Oral health improvement strategy for priority groups

Chapter Three Oral health

This chapter considers the various oral diseases, changes to oral health over time and the impact of deprivation on oral health. It looks at each of the priority groups and considers their oral health status. It also considers the impact of medical conditions and cognitive disorders.

3.1 Oral Health in the United Kingdom

3.1.1 Tooth Loss

Since 1998 oral health has improved steadily across the United Kingdom. The latest Adult Dental Health Survey in 2009³ showed that 94% of adults across England, Wales and Northern Ireland had some natural teeth compared to only 87% in 1998. Comparable data available for Scotland reported that 88% of Scottish adults had some natural teeth.⁵ This is a considerable improvement on the previous figure of 82% reported in 1998.

3.1.2 Periodontal Disease

Periodontal disease^B is an important cause of tooth loss, particularly in older age. In 1998, 12% of all UK adults with their own teeth had moderate periodontal disease³ (gum pocketing of 4mm or more).

Poor oral hygiene contributes to both tooth decay and gum disease. Many older patients suffer from long-term conditions such as diabetes, which increases the risk of developing periodontal disease.²⁰ Rheumatoid arthritis, which influences the ability of patients to adequately control oral hygiene, also increases the risk.²¹ Medications such as calcium channel blocking agents for cardiovascular problems are linked to enlargement of gingival tissues.²² Smoking is also known to contribute significantly to the development of periodontal disease.²³

3.1.3 Oral Cancer

Oral cancers^C are among the most serious of oral diseases. In 2007, 5,410 people across the UK were diagnosed with some form of oral cancer, with 673 of these cases occurring in Scotland. The disease occurs more commonly in men than women, and incidence increases with advancing age.²⁴ In 2008, across the UK 1,822 deaths from one of the oral cancers were reported, 228 of which were in Scotland.²⁵ Survival is poor, with approximately half of those diagnosed dying from their condition within five years of diagnosis.²⁶ Early detection is important for improved survival, and dental SIGN guidelines include checking for signs of oral cancers during routine dental visits.²⁷ Major risk factors for the oral cancers are smoking and drinking,^27,28 as well as poor diet and nutrition.⁸ Human papillomavirus²⁹ and immunosuppression³⁰ have also been identified as significant risk factors.

3.2 Oral Health in Scotland

3.2.1 Tooth Loss and Dental Decay

The 2010 Scottish Health Survey,³¹ which reports on the health of adults in Scotland, found that 89% of adults in Scotland had some natural teeth (91% of men and 88% of women), very close to the national target of 90% of adults to have some natural teeth by 2010. The number of teeth lost rose steadily through the age ranges, until by the age of 75 and above, 57% of men and 46% of women had some natural teeth. There was a small improvement in oral health between the 2008 Survey³² and that carried out in 2010.

Dental health also is improving amongst younger people. The 2009/2010 National Dental Inspection Programme (NDIP) Report on the oral health of 5-year-old children in Scotland³³ reported that 64% of this age group were now free from obvious dental decay and encouragingly, the 2011 NDIP Report on the oral health of Primary 7 children found that 69% of children were free from dental decay.³⁴

These improvements should be reflected in the dental health of the Scottish adults of the future if recent trends are sustained.

3.2.2 Periodontal Disease

The 2008³² Scottish Health Survey reported that 30% of men and 27% of women in Scotland had experienced bleeding gums within the last month, following tooth brushing or flossing, indicating underlying gum disease. The problem was commoner than toothache and declined with advancing years as teeth were lost. For adults with natural teeth, the proportion of those teeth affected by gum conditions was found to be higher with advancing years.

3.2.3 Oral Cancer

In 2007, 673 new cases of cancer of the oral cavity were reported in Scotland. Scotland saw a steeper rise in the number of new cases than elsewhere in the United Kingdom.²⁴ Although oral cancer is relatively rare in those under 45 years of age, worryingly, the disease has also been increasing in younger people. Progress to reduce deaths from oral cancer is proving difficult to achieve, with approximately half of those who develop the disease still dying from their condition.²⁶

3.2.4 The Impact of Deprivation on Oral Conditions

Being from a deprived community makes it more likely that a person may suffer from poorer oral health. The effect is observed from childhood, and shows a clear gradient across society.³⁵

• The 2010 National Dental Inspection Programme³³ reported ongoing inequalities in the oral health of Primary 1 children, with only 46.5% of children in the most deprived communities having no obvious dental decay experience compared to 78.7% in the least deprived.
• Only 5% of men from more affluent communities had no natural teeth, compared to 13% in the most deprived areas. For women, the difference is even greater, with equivalent total tooth loss figures of 8% and 20%.⁵
• Oral cancer incidence is also linked to deprivation.¹⁰ Between 1976 and 2002, there was a general increase in oral cancer incidence with increasing deprivation. The effect is more pronounced in men than women. Smoking and alcohol consumption constitute major risk factors, acting together to increase oral cancer risk. While smoking has reduced across all social groups, cigarette use is lower in more affluent communities. The relationships between alcohol consumption, deprivation and oral cancer incidence are less clear in Scotland. Oral cancer is also associated with reduced consumption of fruit and vegetables, which is seen more commonly in more deprived communities.⁸

3.3 The Oral Health of Dental Priority Groups

3.3.1 The Oral Health of those with Special Care Needs

Adults with either physical or intellectual impairments may face significant challenges in maintaining oral health. Their dental treatment may also be more difficult to carry out, either due to a pre-existing medical condition, disability or frailty. The condition of the mouth may be compromised by prescribed medication.

Dental disease may also place medically compromised individuals at increased risk of ill health, exacerbating existing medical conditions. For adults with special care needs who are affected by these issues, preventing dental disease is central to the management of their overall condition, helping to reduce the complexity of care required.

For those who care for dependent or frail people, the effects of lack of attention to oral health may not always be obvious without training, and the information available on the oral health of people in care homes in Scotland identifies that there is scope for improvement.

A survey of residential and nursing home residents in Glasgow³⁶ reported that dental treatment was needed by approximately half of residents, with 6% needing urgent treatment. Living without care and attention to oral health treatment needs often leads to unnecessary pain and discomfort and difficulty when eating. In the survey, three-quarters of residents had lost all their natural teeth and some of them had no dentures. The provision of dentures when teeth have been lost restores dignity and allows an individual to eat and speak without embarrassment.

In many cases, residents in care homes only require basic oral care provision and ongoing daily preventive maintenance. This could easily be provided if carers had the information and training they need to care for the oral health of patients, and to refer to a dentist when this is needed.

In the Glasgow survey:

• Over three-quarters of care home residents needed attention to basic oral hygiene.
• A third needed fillings or extractions (33%).
• Of those who had kept some of their own teeth, 73% had tooth decay.
• A worrying 38% showed signs of disease in the soft tissues of the mouth.

Despite a genuine willingness to do the best for their residents, the survey found that care home staff are not always aware of the best ways to look after oral health.

3.3.2 The Oral Health of Homeless People in Scotland

Homeless people may find it difficult to maintain oral health. A recently commissioned survey³⁷ as part of the "Smile4life" Programme organised by the National Homeless People's Oral Health Improvement Group, to find out more about how being homeless affects the health and oral health of people in Scotland, found that homeless people suffer from problems likely to affect both general health and oral health:

• 85% smoke cigarettes.
• 31% drink alcohol at least once per day.
• 68% have used drugs.
• Depression is common.

With respect to oral health:

• Tooth decay is common, with homeless people tending to opt for extractions rather than for fillings.
• Losing all the natural teeth is relatively uncommon (6%), but in this situation is much more common in some areas than others.
• Attending the dentist may be difficult for homeless people with the vast majority only attending when they have problems.
• Although 42% had attended the dentist within the last year, only a third were registered.
• Over three-quarters would like to drop in for dental treatment without an appointment.
• Just under half found it difficult to get dental treatment.
• Many experienced extreme dental anxiety.
• Over a quarter of the participants were "always" embarrassed and self-conscious about the appearance of their teeth.

3.4 The Impact of Medical Conditions and Intellectual Problems on Oral Health

3.4.1 The Impact of Medical Conditions

A number of vulnerable and dependent adults have medical conditions which complicate the provision of dental care. These include those suffering from bleeding disorders such as haemophilia, patients with cardiovascular disease and individuals who are immuno-compromised.⁴ For these groups of patients, the prevention of oral diseases will reduce the need for complex oral healthcare and help to safeguard general health. These disorders present with a wide spectrum of clinical severity. In some cases, treatment can be delivered by the normal primary care provider in the practice setting. At the more severe end of the spectrum, hospitalisation may be required.

Bleeding Disorders

Those undergoing anticoagulant therapy, those with coagulation defects and those suffering from thrombocytopenia fall within this group.⁴ Dental extractions and oral surgery procedures may be more complicated for these groups of patients. In many cases, patients may be treated within general practice or by arrangement in dedicated units. However, management may need to be carried out within a specialist unit.

Cardiovascular Disease

Patients suffering from cardiovascular disorders cover a wide spectrum of conditions, ranging from mild ischaemic heart disease and heart valve defects to complex cardiac disorders. At the simple end of the spectrum treatment may be provided in dental practice, with minor adjustments to treatment regimes, whereas for those with complex conditions, management within the hospital setting may be essential.⁴

The dental management of those suffering from heart valve disease remains controversial and has recently been the subject of guidance from the National Institute for Health and Clinical Excellence.³⁸ The risk of bacteraemia following tooth brushing and following procedures such as dental scaling and extraction is recognised. However, for the majority of patients, oral healthcare, including dental scaling and dental extractions, can be provided within the primary care dental surgery setting without the need for antibiotic cover. It is extremely important that such patients are encouraged to maintain good standards of oral healthcare to reduce the risk of transient bacteraemia and that tooth decay is minimised to reduce the need for dental extractions.

Immuno-compromised Patients

Oral diseases such as candidiasis, herpes infections, ulcers, periodontal disease and spontaneous oral bleeding are seen more often in immuno-compromised patients. Oral lesions may also be seen in patients who are HIV positive or suffering from AIDS.³⁹ Oral problems include: ulcers, xerostomia, and interference with salivary gland function.

Candida infection is commonly found in such patients.⁴⁰ Conditions such as hairy leukoplakia are also seen commonly in those with HIV infection but are also seen in other patients suffering from compromised immune systems.⁴¹

3.4.2 The Impact of Intellectual Impairment

It is acknowledged that adults with learning disabilities frequently have poorer oral health than non-impaired individuals.^42,43,44 A number of problems are commonly seen:

• Poor oral hygiene.
• More gum disease and gingivitis.
• Oral mucosal pathology.
• More extractions and lower levels of restorative care than in the rest of the population.

Individuals with intellectual disability are also more likely to suffer from a range of co-existing medical problems and are therefore more likely to be admitted to hospital for dental procedures than those without such disabilities.

Active oral health risk assessment and prevention of disease reduces the risk of developing oral disease and therefore reduces the requirement for hospital admission.

A recent survey of Community Dental Service Clinical Dental Directors in Scotland has highlighted inconsistencies in the approach to risk assessment for the intellectually disabled and in the use of standardised protocols and documentation systems specifically designed for this patient group.⁴⁵