Guidance

Adult oral health: applying All Our Health

Updated 4 April 2022

The Public Health England team leading this policy transitioned into the Office for Health Improvement and Disparities (OHID) on 1 October 2021.

Introduction

This guide is part of ‘All Our Health’, a resource which helps health professionals prevent ill health and promote wellbeing, as part of their everyday practice. The information below will help front-line health and care staff to make the most of their trusted relationships with patients, families and communities to promote the benefits of good oral health for adults.

The guide also recommends actions that can be taken by managers and staff holding strategic roles.

View the full range of ‘All Our Health’ topics.

Promoting oral health in your professional practice

Poor oral health can lead to pain and discomfort, sleepless nights, loss of function and self-esteem, and in turn disrupt family life. It can also lead to time off work. Experiencing tooth decay or having missing teeth or ill-fitting dentures can lead to an individual becoming socially isolated.

Research has shown that such oral complaints can negatively affect a person’s confidence and their employment chances, including being promoted at work. The maintenance of oral health is a life skill that will have long term effects, not only on tooth decay but to a life free from disability.

Tooth decay - once filled - will need ongoing maintenance throughout life. Therefore, preventing teeth from becoming decayed through regular toothbrushing with fluoride toothpaste and minimising the amount and frequency of consumption of sugar-containing foods and drinks is key.

Toothbrushing also has an impact on reducing gum disease (periodontal disease) which can cause infection, bad breath and tooth loss in adult life. Lifestyle choices also impact on a person’s oral health - for example, tobacco use and drinking alcohol above the recommended levels are risk factors for oral cancer.

Recent research shows that poor oral health has an impact on general health, and has been associated with poor diabetic control. It has also been associated with lung disease - mainly pneumonia - among the frail and elderly, living in community care facilities or in hospital. The association between chronic gum disease and cardiovascular diseases is recognised - however, there is ongoing uncertainty regarding the clinical mechanism that causes this.

The impact of disease, and treatments such as fillings, can last a lifetime. Dental decay and gum disease are the most common oral conditions, and are largely preventable. The cost to the NHS of treating oral health conditions is around £3.6 billion per year.

Core principles for health professionals

This information has been created to help all health professionals:

• understand what they can do to help prevent oral disease
• use the guidance that is available to help patients, families and communities maintain oral health

Taking action

If you’re a frontline health professional

Frontline health or care professionals should talk to patients about how they can look after their mouths by taking various actions, including:

• brushing teeth with fluoride toothpaste containing 1350 to 1500ppm fluoride - last thing at night (or before bedtime), and on one other occasion
• reducing the amount and frequency of sugar in their diets, avoid smoking and other tobacco products, and staying within the recommended level of alcohol consumption
• being seen regularly by a dentist for check-ups, even if they have no teeth or are free from any apparent problems with their mouth or teeth - their dentist will advise how often they need a check-up
• seeing a dentist urgently if they have:
  • an unexplained ulceration in the mouth lasting for more than 3 weeks
  • a persistent and unexplained lump in the neck
  • a lump on the lip (inner or outer) or in the mouth consistent with oral cancer
  • a red patch in the mouth consistent with erythroplakia
  • persistent unexplained hoarseness
  • persistent pain in the throat or pain on swallowing lasting for more than 3 weeks

Those with dentures should clean teeth and dentures twice a day, especially just before bed. They should also leave dentures out of the mouth while sleeping.

The amount and frequency of consumption of sugar-containing foods and drinks should be reduced. Avoid sugar-containing foods and drinks at bedtime.

One glass of 150ml unsweetened fruit juice counts as one of your ‘5 a day’, but should be limited to no more than 150ml a day, and be consumed at meal times.

Further advice on healthy behaviours

Health professionals should advise patients:

• to avoid smoking or using smokeless tobacco, including for example shisha or hookah (consider tobacco cessation products or referral services)
• to avoid drinking more than 14 units of alcohol a week, on a regular basis
• eat a healthy diet, including a range of foods in line with The Eatwell Guide (PDF, 7.5MB)
• that people on some low income benefits or who have certain exemption certificate, are entitled to free NHS dental treatment

The combined effect of drinking alcohol and using tobacco multiplies the risk of developing mouth cancer.

Health professionals can use opportunities to share information about how to improve oral health with adults who are vulnerable or have co-morbidities, such as those accessing substance misuse services, memory clinics, diabetic clinics, mental health services.

Where possible, patients should use sugar-free medicines, particularly those using regular liquid prescription medicines such as methadone.

Accessing dental care

NHS dental treatment is free for:

• adults under 19, in qualifying full-time education
• pregnant women, or women who have had a baby in the previous 12 months
• those receiving low-income benefits, or if you’re under 20 and a dependant of someone receiving low-income benefits

The NHS has information about accessing routine and urgent dental care, and finding a dentist near you - alternatively family or friends may be able to recommend a dentist.

If you’re a team leader or manager:

There are many resources available to help you give clear and consistent messages to your patients and service users regarding their oral health including:

• delivering better oral health: an evidence-based toolkit for prevention
• the Inequalities in Oral Health in England Report describes the current picture of oral health inequalities and oral health service inequalities in England by socioeconomic position, geographic area, protected characteristics and vulnerable (disadvantaged) groups. This is the first time that epidemiological data, NHS data and academic literature have been reported in this way. Information in the report may be used to inform the equality impact assessment of proposed public health interventions and to inform the commissioning of services
• Adult oral health in care homes: toolkit. This toolkit will help with the implementation of NICE guidelines for improving the oral health of adults in care homes.

You can have an impact by helping people understand how to look after their mouths and how to find a dentist. There are a range of resources from The National Institute for Health and Care Excellence (NICE) which can be useful for NHS and other professionals who have direct or indirect responsibility for services - when helping people to stop smoking (NICE NG92).

Helping people understand the impact of alcohol misuse and the alcohol consumption guidelines can reduce their risk, see the Alcohol Guidelines Review. (PDF, 2.1MB)^{[footnote 1]}

If you’re a senior or strategic leader

If you are in a commissioning role, there are several documents you can use to support improving the oral health of vulnerable older people in all settings.

The oral health toolkit gives an overview of the impact of oral diseases, and presents evidence of what works to improve oral health to inform commissioning. The toolkit is supported by a rapid review of the evidence and a resource compendium.

NICE guideline PH55 ‘Oral health improvement for local authorities and their partners’ outlines how to improve oral health through improving diet and oral hygiene and access to dental services.

NICE guideline NG48 supports oral health for adults in care homes, by recommending policies on oral health are developed and followed. It advises residents to have their mouths assessed, and put in place care plans which include daily mouth care. Staff should have the knowledge and skills to support people’s oral health, and undertake or support daily mouth care.

‘Improving oral health: a community water fluoridation toolkit for local authorities’ (PDF, 1.17MB), is a toolkit outlining water fluoridation’s role in local oral health improvement strategies - this is the only intervention that does not require behaviour change by individuals.

Understanding local needs

Every regional centre has a consultant in dental public health. They are available to discuss local oral health needs.

There are also other sources of information available online to help find out about local oral health needs. These may be in the form of an oral health needs assessment, or part of a joint needs assessment.

The Dental Public Health Intelligence Programme holds the following oral health survey data:

• oral health survey of mildly dependent older people 2016
• 2019 North West dental health survey of services for older dependent people
• 2015 Oral health of older people in England and Wales

Measuring impact

As a health professional, there are a range of reasons why it makes sense to measure your impact and demonstrate the value of your contribution. This could be about sharing what has worked well in order to benefit your colleagues, or help you with your professional development.

Further reading, resources and good practice

Advice for patients and the public

The Eatwell Guide (PDF, 7.5MB), shows the proportions of different types of foods which are needed to have a well-balanced and healthy diet.

Better Health provides advice and guidance for the whole family. You can download the Change4Life Food Scanner app which lets you look up the sugar, saturated fat and salt in everyday foods and drinks.

Professional resources and tools

The NHS provides a free e-learning resource to deliver ‘simple brief advice’ on alcohol consumption to patients.

Supporting patients to stop using tobacco is simple to do, and this short training module (‘Very brief advice on smoking for dental patients’)will show you how to deliver this outcome.

NICE guidelines

• Oral health: local authorities and partners. NICE guidelines PH55 (2014)
• Oral health promotion: general dental practice. NICE NG30 (2015)
• Oral health for adults in care homes. NICE NG48 (2016)
• Oral health promotion in the community. NICE QS139 (2016)

NHS and other government supporting materials

• Delivering Better Oral Health provides evidence-based interventions and advice on how to support patients improve and maintain their oral and general health
• Smokefree and smiling: (PDF, 2.1MB) Helping dental patients to quit tobacco is a toolkit which gives guidance to dental teams, commissioners and educators on how they can contribute to reducing rates of tobacco use
• Sugar reduction: evidence into action (2014) (PDF, 1.18MB), reported the findings of an earlier review of the evidence for sugar reduction and an assessment of evidence-based actions to reduce sugar consumption
• ‘Making Every Contact Count’ (MECC) helps staff working with the public to give opportunistic, appropriate and timely advice on health and wellbeing. diet, smoking and alcohol which are risk factors for oral health and so the promotion of improvements in oral health will also contribute to general health and wellbeing
• an e-learning training resource on giving very brief advice to patients smoking is freely available and will help you provide advice to encourage people to quit smoking
• an e-learning resource is available to build the knowledge and skills required to deliver very brief alcohol consumption advice to patients
• factsheets are available with information on ulcers and other urgent dental symptoms or conditions that may present to pharmacy teams

Good practice examples

The Commissioning better oral health for vulnerable older people resource compendium contains a range of good practice examples.

Adult oral health in care homes: toolkit - to help with the implementation of NICE guidelines for improving the oral health of adults in care homes.

Mouth Care Matters is a Health Education England website, that offers training and resources to support healthcare professionals, to give advice to patients to improve their general and oral health.

1. Report from the Guidelines development group to the UK Chief Medical Officers. Department of Health (2016) ↩