Oral health and dentistry in England

Background Oral health

Research has found that poor oral health impacts on general health. It has been associated with poor diabetic control, lung disease (mainly pneumonia) among the frail and elderly, and cardiovascular diseases.[1]

Public Health England (PHE) state “the cost to the NHS of treating oral health conditions is around £3.4 billion per year”.[2]

The PHE webpage ‘Oral health’ lists information and resources for practitioners to improve oral health and reduce inequalities in England.

The Health and Social Care Act 2012 conferred the responsibility for health improvement, including oral health improvement, to local authorities.[3]

Local authorities are statutorily required to provide or commission oral health promotion programmes to improve the health of the local population, to an extent that they consider appropriate in their areas. They are also required to provide or commission oral health surveys.[4]

The ‘Oral health survey of adults attending general dental practices 2018’ includes the following:

• More than a quarter of participants (27%) had tooth decay, having on average 2.1 decayed teeth, and more than half (53%) had gingival (gum) bleeding. Furthermore 18% reported currently being in pain and the same number had experienced one or more impacts of poor oral health ‘fairly’ or ‘very often’ in the previous year.
• Poorer oral health disproportionately affected those at the older end of the age spectrum and those from more deprived areas.[5]

Tooth decay is reportedly the most common cause of hospital admissions among children aged between 6 and 10.[6] PHE note that whilst there have been improvements in children’s oral health over the past 40 years, the rate of reduction in tooth decay levels has slowed in the past decade.[7]

The ‘Oral health survey of 3-year-old children 2020’ report says:

• Of the 3-year-olds participating in the survey, 10.7% already had experience of dental decay despite having had their back teeth for just 1 or 2 years. Among the 10.7% of children with experience of dental decay, each had on average 3 affected teeth
• Regional variations existed, with the highest experience of dental decay in northern England. Three-year-old children living in Yorkshire and The Humber were more than twice as likely to have experience of dental decay (14.7%) than children living in the East of England (6.7%).
• In some local authority areas up to a third of 3-year-olds had experience of dental decay, for example Salford, which had the highest prevalence in England (27.5%).
• Children living in the most deprived areas of the country were almost 3 times as likely to have experience of dental decay (16.6%) as those living in the least deprived areas (5.9%).
• There was also variation in prevalence of experience of dental decay by ethnic group and this was significantly higher in the Other ethnic group3 (20.9%) and the Asian and Asian British ethnic group (18.4%) than other groups.
• This is the second national survey undertaken for this age group in England. The first was completed in 2013, also by PHE (1). The findings indicate that the oral health of 3-year-olds has changed little since 2013 when 11.7% had experience of dental decay.[8]

The results of an oral health survey of 5-year old children carried out in 2019 found 23.4% had experience of dental decay. In line with findings from other surveys, prevalence of experience of dental decay was higher in children from more deprived areas (34.3%) than in children from less deprived areas (13.7%).[9]

The report concludes:

• Dental decay is largely a preventable disease. Further work to improve oral health and reduce inequalities is needed as nearly a quarter of 5-year-olds had experience of dental decay and the inequalities gap remains unacceptably high.[10]

Water fluoridation

PHE have published ‘Improving oral health: a community water fluoridation toolkit for local authorities’ (last updated in January 2021).

The toolkit says 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”.[11]

The PHE toolkit provides the following summary:

• 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.
• Reports published by Public Health England (PHE) in 2014 and 2018 comparing a range of health indicators for local authorities in this country, found lower rates of tooth decay among children from fluoridated areas than those from non-fluoridated areas. No evidence of harm to the health of people supplied with fluoridated water was found. PHE will continue to keep the evidence under review and use these reports as part of an ongoing dialogue with local authorities about ways of improving the oral health of their communities.[12]

The document notes that many existing fluoridation schemes in England have been running for 40 years or more, “with the oldest, serving the city of Birmingham, having existed for over 50 years”.[13]

It is estimated that around 6 million people in England have a fluoridated water supply, and an additional third of a million have a water supply with a naturally occurring background level of fluoride around the optimal level.[14] The PHE toolkit includes a map on page 18 indicating which areas this applies to.

The White Paper, ‘Integration and Innovation: working together to improve health and social care for all’, published in February 2021, set out plans for a Health and Care Bill which included reform of fluoridation schemes.

The White Paper set out plans to “streamline the process for initiating proposals for new schemes” by “moving the responsibilities for doing so from local authorities to central government”.[15]

The White Paper states:

• Since 2013, local authorities have had the power to propose, and consult on, new fluoridation schemes, variations to existing schemes, and to terminate existing schemes. […]

Local authorities have reported several difficulties with this process including the fact that local authority boundaries are not co-terminous with water flows, which requires the involvement of several authorities in these schemes, in a way which is complex and burdensome.

• […] we are proposing to give Secretary of State for Health and Social Care the power to directly introduce, vary or terminate water fluoridation schemes. The Secretary of State for Health and Social Care already has the existing power to decide on whether proposals for water fluoridation should be approved and responsibility for the administration of schemes.
• This removes the burden from local authorities and will allow the Department of Health and Social Care to streamline processes and take responsibility for proposing any new fluoridation schemes, which will continue to be subject to public consultation. Central government will also become responsible for the associated work, such as the cost of consultations, feasibility studies, and the capital and revenue costs associated with any new and existing schemes.[16]

The Health and Social Care Committee published their response to ‘The Government’s White Paper proposals for the reform of Health and Social Care’ on 14 May 2021. The report highlighted the Committee received “contrasting views” in written submissions in relation to the proposals on fluoridation.[17]

The Committee report notes that the Association of Dental Groups described a national programme for water fluoridation as “the single biggest preventative measure that could be taken to protect the nation’s oral health in the future”.[18]

However, others argued that fluoridation “must not be imposed on communities without their consent” and some suggested the decision to introduce a fluoridation scheme should remain with local authorities.[19]

The Health and Social Care Committee concluded:

We did not consider the fluoridation proposals during our evidence session. That said, it was covered by a number of submissions from both individuals and organisations that were opposed to the proposal and several clinical bodies that were in favour of it; and we draw the Department’s attention to that evidence. The Secretary of State will recognise the long-standing debate on fluoridation, and we look to him to set out a balanced response to both sides of the argument during the debates on the Bill.[20]

[1] PHE, Adult oral health: applying All Our Health, updated 11 March 2019

[2] PHE, Adult oral health: applying All Our Health, updated 11 March 2019

[3] PHE, Local authorities improving oral health: commissioning better oral health for children and young people, June 2014, page 4

[4] PHE, Local authorities improving oral health: commissioning better oral health for children and young people, June 2014, page 5

[5] PHE, Oral health survey of adults attending general practices 2018, page 4

[6] PHE, Community water fluoridation toolkit for local authorities, page 6

[7] PHE, Community water fluoridation toolkit for local authorities, page 6

[8] PHE, Oral health survey of 3-year old children 2020: a report on the prevalence and severity of dental decay, page 3

[9] PHE, Oral health survey of 5-year olds 2019: a report on the prevalence and severity of dental decay, page 4

[10] PHE, Oral health survey of 5-year olds 2019: a report on the prevalence and severity of dental decay, page 4

[11] PHE, Improving oral health: community water fluoridation toolkit, Last updated 19 January 2021, page 6

[12] PHE, Improving oral health: community water fluoridation toolkit, Last updated 19 January 2021, page 6

[13] PHE, Improving oral health: community water fluoridation toolkit, Last updated 19 January 2021, page 7

[14] PHE, Improving oral health: community water fluoridation toolkit, Last updated 19 January 2021, page 7

[15] Department of Health and Social Care, Integration and Innovation: working together to improve health and social care for all, 11 February 2021, page 58

[16] Department of Health and Social Care, Integration and Innovation: working together to improve health and social care for all, 11 February 2021, page 61

[17] Health and Social Care Committee, The Government’s White Paper proposals for the reform of Health and Social Care, 14 May 2021, page 32

[18] Health and Social Care Committee, The Government’s White Paper proposals for the reform of Health and Social Care, 14 May 2021, page 32

[19] Health and Social Care Committee, The Government’s White Paper proposals for the reform of Health and Social Care, 14 May 2021, page 32

[20] Health and Social Care Committee, The Government’s White Paper proposals for the reform of Health and Social Care, 14 May 2021, page 33