Use a fluoride mouth rinse daily (0.05% NaF) at a different time to brushing

Prevention of caries in adults

All adults:

  • Brush at least twice daily with fluoridated toothpaste

  • Brush last thing at night and on at least 1 other occasion

  • Use fluoridated toothpaste with at least 1350 ppm fluoride

  • Spit out after brushing and do not rinse, to maintain fluoride concentration

  • The frequency and amount of sugary food and drinks should be reduced

Those giving concern (for example, with obvious current active caries, dry mouth, other predisposing factors, those with special needs). All the above, plus:

  • Use a fluoride mouth rinse daily (0.05% NaF) at a different time to brushing

Prevention of periodontal disease – to be used in addition to caries prevention

All adults and children

Self-care plaque removal

Remove plaque effectively using methods shown by dental team. This will prevent gingivitis and reduce the risk of periodontal disease

Daily effective plaque removal is more important to periodontal health than tooth scaling and polishing by the clinical team

Tooth brushing and toothpaste

Brush gum line and each tooth twice daily (before bed and at least on 1 other occasion). Use either:

  • a manual or powered toothbrush

  • small toothbrush head, medium texture

All adults and ages 12–17

Interdental plaque control

Clean daily between the teeth to below the gum line before toothbrushing:

  • For small spaces between the teeth use dental floss or tape

  • For larger spaces use interdental or single tufted brushes

  • Around orthodontic appliances and bridges use kit suggested by the dental professional

Risk factor control

Tobacco

All adults and adolescents:

  • Do not smoke

  • Smoking increases the risk of periodontal disease, reduces the benefits of treatment and increases the chance of losing teeth

Diabetes

Patients with diabetes should try to maintain good diabetes control as they are:

  • At greater risk of developing serious periodontal disease

  • Less likely to benefit from periodontal treatment if the diabetes is not well controlled

Medications

Some medications can affect gingival health

Prevention of peri-implant disease

All adults with dental implants:

  • Dental implants require the same level of oral hygiene and maintenance as natural teeth

  • Clean both between and around the implants carefully with interdental kit and toothbrushes

  • Attend for regular checks of the health of gum and bone around implants

Prevention of oral cancer

  • Do not smoke

  • Do not use smokeless tobacco (such as, paan, chewing tobacco, gutkha)

  • Reduce alcohol consumption to lower risk levels

  • Increase intake of non-starchy vegetables and fruit

Evidence-based advice and professional intervention about smoking and other tobacco use

All adolescents and adults:

Tobacco use, both smoking and chewing tobacco, seriously affects general and oral health. The most significant effect on the mouth is oral cancers and pre-cancers.

  • Do not smoke or use shisha pipes

  • Do not use smokeless tobacco (such as, paan, chewing tobacco, gutkha)

If the patient is not ready or willing to stop they may wish to consider reducing how much they smoke using a licensed nicotine-containing product to help reduce smoking. The health benefits to reducing are unclear but those who use these will be more likely to stop smoking in the future.

Evidence-based advice and professional intervention about alcohol and oral health

All adolescents and adults:

  • Drinking alcohol above the recommended levels adversely affects general and oral health with the most significant oral health impact being the increased risk of oral cancer.

  • Reduce alcohol consumption to low risk (recommended) levels.

The Chief Medical Officers' guidelines for alcohol consumption (2016)

  • All adults: you are safest not to drink regularly more than 14 units per week, to keep health risks from drinking alcohol to a lower level If you do drink as much as 14 units per week, it is best to spread this evenly over 3 days or more.

  • Young people: young people under the age of 18, should normally drink less than adult men and women.

  • Pregnant women: if you are pregnant or planning a pregnancy, the safest approach is not to drink alcohol at all, to keep risks to your baby to a minimum.

  • The risk of harm to the baby is likely to be low if a woman has drunk only small amounts of alcohol before she knew she was pregnant or during pregnancy.

Evidence-based advice and professional intervention about healthier eating

All ages:

  • The frequency and amount of consumption of sugars should be reduced

  • Avoid sugar containing foods and drinks at bedtime when saliva flow is reduced and buffering capacity is lost.

What does this guideline cover?

The Department of Health (DH) asked the National Institute for Health and Care Excellence (NICE) to produce this guideline on oral health needs assessments and community oral health promotion programmes, in particular, for vulnerable groups at risk of poor oral health (see the scope).

This guideline does not provide detail on oral health promotion and dental treatment in residential or care settings or preventive information, or cover treatments and advice provided by dentists.

The absence of any recommendations on interventions that fall within the scope of this guideline is a result of lack of evidence. It should not be taken as a judgement on whether they are cost effective.

Status of this guideline

The draft guideline, including the recommendations, was released for consultation in May and June 2014. At its meeting in June 2014, the PHAC amended the guideline in light of comments from stakeholders and experts and the fieldwork. The guideline was signed off by the NICE Guidance Executive in September 2014.

The guideline complements NICE guidelines on oral health promotion: general dental practice and oral health for adults in care homes.

All healthcare professionals should ensure people have a high quality experience of the NHS by following NICE's guideline on patient experience in adult NHS services.

All health and social care providers working with people using adult NHS mental health services should follow NICE's guideline on service user experience in adult mental health.

The recommendations should be read in conjunction with existing NICE guidance unless explicitly stated otherwise. They should be implemented in light of duties set out in the Equality Act 2010.