Oral health, deprivation & Social Exclusion

1. Oral health, deprivation & Social Exclusion Dental Public Health Dr K Hill Dental Public Health and Behavioural Science 2009

2. Inverse care law Those most in need of services are least likely to receive them Tudor Hart 1971 Dental Public Health and Behavioural Science 2009

3. Inverse care law The double whammy • Prevalence of disease experience tends to rise with increasing deprivation • Experience of treatment tends to fall with increasing deprivation • This applies to most diseases where lifestyle plays a role, one exception being malignant melanoma Dental Public Health and Behavioural Science 2009

4. Proportion of adults with total tooth loss by social class, England & Wales 1968-1998 Dental Public Health and Behavioural Science 2009

5. Proportion of UK dentate adults with some ‘unrestorable teeth’, 1998 Dental Public Health and Behavioural Science 2009

6. Proportion of UK children aged 15yr with active untreated caries, 1993 Permanent teeth Dental Public Health and Behavioural Science 2009

7. Proportion of UK children who have never visited the dentist, 1993 Dental Public Health and Behavioural Science 2009

8. Child Dental Health 1 • Oral Healthcare at Home • More than three quarters of children in all groups in 2003 reported brushing their teeth at least twice a day. • Difference between girls and boys • Social class difference • Non-manual household • 5 years 78% (high social class) • 60% (lower social class) • Small increase overtime Dental Public Health and Behavioural Science 2009

9. Child Dental Health 2 • Electric toothbrushes becoming more popular – 8 years old (65%) 12 year olds (52%) and 48% of 15 year olds • Mouthwashes – ¼ (23%) of 8 year olds use mouthwash (38%) 12 year olds (46%) 15 year olds • Sugar free chewing gums – similar pattern • 18% reported 15 year olds reported using dental floss Dental Public Health and Behavioural Science 2009

10. Child Dental Health 3 • Parental Views (permanent teeth) • Front tooth to be filled (96%-98%) • Back tooth (90% of parents of 8 year-olds) • Little social class variation (front teeth) • Back tooth – higher proportion of parents from social class I,II,III nm prefer a filling than those from social classes IV & V • Parental views (Baby teeth) • (5 and 8 year olds) preferred the tooth extracted • Little variation between social class Dental Public Health and Behavioural Science 2009

11. Huh? 1. Increased disease experience associated with deprivation, NOT A CAUSAL RELATIONSHIP 2. Social inequalities in disease experience caused by differences in diet and self-care 3. Social inequalities in experience of treatment caused by differences in use of services. 4. Deprivation partly explains observed variations in oral health between different ethnic groups Dental Public Health and Behavioural Science 2009

12. Alma Ata Declaration 1. Equitable distribution 2. Community involvement 3. Focus on prevention 4. Appropriate technology 5. Multi-sectoral approach Walt & Vaughan 1981 Dental Public Health and Behavioural Science 2009

13. What can be done? 1. Primary prevention strategies such as water fluoridation benefit high risk groups the most. No evidence that oral health education or other forms of prevention benefit high risk groups 2. Reduce barriers to use of treatment and prevention services e.g. cost, location, opening times, acceptability, fear. Dental Public Health and Behavioural Science 2009

14. Social Exclusion “being shut out, fully or partially, from any social, economic, political or cultural system which determines the social integration of a person in society” Gareth Williams Dental Public Health and Behavioural Science 2009

15. Social Exclusion • UK has become increasingly unequal • Childhood poverty – increases difficulties in adulthood (poor reading, work opportunities etc..) • Social exclusion is multi-dimensional • Unemployment or low income, poor housing, levels of education etc.. Dental Public Health and Behavioural Science 2009

16. Mrs Harris and Social Exclusion • Recently moved to a new part of the country • Moved from an area with higher sugar consumption • Isn’t yet registered at a dentist • The dentist she visits doesn’t do G.A. • Basically she doesn’t yet understand the local scene • She feels intimidated by professionals and other adults Dental Public Health and Behavioural Science 2009

17. Mrs Harris and Social Exclusion • Still relies on her mother in Scotland, for advice • Lives in a socially deprived area • Doesn’t have own transport • Husband’s shift work and probable size of house causes pressures • Fundamentally she is isolated from the social mores of her new home and feels like a new immigrant – which she is. Dental Public Health and Behavioural Science 2009

18. Accessible and responsive dental services Dental Public Health and Behavioural Science 2009

19. Overcoming the barriers : Mrs Harris • ? • New services – will she attend • Cost – Is Mrs Harris on benefits • Professional gap? • Access Dental Public Health and Behavioural Science 2009

20. Essential Reading Prevention of Oral Disease (4th Edn) Edited by Murray J, Nunn J H, Steele JG. Chapter four. ‘The Prevention of Social Inequalities in oral health. By Nigel Nuttall. Dental Public Health and Behavioural Science 2009

21. References - books Kelly M., Steele J.S., Nuttall N., Bradnock G., Morris A.J., Nunn J., Pine C., Pitts N., Treasure E.T., White D. (Ed. Walker A.M., Cooper I.) Adult Dental Health 1998: United Kingdom London TSO 2000 O’Brien M Children’s dental health in the United Kingdom 1993 London HMSO 1994 Community Oral Health, Ed. Pine C. - chapter 3 Wright 1997 The New Public Health John Ashton & Howard Seymour OUP 1991 Dental Public Health and Behavioural Science 2009

22. Tudor- Hart J. The inverse care law The Lancet 1971; i: 405-412 Gray M., Morris A.J., Davies J. The oral health of South Asian five-year-old children in Dudley compared with White children of equal social class and fluoridation status Community Dental Health 2000; 17: 243-245 Jones C.M. Capitation registration and social deprivation in England. An inverse ‘dental’ care law? British Dental Journal 2001; 190: 203-206 Dorling D., Davey Smith G., Shaw M. Analysis of trends in premature mortality by Labour voting in the 1997 general election. British Medical Journal 2001; 322: 1336-1337 References - articles Dental Public Health and Behavioural Science 2009