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Oral health is part of general health and wellbeing and contributes to the development of a healthy child and school readiness.
Tooth decay is the most common oral disease affecting children and young people in England, yet it is largely preventable.
Although oral health is improving in England almost a quarter (24.7%) of 5 year olds have tooth decay, so 1 in 4 children will have tooth decay when they start school. Each child with tooth decay will have on average 3 to 4 teeth affected.
The first survey of 3 year olds found that 12% had visible dental decay with on average 3 teeth affected. Tooth decay was the most common reason for hospital admission for children aged 5 to 9 years in 2012 to 2013. Over 63,000 children aged 0 to 19 years were admitted to hospital for tooth extractions in 2014 to 2015.
Poor oral health impacts on children and families wellbeing and is costly to treat. It suggests wider health and social care issues such as poor nutrition, obesity, the need for parenting support, and in some instances safeguarding and neglect. Children who have toothache or who need treatment may have to be absent from school. Parents may also have to take time off work to take their children to the dentist. Dental treatment is a significant cost, with the NHS in England spending £3.4 billion per year on all ages primary and secondary dental care (with an estimated additional £2.3 billion on private dental care).
Children who experience high levels of disease that are treated with fillings and other restorations will require complex maintenance as they age. Those children with a poor oral health regime and unrestricted dietary habits will fare the worst and have treatment which not only maintains their historic decay and poor oral health but also require treatment of new oral problems as they age.
Poor oral health can be caused by many factors including:
- social inequalities where the imbalance in income, education, employment and neighbourhood circumstances affect the life chances of children’s development
- poor nutrition and infant feeding with high and frequent consumption of free sugars
- lack of access to fluoride including late commencing or infrequent tooth brushing with low or no fluoride toothpaste
Other risks are children:
- who already have evidence of oral disease including previous decay experience or previous extractions under general anaesthesia
- with medical conditions such as cardiac problems, cleft lip and palate and childhood cancers
Regularly consuming foods and drinks high in free sugars increases the risk of obesity and tooth decay. Ideally, no more than 5% of the energy we consume should come from free sugars. Currently, children and adults across the UK are consuming 2 to 3 times that amount. Sugary drinks have no place in a child’s daily diet but account for a surprisingly large proportion of the daily free sugar intake of both children and adults. Almost a third of the free sugars consumed by 11 to 18 year olds come from soft drinks.
Facts about oral health
Although largely preventable, tooth decay remains the most common oral disease affecting children and young people.
In 2015, 20% of 5 year olds had tooth decay in South East England compared to 34% in North West England with even greater inequalities within local authorities. Areas with higher levels of deprivation tend to have higher levels of tooth decay.
5.6% of 5 year old children in England had tooth decay in their incisor (front) teeth in 2015. This measure is useful as it indicates where children have been affected by a particular type of tooth decay. This is an aggressive form of decay that affects upper incisors and can be rapid and extensive in attack. It is associated with long term bottle use with sugar-sweetened drinks, especially when these are given overnight or for long periods of the day.
A recent survey of 3 year olds in England found that 12% had tooth decay ranging from 34% to 2% across local authority areas.
During 2014 to 2015, there were 33,871 cases of children aged 10 and under needing the removal of one or more teeth: a rise of 3% on the previous year.
Tooth decay was the most common reason for hospital admissions in children aged 5 to 9 years old in 2013 to 14.
In 2014 to 2015, hospital trusts spent £35 million on the extraction of multiple teeth for under 18s.
The Scientific Advisory Committee on Nutrition (SCAN) carbohydrates and health report found that high levels of sugar consumption are associated with a greater risk of tooth decay.
Core principles for health professionals
Healthcare professionals should:
- know the needs of individuals, communities and population and the services available
- think about the resources available in health and wellbeing systems
- understand the specific activities which can prevent, protect and promote
Improving the oral health of children is a Public Health England priority, with an ambition that every child grows up free of tooth decay to help give them the best start in life. PHE has established a Child Oral Health Improvement Programme Board (COHIPB) with a range of partners and stakeholders, which aims to improve the health of all children and reduce the oral health gap for disadvantaged children. The Board launched in September 2016 and introduced the COHIPB Action plan infographic detailing the 5 high level objectives of the board, how they will be delivered and what success looks like.
Healthcare professionals should be aware of the interventions that are recommended at a population level, which include:
- those stated in NICE guidelines Oral health: local authorities and partners (PH55), PHE guidance including commissioning better oral health, a rapid review of the evidence of cost effectiveness of interventions and local health and care planning menu of preventative interventions
- knowing about local population level programmes to improve child oral health and engage with commissioners to support them, for example, supervised tooth brushing, fluoride varnish and Starting Well programmes.
- supporting local commissioners, identifying where such programmes are working well and if there are areas for improvement
- advocating for oral health, finding out how an area is performing and seeking action through Health and Wellbeing Boards to address poor oral health
Community level interventions may be based around a specific area or community/setting of interest such as schools or children’s centres.
Healthcare professionals can support these interventions by:
- getting to know about local programmes
- promoting the programmes and encouraging people to get involved
- considering and agreeing signposting or referral arrangements
- building capacity by enabling local families to promote healthy eating through children’s centre group work or peer to peer programmes
- ensuring their clinical space supports good oral health, is breastfeeding friendly and promotes the Healthy Start scheme which provides free vouchers to families on low income that can be exchanged for fresh or frozen fruit or vegetables, milk, infant formula and vitamins
Family and individual level
Healthcare professionals can have an impact on an individual level by:
- ensuring all staff promote good oral health and access relevant training that is regularly updated, including an e-learning resource to support early years and health professionals
- knowing the evidence-based advice and treatment that should be given to. This can be found in delivering better oral health
- understanding how to help people change behaviour, for example, Oral health promotion: general dental practice (NG30)
- making every contact count (MECC) which focuses on staff working with the public giving appropriate and timely advice on health and wellbeing
- encouraging early intervention and evidence based advice, for example, Dental Check by One
There is one indicator with regard to child oral health in the public health outcomes framework (PHOF).
The NHS Outcomes Framework also contains indicators in relation to oral health:
- decaying teeth (3.7i)
- tooth extractions due to decay in children admitted as inpatients to hospital, aged 10 years and under (3.7.ii)
The Everyday Interactions Measuring Impact Toolkit provides a quick, straightforward and easy way for healthcare professionals (HCPs) to record and measure their public health impact in a uniform and comparable way.
The child oral health impact pathway is recommended for healthcare professionals to record and measure actions undertaken as part of routine care which impact on child oral health.
Examples of good practice
Delivering better oral health provides evidence-based interventions and new advice on how dental health professionals can improve and maintain the oral and general health of their patients.
Commissioning better oral health is a toolkit to support local authorities commissioning population level interventions that are effective in improving the oral health of children. These include targeted fluoride toothpaste and toothbrush distribution, supervised tooth brushing schemes, targeted community fluoride varnish schemes and water fluoridation.
Local authorities improving oral health: commissioning better oral health for children and young people is an evidence-informed toolkit for local authorities.
A rapid review of the evidence of cost effectiveness of interventions to improve the oral health of 0 to 5 year olds provides updated economic evidence on oral health prevention measures since the review published by NICE in 2014 (PH55). It includes supervised tooth brushing, fluoride varnish, water fluoridation, provision of toothbrushes and paste, and interventions provided in home visits by health workers.
Return on investment tool includes interventions with high quality evidence of effectively reducing tooth decay in 5 year olds.
Local Health and Care Planning: Menu of preventative interventions document outlines public health interventions that can improve the health of the population and reduce health and care service demand. It includes oral health interventions in Section 12: Maternity and early years.
Infographic for public health nurses, which highlights top tips for oral health improvement and aligns to the 4-5-6 model. Improving oral health for children and young people for health visitors, school nurses and practice nurses.
The RCPCH Healthy Child Programme (HCP) on Health Education England’s e-learning for Healthcare Oral Health module has been updated with new content and video. The e-learning resource is aimed at the early years workforce including health visitors, nurses and the child health team. For public health staff groups outside the NHS, the Oral Health session is available on The Healthy Child Programme Open Access webpage.
A PHE toolkit to support supervised tooth brushing programmes in early years and school settings supports commissioners and providers of supervised tooth brushing programmes in schools and early years settings in England, to gain assurance that they are commissioning and delivering high quality programmes.
‘Smiles 4Children’ is a tooth brushing feasibility report showing the deliverability, acceptability and cost of an early years supervised tooth brushing scheme.
Improving oral health: community water fluoridation toolkit aims to help local authorities make informed decisions on whether to implement, vary or terminate a water fluoridation scheme.
Scottish Dental Clinical Effectiveness Programme (SDCEP) is an initiative of the National Dental Advisory Committee (NDAC) and part of NHS Education for Scotland (NES).
Dental interventions to prevent dental caries in children provides recommendations, based on current evidence, to prevent caries in children and young people aged 0 to 18 years.
In July 2015, the Scientific Advisory Committee on Nutrition (SACN) published their carbohydrates and health report. It recommended that for all age groups from 2 years upwards, the average intake of free sugars should not exceed 5% of total dietary energy intake. Younger children should have even less than this.
The recommended intake of free sugars is no more than:
- 19g (5 sugar cubes) per day for 4 to 6 year olds
- 24g (6 sugar cubes) per day for 6 to 10 year olds
- 30g (7 sugar cubes) per day for 11 years and older
Sugar reduction: evidence into action reported the findings of an earlier review of the evidence for sugar reduction and an assessment of the evidence-based actions to reduce sugar consumption.
The Government measures to reduce sugar consumption will have a positive effect, including the soft drinks industry levy announced last year, and the reformulation programme with the gradual reduction of sugar in everyday food and drink.
The Eatwell Guide is an important policy tool that defines the government’s recommendations on a healthy diet. It makes healthy eating easier to understand by giving a visual representation of the proportions in which different types of foods are needed to have a well-balanced and healthy diet. The proportions shown are representative of food consumption over the period of a day or even a week, not necessarily each mealtime.
Oral health: local authorities and partners (PH55) makes recommendations on undertaking oral health needs assessments, developing a local strategy on oral health and delivering community-based interventions and activities.
Oral health promotion: general dental practice (NG30) covers how general dental practice teams can convey advice about oral hygiene and the use of fluoride. It also covers diet, smoking, smokeless tobacco and alcohol intake.
Oral health promotion in the community quality standard (QS139) December 2016 covers activities by local authorities and general dental practices to improve oral health, focusing on people at high risk of poor oral health, or who find it difficult to use dental services.
PHE, NHS and other government supporting materials
Health Matters – Child dental health (June 2017) This resource outlines how health professionals can help prevent tooth decay in children under 5 as part of ensuring every child has the best start in life.
Dental Public Health Epidemiology programme Oral Health Survey of 3 year old children 2013 is a report on the prevalence and severity of dental decay in 3 year old children.
National Dental Epidemiology Programme for England: oral health survey of 5 year old children 2015 is a report on the prevalence and severity of dental decay.
Local Authority Profiles – dental health of 5 year old children 2015. These profiles provide analysis and key findings on the dental health of 5 year old children in each upper tier local authority area in England. They can be used to help plan and commission evidence-based services based on local need.
The National Child Dental Health Survey has been carried out every 10 years since 1973. It includes children aged 5, 8, 12 and 15 years and reports on a dental examination and questionnaires for parents and 12 and 15 year olds.
The Eatwell Guide shows the proportions of different types of foods which are needed to have a well-balanced and healthy diet.
Change4Life is a campaign to tackle the causes of obesity. It aims to help families and middle-aged adults make improvements to their diet, activity levels and alcohol consumption. The Sugar Smart app gives information about how much sugar is in food and drink
Change4Life Be Food Smart app alerts parents to the hidden sugar, saturated fat and salt in everyday food and drink and highlights the harm this can do to their child’s health, including oral health.
Change4Life Guide for dentists provides dental specific key messaging and information on how dentists can support the Be Food Smart campaign and new app.
Change4Life Be Food Smart breakfast cereal commercial highlights the impact of sugar on oral health showing a disintegrating tooth.
Rapid review to update evidence for the healthy child programme 0 to 5 reviewed the evidence base supporting the healthy child programme (HCP) for 0 to 5 year olds. The HCP is the main universal health service for improving the health and wellbeing of children.
The relationship between dental caries and obesity in children: an evidence summary is a review of current evidence which explores whether they are found in the same individuals and populations.
Food labels gives information on identifying products and checking on foods that are high in fat, salt and added sugars.
How does sugar in our diet affect our health gives advice on the effects sugar can have on health.
Local Government Association (LGA) Tackling poor oral health of children – updated April 2016
Healthy futures Supporting and promoting the health needs of looked after children published by the LGA in 2017 and includes an oral health case study.