Improving Oral and dental health in the UK charted by the Adult and Child Dental Health Surveys
Submitting InstitutionUniversity of Birmingham
Unit of AssessmentAllied Health Professions, Dentistry, Nursing and Pharmacy
Summary Impact TypeSocietal
Research Subject Area(s)
Medical and Health Sciences: Dentistry, Public Health and Health Services
Summary of the impact
"One in 10 adults in Wales has no natural teeth" (BBC News), "Cost
puts off some going to the dentist" (BBC News) and "Overall
improvement masks dental health concerns", (British Dental
Association, Press Release). These are examples of the sensational
headlines which accompanied the publication of the findings of the 2009 Adult
Dental Health Survey (ADHS). Researchers at Birmingham's Dental
School were key members of the research consortium that carried out both
the ADHS as well as the 2003 Child Dental Health Survey (CDHS).
The findings from these surveys demonstrated an overall improvement in the
nation's oral health but also highlighted areas of inequality. The
Government regards these surveys as being of vital importance in providing
gold-standard information about the nation's oral health and uses the
findings to inform oral health policy in the areas of workforce planning,
the provision of, and access to, dental services. The impact of these
internationally-leading studies is reflected in Government policy
documents and in public debates about the future provision of dentistry.
Every ten years the UK Government has commissioned national
epidemiological surveys of the oral health of the nation. The Adult
Dental Health Survey (ADHS) was first undertaken in 1968 and has
been carried out each decade, with the last ADHS survey in 2009.
Similarly, a Child Dental Health Survey (CDHS) has been performed
every 10 years since 1973. The robust oral epidemiological data obtained
through these surveys, and Birmingham's long-standing expertise in and
contributions to these surveys, informs Government strategic policy
decisions on UK oral/dental healthcare provision and workforce planning.
Working with the Office for National Statistics, a research consortium of
dental schools (Birmingham, Newcastle, Cardiff, Dundee, Kings College
London and University College London) performs these surveys (under
competitive tender). All partners are involved equally in every aspect of
the survey, which includes development of criteria, recruitment and
training of dental examining teams, questionnaire development, analysis of
data and report writing. As one of the key partners since 1993, the
Birmingham team has contributed to all these aspects of the surveys and
provided leadership in examiner training and questionnaire development.
Seminal longitudinal research by Anderson (Professor of Dental
Public Health until 1998) provided the first evidence (Br Dent J
1995;179:125) of reducing caries rates (dental decay) amongst UK children
over a 30 year review interval. This provided valuable information which
complemented and underpinned the CDHS in 1993 & 2003 by White
(Senior Lecturer/Associate Professor), Morris (Lecturer/Hon Senior
Lecturer), Anderson, and Bradnock (Senior Lecturer/Hon Senior
Lecturer) (1). The 2003 CDHS showed: Improving oral health in 12
and 15 year olds, i.e. permanent teeth over a decade - less decay and most
decay treated; little change in the condition of primary teeth of younger
children (5 and 8) over a decade.
The ADHS of 1998 & 2009 involved the Birmingham team of White,
Hill (Lecturer), Morris, Anderson, and Bradnock. The
Birmingham team took the lead in two key areas of the 2009 ADHS: Dental
attendance patterns, oral health behaviour and the current barriers to
dental care (2); and, Common oral health conditions and their
impact on the population (3). The 2009 ADHS demonstrated:
- A significant reduction in the proportion of edentate adults in the
- A divergence between adults up to the age of 45, who generally have
better oral health and have had less restorative care, and those aged
45+ (the 'heavy metal' generation) who have less teeth and more
- Inequalities in oral health related to social class.
All of these findings have significant implications for planning dental
services in the future, in particular the need to meet the high treatment
demands of older adults, whilst acknowledging that younger adults will
require less treatment and therefore the skill mix requirement within
dentistry will change. This will in turn have an impact on training
provision and workforce planning and there will also be challenges in how
to reduce oral health inequalities.
This extensive body of oral epidemiological data has underpinned models
adopted by the Department of Health for provision of, and access to, oral
healthcare in the UK. Implementation of a new General Dental Services
(GDS) contract in 1990 with a capitation payment to dentists was new to
the UK and our research (White, Anderson) was crucial in
determining the efficacy of this model (4). Birmingham research
also provided evidence of how to map oral health needs and service
provision across a population, which in turn allowed planning of dental
manpower to meet these requirements (5). Increasing recognition of
the importance of access within the provision of oral healthcare
contributed to the introduction of the Personal Dental Services (PDS)
scheme (employing a locally-negotiated contract and capitation-based
funding of adult GDS) following the Health and Social Care Act 2003. The
Birmingham research team of Hill, Morris, Anderson, Bradnock and Burke
(Professor of Primary Dental Care) was central to the evaluation of the
PDS pilots (6) and demonstrated an increased capacity in the
system to deliver primary and emergency care as well as encouraging a new
skill-mix, improved job satisfaction and working conditions thereby moving
us towards primary care provision based upon quality in addition to
activity and cost.
References to the research
1. Morris AJ, Nuttall NM, White DA, Pitts NB, Chestnutt
IG, Evans D. Patterns of care and service use amongst children in the UK
2003. Br Dent J. 2006; 200: 429-34. doi:10.1038/sj.bdj.4813462
2. White DA, Tsakos G, Pitts NB, Fuller E, Douglas GV, Murray JJ,
Steele JG. Adult Dental Health Survey 2009: common oral health conditions
and their impact on the population. Br Dent J. 2012; 213: 567-72.
3. Hill KB, Chadwick B, Freeman R, O'Sullivan I, Murray JJ. Adult
Dental Health Survey 2009: relationships between dental attendance
patterns, oral health behaviour and the current barriers to dental care.
Br Dent J. 2013; 214: 25-32. doi:10.1038/sj.bdj.2012.1176
4. White D and Anderson, R. Children's dental health
under the capitation scheme. Community Dental Health 1996; 13 (Suppl 1):
21-48. PMID: 8689496
6. McLeod HST, Morris AJ, Hill KB. Evaluation of personal dental
services (PDS) first wave pilots: the alternative to general dental
services (GDS) offered by the capitation-based pilots. Br Dent J. 2003;
195: 644-650. doi:10.1038/sj.bdj.4810782
Details of the impact
The research described above has impacted the development of UK
Government oral health policy including workforce and dental service
planning, oral health promotion and dental education. Understanding how
the oral health of the population has changed and will change in the
future through the UK Dental Health Surveys is "pivotal to the
planning of oral health services" (e1).
1. Informing Government policy on dental health: 2005 onwards
Access to dentists is an area that motivates public opinion and the ADHS
findings have led directly to strategic policy decisions by the UK
Government on the distribution of dentists in order to match oral health
needs. Published by the Department of Health in 2005, the last National
Oral Health Strategy (still current) drew upon evidence from the UK
Dental Health Surveys to outline measures by which improvements needed to
be made to dental services to enable good oral health and reduce oral
health inequalities across all age groups in England (e2). While
many of the key action points have been implemented, an independent review
of dentistry published in 2009 (e3), drawing upon evidence from
the recent UK Dental Health Surveys, indicated that "The trends in
disease prevalence and the way it has been managed are visible in the
oral health of different generations. We still need to deal with this
burden of the past...".
Various recommendations for the improvement of NHS dental services are
now being acted upon and are reflected in the Coalition Government's 2010
white paper `Healthy Lives, Healthy People: Our strategy for public health
in England' (e4): "The dental public health workforce will
increase its focus on effective health promotion and prevention of
oral disease...[ ]. It will also make a vital contribution to
implementation of a new contract for primary care dentistry, which the
Government is to introduce to increase emphasis on prevention while
meeting patients' treatment needs more effectively".
2. Improvements to provision of dental services: 2006 onwards
Alterations to dental services and the dental contract models adopted
within the NHS are influenced, and monitored over time, by the results of
the Dental Health Surveys, with the Department of Health outlining in
2010: "The latest surveys of the oral health of adults and children
show that about two-thirds are free of visible tooth decay. People
want a dental service that helps them to prevent oral health problems
and maintain good oral health. [ ] Until now, the NHS dentistry
contract has remained focused on treatment; there has been little or
no incentive for dentists to practise the sort of preventative
dentistry that most people today want and need. It is time for this to
The new dental contracts piloted (2011-3) aim to deliver the Government's
commitment of increasing access to dental services and improving oral
health and represents a fundamental reform of NHS dentistry. "In
moving to a capitation and quality model, we are therefore proposing a
completely new way of remunerating dentists for the clinical care they
deliver. We are building on the lessons of the past" (e5).
The new pilot contracts are working under a full capitation scheme with
payments for quality and clinical outcomes using quality measures first
suggested by the Birmingham team's PDS evaluation findings. The General
Dental Services contract was first introduced in 1948, changed in 1990 and
again in 2006. The new dental contracts would only be the 3rd
change since the inception of the NHS.
3. Government Workforce Planning: 2004 onwards
The impact of the Birmingham research in monitoring and identifying
trends in population oral health is continuing to inform government
workforce planning. Higher Education undergraduate dental training numbers
are set by government on the basis of workforce needs and the Office of
Fair Trading wishes to see open and fair competition for dental services.
In the last decade, the UK dental health surveys highlighted the
difficulties people experienced identifying an NHS dentist and it was
generally assumed that this was due to a shortage of dentists. To address
this, and specific geographical needs, in 2004 the Government agreed to a
25% expansion in dental training in England and approved the establishment
of two new dental schools in the SW Peninsula and Central Lancashire. Due
to the long lead time (5 years to train a dentist), this expansion
programme of the NHS workforce, aimed at improving access to local dental
services and oral health, began to have an impact only in 2010 (Review of
Medical and Dental School Intakes in England, 2012).
More recently, the 2009 ADHS demonstrated that there had been a
considerable shift in demographics and the way in which people access
dental services, with access to services and standards of general oral
health in lower socioeconomic groups still remaining a challenge.
Reflecting these findings, the 2010 Government policy on workforce
planning (e6) outlined a vision: "The NHS commissions to
improve the oral health and well-being of the population, to reduce
oral health inequalities and to make oral health services available
for all and tailored to meet the needs of each individual".
Subsequently, in 2013, Medical Education in England reviewed the dental
skill mix, which includes Dental Care Professionals (DCPs) such as nurses,
therapists and dental technicians, and recommended "that the
Government consider how DCPs can make a greater contribution to
outreach services to adults and children in the lowest socio-economic
4. Oral Health Strategy across the UK: addressing oral health
One of the most significant findings to emerge from the recent UK Dental
Health Surveys was the issue of inequalities of oral health. Oral health
inequalities are recognised as a major public health challenge because
lower income and socially disadvantaged groups experience
disproportionately higher levels of oral disease. In response to these
findings, oral health policy has shifted to targeting vulnerable groups.
For example, in Scotland, the government is implementing a strategy which
targets oral health for frail older individuals, people with special care
needs and those who are homeless (e8). Also, at the BDA conference
in April 2013, the Department of Health Minister, Earl Howe quoted
findings from the ADHS 2009 and announced the formation of a dental task
group to determine how to improve dental services for vulnerable patients
and individuals who are not accessing care.
At a local level, implementation of the Government's strategy for oral
health is the responsibility of local NHS Trusts, which publish their
local oral health strategy on a 5-year cycle. These local strategies (for
example e9) are written against a backdrop of the 2009 ADHS findings
of oral health inequalities and a need to ensure equitable access to
dental services for all. For example, the Isle of Man dental services are
considering adopting the protocol of the 2009 Adult Dental Health Survey
to improve and inform a health needs assessment of adult residents (e10).
The UK Dental Health Surveys have started to provide the international
dental community with robust and rich epidemiological data resulting in an
evidence-base for influencing international oral health policies (as
reported at leading global conferences, eg e11).
Sources to corroborate the impact
e1 Letter from the Chief Dental Officer, NHS England, Department of
e2 Choosing Better Oral Health: an oral health plan for England.
Department of Health, November 2005.
(accessed August 2013)
e3 NHS dental services in England. An independent review by Professor
Jimmy Steele. 2009. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_101180.pdf
(accessed August 2013)
e4 Healthy Lives, Healthy People: Our strategy for public health in
England. 30 November 2010. https://www.gov.uk/government/publications/healthy-lives-healthy-people-our-strategy-for-public-health-in-england
(accessed September 2013)
e5 NHS Dental Contract: Proposals for Pilots. Department of Health.
(accessed August 2013)
e6 Improving oral health and dental outcomes: Developing the dental
public health workforce in England - Full report. 15 March 2010.
(accessed September 2013)
e7 A Review of Skill Mix in Dentistry, Medical Education in England 2013.
(accessed August 2013)
e8 The National Oral Health Improvement Strategy for Priority Groups by
the National Older People's Oral Health Improvement Group 2012.
(accessed August 2013)
e9 Oral Health strategy - Devon and Torbay NHS, 2012 to 2015.
(accessed August 2013).
e10 Oral Health Strategy - Isle of Man Government - A five year
(accessed August 2013)
e11 Borgnakke WS, Yl Ostalo PV, Taylor GW, Genco RJ. Effect of
periodontal disease on diabetes: systematic review of epidemiologic
observational evidence. J Periodontol. 2013; 84: S135-52. doi: