Oral Health is defined as the 'standard of health of the oral and related tissues which enables an individual to eat, speak and socialise without active disease, discomfort or embarrassment and which contributes to general well-being' (Department of Health, 1994).

Inequalities in oral health reflect broader health differences across the population, both in terms of pattern and cause. Socio-economic factors are recognised as being key determinants of oral health inequalities. This gradient is particularly strong amongst young children. Trans-London surveys highlight disparities between boroughs and within localities. Action to address this public health problem requires collaborative strategic input.

Health policy places great emphasis on addressing oral health inequalities. There are stark inequalities in oral health in young children. These exist across and within London's PCTs.

Despite general improvements in oral health in recent decades, dental diseases remain common. Over one third of London's five-year-olds have active tooth decay. Caries prevalence and untreated decay levels raise the need for effective oral health promotion amongst pre-school children. National data also reveal other significant oral health problems affecting the primary and secondary teeth of children which include gum diseases, tooth surface loss (due to erosion or wear), fractured teeth (due to trauma) and mal-positioned teeth which require orthodontic treatment.

Older people who have retained their natural teeth are at particular risk of oral diseases, with tooth decay affecting the roots of teeth. This is becoming a significant public health challenge.

A detailed referenced report is also available that contains further information - Oral Health Report.

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Despite dramatic improvements in oral health over the past three or more decades,oral disease is still very common in children. The main condition affecting children is dental caries (tooth decay); however they also experience a range of other conditions, each of which will be dealt with in turn below.

Epidemiological surveys highlight disparities between boroughs and within localities. Inner London, in particular has some of the worst levels of decay in England and Wales. The national targets for oral health in 5 year olds suggest that by 2003:

Only two PCTs in London have an average dmft (number of decayed, missing, or filled teeth) of less than one and only three PCTs have 70% or more children with no experience of decay. Too many disadvantaged children carry the avoidable burden of pain, distress and disfigurement associated with severe tooth decay and its treatment. Young children in particular find dental treatment difficult to tolerate and for many the solution involves a general anaesthetic in a hospital setting with removal of multiple teeth.

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Socio-economic deprivation is recognised as being the key determinant of oral health status. The inequalities that exist show no single cause of poor oral health, but a range of factors including unemployment, poverty, social deprivation and lifestyle. Nationally there have been dramatic improvements in oral health over the last 30 years. However inequalities in oral health across London persist and reflect the social gradient across social classes.

In regards five year olds the inner London population in particular has some of the worst levels of dental decay in England and Wales, joining the North West and Wales with mean dmft values greater than 1.5. Caries prevalence trends nationally in the 5 year old age group appear to be worsening a little following a long plateau after the dramatic improvements in the late 70s and 80s. The national target for oral health in five year olds is that by 2003, five year old children should have an average of know more than one decayed, missing or filled primary tooth and seventy per cent of five year olds should have no experience of tooth decay. Only 2 PCTs in London have an average dmft of less than one and only 3 PCTs have 70% or more children with no experience of dental decay.

In comparison with other parts of the country, the North of England which also experiences some of the worst dental decay, has an average dmft of 3.5, the London average being 3.3. Over one third (35%) of 5-year-olds in London have active dental decay.

As dental caries reduces and diet changes, so other conditions affecting teeth become more apparent.

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National data in 2003 show that the oral hygiene of teenagers in general, and boys in particular, is getting worse. Whereas in 1993 57% showed plaque present on their teeth, by 2003 this had risen to 63% which suggests that oral cleanliness is on the decrease in teenagers.

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National data from the 2003 UK Child Dental Health Survey reveal that over half five to six year olds had some wear on their primary incisors. The lingual surfaces (surface next to the tongue) were most affected; almost a quarter of children had more extensive erosion into the middle of the tooth. In contrast erosion of permanent incisors less common with one third (33%) of 15-year-olds demonstrating lingual tooth surface wear and 22% showing wear on the occlusal (biting surfaces) of their molar teeth. This wear was mostly limited to enamel, especially lingually. The level of wear is on the increase in 15-year-olds by 6% since 1993. This is a particular issue as many of these young people will expect to retain their teeth into old age.

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The 2003 Child Dental Health Survey shows that 13% of 15 year-olds nationally had accidentally damaged incisors compared with 17% in 1993. This was more common in boys than girls. Small fractures restricted to tooth enamel are more common.

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The need for orthodontic treatment is measured using the index of orthodontic treatment need (IOTN). A score of 5 denotes the highest need for treatment and a score of 1 is the lowest need for treatment. The demand for orthodontic treatment relates to young people's psychosocial functioning and high need as assessed by dentists will not always translate into demand by individual patients and vice versa. The 1993 children's dental health survey provides information on orthodontic treatment need, with the results of this element of the 2003 UK survey awaited. Approximately one third of young teenagers surveyed had a moderate to severe orthodontic need. Some of these subjects were in treatment. By the age of 15 years, just over one quarter (26%) of children had received or were receiving orthodontic treatment, which involves the wearing of braces, either fixed or removable appliances. There were no reported geographic or social class differences in the national data.

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Data on the oral health of adults may be drawn from the National Adult Dental Health Survey, 1998 (Kelly et al, 2000). These national data show that the oral health of adults has improved over time, particularly in London; however, oral health needs vary with age and social class.

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As the oral health of children has improved, many young adults have little or no dental caries and restorations; however their risk of oral disease remains. The last adult dental health survey showed that 16-24 year olds have more untreated primary dental caries than the adult dentate population as a whole. This is important locally as London's population is young, and there are many young people studying in the capital.

When compared with the other seven government regions, adults in London were the least likely to be edentate (9% in London 12% in England). However, 57% of adults in London had one or more decayed teeth compared to a national average of 55%. Londoners were also least likely to attend for regular dental check-ups.

The condition of natural teeth varied in association with social class. In 1998 46% of adults in England had active tooth decay and 6% had 6 or more decayed or unsound teeth . Adults in lower social classes had the highest prevalence of dentate adults with decayed or unsound teeth (69%) and the lowest average number of restored (otherwise sound) teeth (6.5). In comparison, affluent people had the lowest proportion of dentate adults with decayed or unsound teeth (47%) and the highest number of restored (otherwise sound) teeth (8.6).

Across England, the proportion of people with one or more decayed or unsound tooth varied according to dental attendance; it was 49% for people who cited the usual reason for attendance at the dentist as 'for a check up' and 67% for those people who cited the usual reason for attendance as 'only with trouble'.

Adults over 35 years of age have more extensive dental caries experience and will require high maintenance dentistry of a high standard for the rest of their lives. Older people are an increasing section of the population and present a particular public health challenge. This section of the population is are increasingly retaining their natural teeth into old age and their risk of oral diseases increases, particularly as the roots of their teeth become exposed and dental caries attacks these tissues. The roots of teeth are made of softer dentine and thus easily decay making root caries common in older people.

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The National Adult Dental Health Survey of 1998 reported on the condition of the supporting structures of the teeth. Plaque induced periodontal disease (gum disease) was evident, with 72% of adults having visible plaque covering on average a third of all their teeth. Plaque induced gum disease causes periodontal pockets around teeth and 54% of adults had pockets of 4mm or more and 5% had deep pockets of 6mm or more. The prevalence of pocketing increases with age, so with an ageing population who are keeping more of their teeth, the prevention and treatment of periodontal disease will become an ever increasing public health problem, particularly as the disease process is not fully understood. Fewer than 1 in 10 adults nationally had evidence of more severe gum disease.

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Dentists play an important role in detecting oral cancer and precancer. Data from Thames Cancer Registry (2001) show an incidence of 950 new cases of head and neck cancer in 1998 and a male: female ratio of 1.6:1 Table 2. This represented a 12% increase for new head and neck cancer cases and includes a 25% increase in oral cancer over a four-year period.

Oro-pharyngeal cancer shows the highest increase of all head and neck cancers. The 25% increase in oral cancer for the period, between 1994 and 1998 must be viewed in the context of past research that estimated 25% under-reporting of oral cancers, 1971 to 1987. Subsequent work to address this anomaly coincides with this documented increase. Whether this means that all of the increase between 1994 and 1998 is due to better reporting, and this can be extended to the increase in reported salivary tumours (40%) and the nasopharynx (26%), is unclear. However, this highlights the importance of good data collection, and the need for evidence of inaccuracies to be identified and documented in the public domain as they impact on the interpretation of recorded trends.

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Social determinants are well recognized as poor oral health, particularly dental caries experience (tooth decay), is strongly linked with social deprivation. In addition the following behavioural and lifestyle issues impact on oral health:

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In London, a full range of health services, (both NHS and private) is provided by a large number of service providers. London's primary dental care services are different from the rest of the country in that there are major issues relating to service uptake and utilization. The providers comprise the following public services in addition to private dental care:

• General Dental Services
• Personal Dental Services
• Community & Salaried Dental Services
• Out of Hours/Emergency Dental Services
• Access centres
• Options for Change Pilots
• Prison Dental Services
• Dental teaching hospitals
• Hospital specialist dental services
• Tertiary care including Head & Neck Cancer Services, Cleft Lip and/or Palate services and facial trauma

General Dental Services are the major providers of care and have the following profile in addressing the oral health needs of Londoners:

• Overall service uptake and utilization, as defined by the current 15-month registration period, is low with 2.7 million residents registered for care (38%) at 31st January 2004. This ranges from 47% of children down to 31% of older people. About 5% of dental claims nationally cannot be postcoded and therefore this figure is an under-representation of service uptake.
• Just over one in three adults (35%) is registered for NHS dental care at any one point in time.
• In general London PCTs have registration rates for children which are below the national average of 59% for children
• Dentist list sizes are consistently less than the national average at about 1,020 patients per dentist compared with 1400 per dentist in England (September 2004).
• The treatment profile of contracting dentists is one of greater volumes of treatment per patient, with only 38% having no dental intervention on the NHS compared with 51% nationally (March 2004)
• 38.4% of GDS claims are from patients who are exempt NHS charges compared with 24.3% for England (in Sept 2003)
• GDS spend in London is around of £252 million annually (15.7% of the national spend 2002/03)
• national surveys support the view that there is more private dental care in London than in other parts of the country and therefore the level of service uptake by adults will be higher than NHS data suggest, if some adults have all of their care undertaken privately.

Overall there is a net inflow of patients to the capital. Patient flows within London tend to occur to services within adjacent PCTs, with about 70% of patients attending services in their local PCT.

London had 2,956 dentists at principal or associate level working within the GDS who held 4,198 contracts with PCTs at 31st March 2004. Workforce challenges include recruitment and retention of the dental team as well as supporting dental nurse training and registration and all Professions Complementary to Dentistry. Registration is due to become a legal requirement in 2005 and will be a particular issue for dental nurses.

Dental care is provided from approximately 1,000 premises across London. Premises need to comply with the Disability Discrimination Act and Health and Safety requirements and facilitate modern styles of team working. To date, a significant proportion of dental practices are single handed and some located in high street premises which have limited potential for redesign.

Health care providers face financial and political challenges associated with their location in a world capital. There are also large educational establishments in London which provide training, educate health professionals and contribute to their life long learning. This is reflected in the current Health and Education Strategic Partnership which brings together key players in the process to seek creative solutions for London. National health and healthcare issues are magnified in this melting pot, and the population profile is replicated in the health care workforce, from whom turnover, recruitment and retention of staff is a major issue.

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General dental services [GDS] are the main providers of care supported by community dental services which have a complementary function and increasingly by a new range of dental services through local commissioning arrangements. GDS remain the main providers of care and their profile is outlined in the following section which highlights the gaps in provision:

The principal functions of the Dental Practice Board [DPB] are to approve payment applications; the calculation and transfer of payments; the prevention and detection of fraud and abuse; and the provision of dental health information. The latter includes data on the number of contract holders, details about the number of patient registrations for each contract including, recently, where any registrants live, and information on patterns of claims. Such data allow considerable opportunities to examine the current provision of NHS dental care through the GDS within the planning unit and to make comparisons with other units.

Table 3 show the changes in the average number of patients that each principle contract holder has for five regions on a quarterly basis for a 5-year period starting September 1997. The data highlight that the trends in lists size for the GDS are consistent at a regional level and that contract holders in London have the smallest list size, almost 50% that of a contract holder in the Midlands. Overall, in all regions, NHS average list sizes have fallen since 1997 although this must be set against an increase in the number of contract holders. Throughout that period, list sizes in London have consistently remained below the national average and are currently at 1,020 (Sept 2004).

Table 4 show the variation in the rates of treatments per 100 adult claims using the same aggregate variable. These data highlight that a patient attending a GDS dentist in London is nearly 1.5 times more likely to have a filling when compared to a patient attending a dentist working in the rest of the South of England.

Dentists in London have a higher proportion of patients exempt charges than other regions of the country and the national picture as shown in Table 5.

Although full details of the new dental contract have not formally been published, the Department of Health has indicated that the fee-per- item system will be replaced. This is likely to reduce the validity of the data on prescribing patterns although developments in the IT strategy may allow patient records to be accessed.

The DPB in its new form as part of the Health Business Agency will remain an important source of information to monitor and inform commissioning. Changes through the Health and Social Care Act present a unique opportunity to influence where and how dental teams address the oral health challenges of local residents and those who choose to seek care in an area. Table 6 provides an indication of the level of GDS fees authorised for services provided in London in 2002/03. Recent cash injection into NHS dental services will result in additional monies coming into London for the commissioning of dental services from 1st October 2005.

Registration rates for Londoners are below the national average for all groups when the actual registrations of Londoners at 31st Jan 04 are compared with DPB stats nationally for 31st December 2003: children (49% cf 60%) and adults 35% cf 45%. Not all dental claims are postcoded and therefore the actual calculated registration rates will be about 5% lower, all other things being equal Table 7. Taking these issues into account the data still show that dental service uptake in the capital is lower than nationally.

Primary dental care services in London differ from the rest of the country with smaller average list sizes, rapid turnover of patients, more intricate care per patient and more patients who are partially or completely exempt charges.

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One of the major differences between NHS dental care provision and medical care is the ability of a patient to seek care from any provider in the country. This has led to many patients seeking care with a provider in a different PCT than the one in which they reside; over 30% of all patients seek treatment outside their PCT boundary.

Table 8, Table 9a and Table 9b shows that the high level of patient flows tends to be across PCT boundaries, to dentists working in adjacent PCTs. Patients can and do use services wherever they wish in the country and the local residents of any PCT may access care in 100 or more different PCTs.

Date	Title	Format	View
31 Dec 2008	Dental public health functions of primary care trusts: regulations 2006 and the supplementary directions 2008. Summary
31 Dec 2008	Proposed framework for NHS dental epidemiology for England 2008/09 – 2012/13
20 Dec 2006	A vision for Londoners’ oral health 2016
6 Apr 2005	Average Decayed, Missing and Filled Teeth in 5 Year Olds by PCT and SHA 2001/02
6 Apr 2005	Distribution of Dental Care Items for Adults by SHA within London and Nationally, March 2004
6 Apr 2005	GDS and PDS Service Uptake for London, 31st January 2004
6 Apr 2005	GDS Fees Within London, by SHA, 2002/03
6 Apr 2005	Number of New Head and Neck Cancers in London Residents, 1998
6 Apr 2005	Patient Flow to GDS & PDS Providers in London, by PCT, 31 January 2004
6 Apr 2005	Percentage of Claims for Patients aged 18 and over who are exempt or remitted charges, by Area (Dec 02 – Sept 03)
6 Apr 2005	Principal Dentists by List Size by SHA Within London and Nationally, June 2004
6 Apr 2005	Service Uptake by Residents in North West London, by Borough, 31 January 2004
6 Apr 2005	Service Uptake by Residents in South East London, by Borough, 31 January 2004

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• British Dental Association (2003). Oral Healthcare for Older People: 2020 Vision. London: British Dental Association.
• Chadwick B and Pendry L (2004) Non-carious dental conditions: childrens' dental health in the UK. London: ONS.
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• Warnakulasuriya KA, Acworth P, Bell J, Johnson NW. Incompleteness of oral cancer registration in south-east England, 1971-87 (1994) British Journal of Cancer. 70(4): 736-8.

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• One In A Million' Report By The British Fluoridation Society: Review Of The Scientific Facts About Fluoridation To Help NHS Decision Makers
• Department of Health Dental Services Web Page
• Oral Health and Dental Care in London - A Dental Public Health Report

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