Challenging oral health inequalities through a public health approach to policy
Submitting InstitutionUniversity College London
Unit of AssessmentAllied Health Professions, Dentistry, Nursing and Pharmacy
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Dentistry, Public Health and Health Services
Summary of the impact
The UCL Dental Public Health Group have made a significant contribution
to oral health policy in the UK and internationally through their research
on oral health inequalities and the need for a reorientation of dental
services towards a more evidence based, integrated preventive approach
addressing common risks for oral diseases and other chronic conditions.
Our work has influenced local national oral health policies and the
development of clinical practice guidelines to reduce oral health
inequalities and provide the opportunity for dental professionals to
prevent both oral and systemic disease.
Since 1995 the UCL Dental Public Health group have conducted research
that has detailed the patterns of oral health inequalities, the presence
of social gradients in oral health, and explored the psychosocial causes
of oral health inequalities. This has led to the development and
evaluation of community-based health improvement strategies which seek to
lessen oral health inequality through adopting a common risk approach for
both oral and general health.
During the 1990s, the issue of inequalities in health more generally grew
to prominence. We conducted pioneering work during this period to
incorporate a consideration of inequalities in oral health into this wider
health agenda. In a review in 1999, we provided, for the first time, a
synthesis of the evidence for widening inequalities in oral health between
social classes, regions of England, and among certain minority ethnic
groups in pre-school children . Leading on from this work, we
developed a common risk factor approach based upon the general principles
of health promotion, aiming to ensure that oral health programmes are not
developed and implemented in isolation from other health programmes. The
common risk factor approach addresses risk factors common to many chronic
conditions within the context of the wider socio-environmental milieu.
Oral health is determined by diet, hygiene, tobacco, alcohol use, stress
and trauma. As these causes are common to a number of other chronic
diseases, adopting a collaborative approach is more rational than one that
is disease specific .
We undertook secondary analyses of national data sets from a diverse
range of countries including the UK, US, Brazil, Japan, South Korea and
across the EU. These identified a social gradient (graded stepwise nature
of outcomes across the entire social hierarchy) in a variety of oral
health outcomes and at different points in the life course from early
childhood, through adolescence to adulthood and older age . Our
work highlighted that the influences upon oral health inequalities are
complex and include broad community, social, economic and psychosocial
factors. Through systematic review we demonstrated the limitations of
dental health education and clinical preventive interventions in tackling
oral health inequalities as they fail to address the underlying social
Two of the common risk factors which our work has focussed on are smoking
and diet. In these areas we have developed, implemented and evaluated a
range of community-based oral and systemic health improvement population
Following the publication of the government's 1998 White Paper on
measures to reduce smoking rates across the population, we conducted work
to examine how dentists and their team members could become actively
involved in these efforts. We conducted a needs assessment on behalf of
the Health Education Authority to examine the status of smoking cessation
in dental hygiene and dental therapy curricula and to develop appropriate
teaching resources in this area. This identified a number of barriers to
both teaching and practising smoking cessation . We also
conducted research to explore perceived barriers within dental teams. Key
issues identified were: a fatalistic and negative concept of prevention;
perceived lack of relevance of smoking cessation to dentistry; patient
hostility; and organizational factors within the practice setting .
Leading directly from this work, Watt co-wrote Helping Smokers Stop: A
Guide for the Dental Team which was published by the Department of
Health in 2004. Watt's work to develop smoking cessation activities in
dental practice have continued since that time, and further aspects are
described in Section 4 below.
We have also conducted extensive research into diet and nutrition, as
they relate to oral health. In the late 1990s, for example, we conducted a
survey of infant feeding practices within the Asian community in Britain .
We have conducted a randomised controlled trial to assess whether monthly
home visits from trained volunteers could improve infant feeding practices
at age 12 months in two disadvantaged inner city London boroughs. This
found the home visits promoted aspects of recommended infant feeding
practices including eating three solid meals per day, and eating more
fruit and vegetables . Our work also demonstrated that
preventive dietary interventions to lessen obesity in young persons in the
UK can be effectively delivered in the primary dental care setting.
Researchers of UCL Dental Public Health who contributed to this work
included: Professor Aubrey Sheiham (Emeritus Professor of Dental Public
Health), Professor Richard Watt (Professor of Dental Public Health) and Dr
George Tsakos (Senior lecturer in Dental Public Health).
References to the research
 Sheiham A, Watt RG. The common risk factor approach: a rational basis
for promoting oral health. Community Dent Oral Epidemiol. 2000
 Dykes J, Watt RG, Robinson M. Smoking cessation and the dental
hygiene and dental therapy curriculum. Int J Health Promot Educ.
2001;39(1):21-5. Copy available on request, and see also: http://www.ihpe.org.uk/jour/3901-04.htm
 Watt RG, Tull KI, Hardy R, Wiggins M, Kelly Y, Molloy B, Dowler E,
Apps J, McGlone P. Effectiveness of a social support intervention on
infant feeding practices: randomised controlled trial. J Epidemiol
Community Health. 2009 Feb;63(2):156-62. http://doi.org/b3phqw
Details of the impact
The research undertaken by the UCL Dental Public Health Group on the
nature of oral health inequalities, the common shared determinants of oral
and general health inequalities, and the design and approach needed to
reduce inequalities has been highly influential in national and
international oral health policy and in changing professional practice.
Our research has helped to shift oral health policy from an isolated
perspective, towards a more integrated public health approach.
Our research on the common risk factor approach and the determinants of
oral health inequalities has been highly influential on national oral
health policy. As a result of the expertise developed through the
underpinning research described above, Watt has advised on and authored a
number of key national policies over the last decade, including the
national strategy "Choosing Better Oral Health: An Oral Health Plan for
England" which was first published in 2005 [a]. This key document
has continued to inform national oral health policy throughout the current
REF period including the approach adopted by Public Health England, who
state that the research of our group provides a very important
contribution to their overall agenda to improve the nation's health and
address health inequalities [b]. In view of his common risk
approach to oral and systemic health Watt was also a core member of the
Department of Health working group which produced Delivering Better
Oral Health: An evidence-based toolkit for prevention [c].
This document was distributed to all general dental practitioners in
England in April 2009. Its goal was to re-orientate dentists towards
working in a more preventive manner based upon up-to-date scientific
evidence. Specific areas of work included diet advice, smoking cessation
support and brief interventions to reduce harmful alcohol intake.
Smoking cessation: Watt chaired the group which wrote the
Department of Health guidance document, Smokefree and Smiling: helping
patients to quit tobacco [d]. This document provided
guidance for primary care dental teams on the contribution that they can
make to smoking cessation. In the same year he authored a smoking
cessation training resource for dental teams, published by NICE which was
designed to equip members of the dental team with the skills and knowledge
needed to provide effective smoking cessation support [e]. The
training materials were distributed to all undergraduate dental and oral
hygiene and therapy schools in England. As a result of this work, combined
with the toolkit set out in Delivering Better Oral Health,
dentists do now routinely take a smoking history and are beginning to
offer cessation advice or refer patients for specialist support. This is
demonstrated by the results of the 2009 Adult Dental Health Survey which
report increasing rates of smoking cessation advice delivered by dental
Maternal and child nutrition: In 2008, NICE issued guidance on
Maternal and child nutrition (PH11) which aimed "to improve the
nutrition of pregnant and breastfeeding mothers and children in
low-income households." As a consequence of his earlier work on the
social gradients associated with breast feeding and reference nutrient
indicators in pre-school children, Watt was a member of the Programme
Development Group and the only representative from an oral health
background [g]. Specifically based upon the outcome and process
evaluation of peer support infant feeding interventions, Watt provided
detailed input on the peer support elements of the guidelines and also the
incorporation of oral health in relation to sugars consumption.
The incorporation of our research into oral health policy has since led
to various changes in professional clinical practice amongst primary care
dentists in England. The current care pathway of the Dental Contract
Reform Programme is seeking to develop "a new contract model and
way of working which shifts the focus of NHS dentistry from treatment
and repair to prevention and oral health" [h]. The more
integrated preventive approach based very much on our model of common risk
factors through the inclusion of advice on diet, tobacco and alcohol.
Present evidence suggests that this model would be acceptable to patients
(for example nearly three-quarters of responding patients of the a pilot
scheme of a new NHS contract "said they had a better understanding of
their oral condition following their recent visit under the new system
and a similar proportion said they had actually changed their oral
hygiene habits as a result of their visit"), and that dentists will
utilise resources more effectively and positively influence future NHS
dental care as a result (only 8% of responding dentists indicated that
they would not align their clinical practice to the new contract) [h].
At a local level, the research outcomes have been highly influential in
supporting the development of local oral health strategies and in
particular the importance of adopting a common risk factor approach in
tackling shared risks for a range of chronic conditions including oral
diseases. Across the country many Primary Care Trusts and Local
Authorities have used our work in shaping their local strategies. Good
examples of this include the oral health strategies for Islington,
Cambridgeshire and Norfolk [j, j, k].
Our research has gone on to have an influence on oral health policy and
practice in other parts of the world also. In Australia, our work
was influential in informing the development and contents of both national
and local policies. The Principal Population Oral Health Advisor in the
Victoria State Government writes that "Over the last ten years their
work has shaped key population oral health plans, policies and
resources. These documents include the National Oral Health Plan —
Health Mouths, Healthy Lives 2004-2013, the Evidence-based oral
health resource, Department of Health Victoria, 2011 and the soon to
be released National Oral Health Promotion Plan" [l].
Attesting to a broader impact on the oral health agenda, the Chair of the
Australian National Oral Health Promotion Plan Committee writes that: "International
leadership in population oral health, especially with regards to
promoting effective policies and interventions to reduce oral health
inequities, is not a feature of the organized dental profession either
in Australia or internationally... The work that you and your graduates
have been championing is a major support to numerous academic, public
health educators and researchers throughout the world struggling to have
a policy impact in their national health agenda" [m].
Sources to corroborate the impact
Copies of archived documents are also available on request.
[a] Department of Health. Choosing Better Oral Health: An Oral Health
Plan for England. London: Department of Health; 2005.
[b] Letter from the Director of Dental Public Health, Public Health
England. Copy available on request.
[c] Department of Health. Delivering Better Oral Health: An
evidence-based toolkit for prevention. London: Department of Health; 2009.
[d] Watt RG. Smokefree and smiling: helping dental patients to quit
tobacco (Gateway 8177). London: Department of Health; 2007.
[e] Watt RG. Smoking cessation training resource for dental teams.
London: National Institute of Health and Clinical Excellence; 2007. ISBN
1-84629-427-4. Copy available on request.
[f] The Health and Social Care Information Centre (2011). Adult Dental
Health Survey 2009; http://www.hscic.gov.uk/catalogue/PUB01086
[g] Full guidance here: http://guidance.nice.org.uk/PH11/Guidance/pdf/English.
See p.65 for Development Group membership.
[h] Department of Health. NHS dental contract pilots — Early findings: A
report by the dental contract pilots evidence and learning reference
group. London: Department of Health; 2012. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/212999/NHS-dental-contract-pilots-early-findings.pdf
[i] NHS Islington Clinical Commissioning group (2009) The Islington
2009/10 JSNA. Chapter 9: Oral Health. http://www.islingtonccg.nhs.uk/jsna/Chapter-9-Oral-health-JSNA-200910.pdf
[j] Cambridgeshire Oral Health Strategy, 2010. Copy available on request.
[k] NHS Norfolk. Oral Dental Health Needs Assessment for NHS Norfolk;
[l] Letter from Principal Population Oral Health Advisor, Victoria State
Government. Copy available on request.
[m] Letter from the Chair of the National Oral Health Promotion Plan
Committee, Australia. Copy available on request.