Oral Health

Oral health is essential for general health and wellbeing, but good oral health is not equal across the population.  Poor oral health can have a negative impact throughout the life course, resulting in difficulties with eating, sleeping, and socialising. Most people are at risk of developing some oral disease during their lifetime. The most common diseases are dental caries (tooth decay), and periodontal (gum) diseases. While oral cancers are the most serious of oral diseases, tooth wear is of increasing concern. The impact of oral disease, particularly dental caries, includes pain, days lost from work or school, and general impacts on quality of life. 

The Inequalities in Oral Health in England Report identified poor oral health as almost entirely preventable, yet despite decades of good progress, oral health inequalities remain a significant public health priority in England. Some groups within the population display greater incidence of poor oral health, for example people who are homeless, in secure settings, or the traveller community. The prevalence of dental caries is highest in people from the most socioeconomically deprived areas. 

A wide range of risk factors are associated with oral diseases, for example diet, poor oral hygiene, smoking and alcohol use. Effective self-care and professional support are important for good oral health. 

Data from the Global Burden of Disease (GBD) shows ‘oral disorders’ to be the tenth cause of Years Living with Disability (YLD) in Lincolnshire. The National Dental Epidemiology Programme (NDEP) surveys provide information on the oral health of the Lincolnshire population and the health inequalities that exist. 

The Health and Care Act 2022 has brought changes to oral health provision, with the introduction of Integrated Care Systems (ICS). The responsibility for oral health improvement remains with the local authority, and Integrated Care Boards (ICBs) will take on delegated responsibility for dental services by April 2023. The NHS England Midlands Region Dental Strategy 2022-2024 helps the ICS understand the common issues relating to dental commissioning. 

The NHS Outcomes Framework and the Public Health Outcome Framework  have a number of indicators that relate to oral health, for example, “decayed, missing or filled teeth in five year olds“, and, “Access to NHS dental services – successfully obtained a dental appointment”. 

The NHS Long Term Plan has a focus on prevention (of ill health) and on health inequalities, with specific actions on factors that impact oral health, e.g. smoking and alcohol. The Plan commits to rolling out the Enhanced Health in Care Homes model across England by 2024. Oral health is one of the areas in the framework.  

Delivering Better Oral Health: An Evidence-Based Toolkit for Prevention sets out a consistent, UK wide approach to prevention of oral diseases, using evidence-based interventions. 

Core20PLUS5 is a national approach to support the reduction of health inequalities at both national and system level. The approach identifies ‘5’ focus clinical areas requiring accelerated improvement.  Within the Core20PLUS5 for children and young people, this includes oral health.  

There are various National Institute for Health and Care Excellence guidelines and quality standards relating to oral health, for example, oral health for adults in care homes and oral health promotion in the community.  

The Joint Health and Wellbeing strategy for Lincolnshire has aims, themes and priorities which are relevant to oral health. The strategy focusses on early intervention and prevention of ill health, to tackle inequalities and secure equitable provision of services. 

The pattern of deprivation across Lincolnshire reflects the national picture in that urban and coastal areas show relatively higher levels of deprivation. This is important for oral health given its association with levels of deprivation. 

2019 Global Burden of Disease data show ‘oral disorders’ to be the tenth most common cause of YLD in Lincolnshire for all persons, and ninth most common among males.

National Dental Epidemiology Programme (NDEP) surveys provide a local picture of oral health. The NDEP survey for 5-year-olds (2019) shows that about a quarter of 5-year-old children have experienced some form of dental decay in England – but figures vary considerably across Lincolnshire. Boston has the highest proportion of 5-year-olds with dental decay – significantly higher than the other districts, Lincolnshire and England. North Kesteven and South Kesteven have the lowest proportions and are significantly lower than England.  

The Lincolnshire NDEP survey of adults (2018/19) findings are comparable with national averages for functional dentition (i.e. that chewing, appearance, comfort, is satisfactory); Dental decay, filled teeth and gum bleeding are lower than the national average; The number of fitted dentures – slightly higher than England. 

The PHOF and NHSOF provide information on hospital tooth extractions for different ages, with Lincolnshire having lower rates than England. Rates of oral cancer mortality in Lincolnshire increase with age, with the highest rates exhibited in those aged over 75. 

In some areas of Lincolnshire, it is very difficult to access general dental services. Some of the most deprived communities on the East Coast are particularly impacted.  NHS dental services are not provided evenly across the county, with Lincoln City and the larger towns (e.g. Louth, Skegness, Boston, Stamford, Grantham) having multiple practices (in part because of the greater population density in these places), and other areas, for example large parts of East Lindsey, being serviced by a single dental practice. There is no system of patient registration with a dental practice – patients can choose to attend any dental practice that has capacity to accept them.  

The NHS England Midlands Region Dental Strategy 2022-2024 highlights that, across the Midlands, dental services are facing pressure from increasing demand and lack of resources to provide. The dental sector faced particular challenges during the Covid pandemic as infection prevention and control (IPC) protocols were put in place to ensure safety of patients and staff. 

There is strong evidence that water fluoridation is an effective public health intervention for reducing the prevalence of tooth decay whilst improving dental health. Approximately 250,000 people – a third of the population in Lincolnshire – are supplied with artificially fluoridated water as reported in the British Fluoridation Society the Extent of Water Fluoridation Report. This includes Lincoln, Gainsborough, Sleaford, Grantham, parts of Market Rasen and a large number of rural communities across the west and central areas of the county.  

From April 2023, the Lincolnshire ICB will assume responsibility for commissioning dental services while Lincolnshire County Council retains responsibility for oral health improvement. The Lincolnshire Oral Health Alliance Group (OHAG) coordinates oral health improvement work across the Lincolnshire system. 

NHSE/I is currently responsible for commissioning all NHS dental services. Private dental services are not within the scope of NHSE/I responsibility. NHS dental services in Lincolnshire include general dental services, urgent dental services, community dental services and dental services in NHS Hospitals.  

The NHS will provide clinically necessary treatment to keep the mouth, teeth and gums healthy and free of pain. Common dental treatments available on the NHS include scale and polish, fillings, root canal treatment and crowns and bridges. NHS dentists are commissioned for Units of Dental Activity (UDAs) which are a measure of the amount of work done during dental treatment. 

Where patients require a complex dental extraction within a primary care setting, this is provided by the Intermediate Minor Oral Surgery Service (IMOS). Where a patient requires referral for dental treatment at a hospital, within Lincolnshire this is provided by the United Lincolnshire Hospitals NHS Trust (ULHT). Special care dental services for adults and children are provided by Community Dental Services (CDS). 

Lincolnshire County Council commission an oral health promotion and epidemiology service, currently provided by the CDS. This service delivers a range of prevention activities to support good oral health, for example;   

• A supervised toothbrushing programme (Lincolnshire Smiles) across targeted education settings. 
• Training so staff are able to deliver the oral health component of the Early Years Foundation Stage (EYFS) Framework. 
• Carrying out the national dental epidemiology surveys in sampled settings.   
• Carrying out targeted oral health activities for vulnerable groups, for example, Afghan refugees, and people who are homeless. 
• Supporting the Swallowing, Oral Health and Nutritional Ambassadors (SONA) programme for social care providers. 
• Supporting oral health campaigns which promote good oral health, such as National Smile Month. 
• Supporting the Holiday Activities Food (HAF) Programme which supports children in receipt of free school meals during holiday periods. 

Whilst not specifically oral health improvement, a range of other commissioned services support people to maintain their oral health. For example, Lincolnshire’s integrated lifestyle service, ‘One You Lincolnshire’, supports people with a range of issues such as drinking less and becoming smokefree. 

This JSNA factsheet has been developed in collaboration with the Oral Health Alliance Group, with representation from the Local Dental Council, the Community Dental Service, NHS England, the Lincolnshire Integrated Care Board, Lincolnshire County Council and Health Education England. 

The NDEP surveys provide an opportunity to gain the views of the public on dental services. 

Healthwatch Lincolnshire published their findings from a Quick Poll Survey on Dental Services carried out in March 2022 amongst 236 people (Dental Survey Report). The aim was to gain an insight into the accessibility of NHS dental services in Lincolnshire and the ability to seek NHS dental treatment in the past 12 months. The report summarises how access to NHS dental services is a key issue throughout Lincolnshire. The Information and Signposting team have repeatedly heard from individuals who have contacted 10+ dentists to try to register with an NHS practice with no success. However, patients are able to register with many of these practices as private patients. 

Three key themes were identified in the Healthwatch report from December 2021 relating specifically to dental services: A lack of NHS provision; A lack of NHS treatment (private offered but unaffordable for many); and long waits for orthodontic services. 

• Data on the oral health of the population is limited and outdated.  As further NDEP surveys are carried out, updated data will allow us to formulate intelligence on the oral health needs of the population.   
• The COVID-19 pandemic has had a considerable impact on dental services and access to dental services. Long-term impacts of the pandemic on oral health are yet unknown. Continuing to gather intelligence and adjusting practice to address emerging needs form key components of the recovery and restoration work being undertaken in Lincolnshire.  
• Water fluoridation is an effective public health intervention for reducing the prevalence of tooth decay, yet a large proportion of the Lincolnshire population do not receive artificially fluoridated water. 
• There are inequalities in oral health in Lincolnshire, particularly evidenced in the NDEP surveys. Some preventative interventions, e.g. Lincolnshire Smiles, are targeted to areas of greatest need, however, there are gaps in provision due to lack of resources, with many more areas and their communities having need to benefit from these programmes. 

• Members of the Lincolnshire Oral Health Alliance Group will continue to work together to address oral health needs of Lincolnshire’s population.  This will support the oral health needs of the wider population whilst having a focus where there are the greatest health inequalities, for example, certain geographical areas and specific populations. 
• Organisations will continue to commission and provide services to meet the oral health needs of the population.  The Lincolnshire ICB will take on delegated responsibility for dental services, and Lincolnshire County Council will maintain responsibility for oral health promotion. 
• Recognising that changes are taking place to how decisions are made on areas that receive artificially fluoridated water, OHAG will continue to raise the awareness of the provision in Lincolnshire, to seek to address the differences in provision. 
• The Lincolnshire system will continue to support the National Dental Epidemiology Programme, by supporting and participating in surveys to gather data on the oral health needs of the population, to enable interventions to be focussed on those with greatest need. 

• Bristish Association for the Study of Community Dentistry
• Community Dental Services
• Lincolnshire Rapid Oral Health Needs Assessment 2022
• Lincolnshire Rapid Oral Health Needs Assessment 2022 – Summary
• Topic Statement (World Health Organisation)