Healthy Teeth for a Healthy Nation: Fighting Tooth Decay in the UK's Marginalised Regions

Introduction

Unmet dental needs and untreated dental decay, also known as dental caries, present a significant disease burden for children and adults.¹ Between 2015-2016 and 2020-2021, there was a total of 57055 hospital admissions for dental caries in London for children aged between 1 and 19 years.² Notably, research has shown that in preschool children, predictors such as ethnic minority groups consisting of children of Pakistani, Bangladeshi, and/or African and Caribbean descent, are likely indicators of higher rates of caries compared to their White British counterparts.³ Conversely, in the adult population, the opposite was observed where oral health was better among non-White groups due to poorer diets and lifestyle factors observed in the white British population.⁴

While the wider health workforce and local authorities have implemented preventative programs and legislation to tackle the multifactorial causes of tooth decay, health inequalities and access to dental care remain critical public health issues.

This article explores the causes of tooth decay and examines the structural determinants of oral health, which are significantly influenced by socioeconomic backgrounds. Additionally, it discusses current initiatives aimed at curbing this epidemic and highlights necessary changes. The article also delves into various strategies for addressing tooth decay in resource-constrained communities. 

What is tooth decay?

Tooth decay, commonly known as dental caries, is damage to the tooth’s surface or enamel caused by acids produced by bacteria in the mouth.⁵ The acid can cause small holes in the tooth called cavities. If the cavities are left untreated this can progress into deep caries involving the living tissue, the pulp causing pain, infection, and potentially tooth loss.

Prevalence of tooth decay in children

People of all ages can get tooth decay; however, younger children are at significant risk of “early childhood caries” due to various reasons. This typically presents as tooth decay starting in a baby’s front teeth and extending to the back teeth.⁷ Researchers have attributed this kind of tooth decay to the sugary drinks in baby bottles or sipping cups and is seemingly more prevalent in children of minority ethnic backgrounds.⁶ In children of Asian and Black descent, researchers found that they were less likely to have an established teeth-brushing routine, less likely to have dental ups within their first year of life and less likely to visit the dentist regularly compared to children of white ethnicity.⁹ These differences could be ascribed to varying socioeconomic differences between the groups, for instance, access to dental services could be a significant barrier to accessing preventative advice and care. This is evident for many over the UK, especially after the COVID-19 pandemic where deprived areas all over the country, with a large presence of ethnic minorities and low-income families, had a reduction in dental services and dental workforces, exacerbating already existing child oral health inequalities within the area.^{9 10 11 12}

Coupled with a lack of information about the importance of dental hygiene, The World Health Organisation (WHO) recognizes the consumption of sugar as a leading cause of tooth decay and a common risk factor for many other chronic diseases.⁴ This is a serious problem for children of all ages as in 2019, Public Health England (PHE) reported that in England, 141 children a day are having their teeth removed. This costs the NHS £3.4bn yearly and equates to an average of 60,000 school days missed a year.⁶ While parents are being urged to limit fruit juice and fizzy drinks, evidence reveals that many parents have a lack of understanding about the importance of maintaining children’s teeth and gums. This lack of understanding was more prevalent in parents with less education and lower socioeconomic status and further exemplified in a cross-sectional study conducted between 2018 and 2020 where children with parents with a higher education level and income, were associated with a lower prevalence of dental caries and improved oral health of children.⁸

Prevalence of tooth decay In adults

While lack of education on dental hygiene and poor oral health practices, children from a young age can have dental complications in adulthood, the Adult Dental Health Survey conducted in 2009 found that conversely, oral health was better among non-White Groups despite less use of dental services. These differences could be explained by reported differences in dietary sugar,⁴ and although ethnic minorities may have cultural and financial barriers towards accessing dental treatment, these groups are less likely to consume sugary snacks, add excess sugar, and smoke, amongst other detrimental lifestyle variables. This, in turn, lowered their risk of dental caries and the prevalence of oral complications in their subgroup.

Strategies for addressing tooth decay

The National Institute for Health and Care Excellence (NICE) developed a set of guidelines for local authorities to implement in developing improvement strategies for oral health. This guideline focused on people whose socioeconomic/environmental circumstances or lifestyles placed them at high risk of poor oral health, in addition to addressing risk factors such as diet, oral hygiene, smoking, alcohol, stress, and trauma; to improve general health as well as oral health.¹³

Action points from the guideline

• Promote and protect oral health by improving diet and reducing consumption of sugary food and drinks, alcohol, and tobacco (and so improve general health too)
• Improve oral hygiene
• Increase the availability of fluoride
• Encourage people to go to the dentist regularly
• Increase access to dental services

However, addressing this epidemic of tooth decay in the UK requires a multidisciplinary approach. Local authorities and government agencies may implement these strategies on a national and local level,  empowering and collaborating with local stakeholders, community health workers, and organizations to ensure that the importance of oral hygiene and its preventative measures is reaching and educating the right people.

Success stories and case studies

• Boroughs and researchers across the UK have successfully launched initiatives in deprived areas with the agenda of improving public education on oral health. Notably, the local government association, London Borough of Hammersmith and Fulham commissioned a project called ‘Book and Brush at Bedtime’ which was eventually incorporated into a wider oral health promotion program across the boroughs of London. Written by a local author, the book was deployed in children’s centres and local libraries, alongside the distribution of fluoride toothpaste and brush packs in addition to the ongoing parenting workshops that the borough's parents received. The project provided access to resources, helped establish bedtime routines and ultimately promoted oral health behaviours for parents and children while supporting literacy, pre-literacy skills and schools’ readiness.¹⁴
• In Liverpool, they took a more direct approach to tackling the source of tooth decay- sugar. While this is not new, as in 2018, the UK government introduced the “Sugar Tax” to reduce childhood obesity,¹⁵ Liverpool City Council’s public awareness campaign “Save Kids from Sugar” was launched in 2016 initially targeting drinks but further addressed breakfast cereals and seemingly healthy snacks like yoghurts sugar content.¹⁷ The campaign included the distribution of leaflets, posters, and adverts on social media and via hard copies in dentists, GP practices, hospitals, and children's centres. Public health teams also set up information stalls in supermarkets to spread awareness of the sugar content in these everyday items and how it can affect teeth.

While education and diet were two of the main obstacles to achieving good oral health in low socioeconomic communities, NICE recognised that another hindrance was access to dental services- especially in the first year of life. However, the health and social care in Greater Manchester has allowed the region to do some targeted work in these areas. Understanding that treating tooth decay is a multidisciplinary approach, in the metropolitan areas of Manchester,⁷ health visitors have been trained in key oral health messages pertaining to information that educates parents on the best brushing techniques and when to start brushing and providing toothbrush and paste packs at 9 months, and 2 years. This has allowed over 90% of infants in these identified deprived areas to receive oral health advice and a brush pack. In addition to this, in Leicester, they were able to see tooth decay in 5-year-olds due to the accreditation scheme they set up for dental practices. By employing oral health champions and establishing dedicated clinics to reduce tooth decay in those at risk, they can reach a wider audience and provide necessary dental care. This approach addresses the dental needs of the community whilst also emphasizing preventive measures and education to empower individuals and communities to take charge of their oral health.

Summary

combating tooth decay, particularly in underprivileged communities, demands a comprehensive and multidisciplinary approach. Education on oral hygiene, dietary adjustments, and improved access to dental services are pivotal. Despite the health and government authorities’ initiatives to promote better oral health, persistent socioeconomic disparities continue to challenge these endeavours. However, the success of many local programs highlights the potential of community-driven strategies.

 To truly bridge the oral health gap, sustained, coordinated efforts between health services, local authorities, and community organizations are essential, emphasizing prevention and tailored health messaging.

Key points

• Dental health issues, particularly tooth decay, affect all ages and disproportionately impact children in lower socioeconomic and minority groups.
• There were 57,055 hospital admissions for dental decay among London children from 2015 to 2021, with a notable risk for pre-schoolers from minority backgrounds.
• Despite preventive measures and legislation, health inequalities and access to dental care persist as significant public health concerns and critical in today’s climate.
• Initiatives implemented by NICE, and local government authority programs across the UK exemplify successful strategies that address the multifaceted issue of tooth decay.
• Addressing tooth decay requires a multidisciplinary, collaborative approach that includes education, improved access to care, and preventive strategies, particularly focusing on high-risk populations.