Research and analysis

Inequalities in oral health in England: summary

Published 19 March 2021

1. Executive summary

Poor oral health is almost entirely preventable and despite good progress over the last few decades, oral health inequalities remain a significant public health problem in England. Reducing oral health inequalities is a matter of social justice, an ethical imperative and for public bodies across the health sector, a legal duty.

This report represents the first-time data and evidence has been compiled on oral health inequalities and oral health service inequalities in England by socioeconomic position, geographic area, protected characteristics and vulnerable (disadvantaged) groups.

There are marked inequalities in oral health in England across all stages of the life course and over different clinical indicators such as dental decay and related quality of life measures. The relative inequalities in the prevalence of dental caries in 5-year-old children in England increased from 2008 to 2019. There are also inequalities in the availability and utilisation of dental services across ages, sex, geographies and different social groups.

Inequalities by individual socio-economic position and area deprivation were the most researched topics and there is clear and consistent evidence for social gradients in the prevalence of dental conditions, impact of poor oral health and service use.

For most of the protected characteristics there was no available evidence, or inconsistent evidence, on associations between oral health, care services and the protected characteristic.

For vulnerable groups including homeless people, prisoners, travellers and looked after children, the available evidence was very limited, with existing studies showing that these populations have considerably poorer oral health across all assessed outcomes and face substantial difficulties accessing dental care.

There are barriers to NHS care at individual, societal and policy level which include costs, lack of availability of services and services not commissioned to meet local needs.

The report recognises the paucity and, in some cases, total absence of data or evidence needed to fully understand inequalities in oral health in England and suggests improvements of how data could be collected and what further research could be undertaken to inform future reports.

More evidence is needed on how community-level and service utilisation interventions impact on oral health inequalities. Public Health England (PHE) and NICE (PH55) have recommended a number of community interventions that not only improve oral health but also have encouraging impacts on reducing oral health inequalities including targeted supervised-tooth brushing in childhood settings. PHE recommends water fluoridation as a whole population intervention as there is evidence that it reduces oral health inequalities with a greater benefit for those living in more deprived areas.

Action is needed to address the inequalities described in this report, and PHE will continue their work with partners to take action to address information gaps and reduce oral health inequalities.

2. Document summary

Main points from the chapters in the report are captured in the summary below.

2.1 Purpose of the report

The report describes the current picture of oral health inequalities and oral health service inequalities in England by socioeconomic position, geographic area, protected characteristics and vulnerable (disadvantaged) groups. This is the first time that epidemiological data, NHS data and academic literature has been reported in this way.

Information in this report may be used to inform equality impact assessment of proposed public health interventions and to inform the commissioning of services.

2.2 Introduction

Poor oral health is almost entirely preventable and despite good progress over the last few decades, oral health inequalities remain a significant public health problem in England.

Oral health inequalities are the differences in oral health between different groups that are avoidable and deemed to be unfair, unacceptable and unjust.

The impacts of poor oral health disproportionally affect vulnerable and socially disadvantaged individuals and groups in society.

There are upstream, midstream and downstream causes of oral health inequalities.

Public bodies across the health sector in England have legal duties and responsibilities to address inequalities.

Reducing oral health inequalities is a matter of social justice and an ethical imperative.

2.3 Epidemiological surveys, cancer registers and NHS service data

Data from decennial and annual oral health surveys, cancer registers and from NHS service activity show that there are:

• marked inequalities in oral health in England across all stages of the life course and over a number of different clinical indicators, such as dental decay, and related quality of life measures
• inequalities in the availability and utilisation of dental services across ages, sex, geographies and different social groups
• relative inequalities in the prevalence of dental decay in 5 year old children in England and that these increased from 2008 to 2019

Information sources could be improved by a requirement of public bodies to collect data and report on the different domains of health inequalities and any trends, and for the private dental sector to report health inequalities data.

2.4 Published literature on inequalities

The scoping review examined the evidence for oral health inequalities in the UK, including socio-economic inequalities, and inequalities affecting those with protected characteristics and vulnerable groups.

Socio-economic inequalities

The most researched topics were inequalities by individual socio-economic position and area deprivation.

There was clear and consistent evidence for social gradients in the prevalence of dental decay, tooth loss, oral cancer, self-rated oral health, OHRQoL, oral hygiene, and service use. For dental decay and tooth loss, studies that assessed time trends tended to find that absolute inequalities had narrowed over time but that relative inequalities had not. Inequalities in dental decay were less pronounced in fluoridated areas.

There was some evidence that differences in access to dental services partly explained social inequalities in dental decay, while smoking played a role in inequalities in periodontal disease.

Inequalities in oral cancer by level of education may have been partly due to differences in smoking and alcohol consumption.

Protected characteristics

The evidence on inequalities by ethnic group was inconsistent. The literature had methodological limitations around representativeness and the combination of ethnic groups with very different characteristics into broad categories.

No conclusions could be drawn on associations between religion and oral health.

Studies on oral health in pregnancy and maternity were scarce and on unrepresentative samples, and findings were therefore inconclusive.

Associations between disability and oral health outcomes varied by type of disability and nature of the sample.

Most studies suggested poorer oral health outcomes and greater difficulties accessing services but for some conditions there were no differences or even better outcomes among those with a disability.

No conclusions could be drawn for associations between sexual orientation, gender reassignment and oral health.

Vulnerable groups

For vulnerable groups including homeless people, prisoners, travellers and looked after children, the available evidence was very limited, with the existing studies showing that these populations had considerably poorer oral health across all assessed outcomes, and faced substantial difficulties accessing dental care.

Barriers to dental service utilisation

There were barriers to NHS care at individual, societal and policy level which can be common across vulnerable groups or specific to one group.

Barriers included costs, lack of availability of services and services not commissioned based on local needs.

Suggested ways of overcoming barriers to care included:

• provision of appropriate training to both service users and care providers
• policies to ensure dental services meet the needs of vulnerable people
• the use of appropriate skill mix to deliver services

Future research is needed

The pathways between socio-economic disadvantage and poorer oral health are still under researched.

There is a no evidence or a paucity of evidence on the associations between oral health and access to services of those with protected characteristics and vulnerable populations.

2.5 Reducing oral health inequalities

There was a paucity of evidence on whether and how community-level and service utilisation interventions impacted on oral health inequalities.

PHE and NICE (PH55) have recommended programmes that not only improve oral health but also have encouraging impacts on reducing oral health inequalities.

PHE have recommended targeted supervised-tooth brushing in childhood settings, targeted community-based fluoride varnish schemes, integration of oral health into targeted home visits by health and social care workers, targeted provision of toothbrushes and toothpaste by health visitors or post, healthy food and drink policies, targeted peer support groups, oral health training for the wider professional workforce and influencing local or national government policy (for instance fiscal policy).

PHE have also recommended water fluoridation as a whole population intervention as there is evidence that it reduces oral health inequalities with a greater benefit for those living in more deprived areas.

2.6 Next steps

It is recognised that although this report describes oral health inequalities, further action is needed to reduce these inequalities.

Collaboration by a number of partners is already happening across the health and social care system and PHE intends to publish a companion piece to this report, setting out in more detail what further action is needed to address research and epidemiological gaps, and reduce oral health inequalities. Work will also include addressing the impact of oral health inequalities created by the coronavirus (COVID-19) pandemic.