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Within the space of a few months the political agenda facing the NHS has changed. The new Labour government has appointed for the first time in the UK a Minister for Public Health, Tessa Jowell, who has made a clear commitment to tackle the widening health inequalities. Sir Donald Acheson is currently collecting expert opinion on effective strategies to combat health inequalities including oral health. Publication of the Green Paper Our healthier nation has set out a new public health agenda for the NHS and stresses the importance of establishing partnerships to promote health.1 The recently published White paper The new NHS has set out the government's plans for the NHS for the next 10 years and places GPs and community nurses in a central role in the commissioning process through the formation of primary care groups.2 In addition to these government initiatives the increasing importance placed upon evidence-based care has been extended to oral health promotion with the publication of several recent effectiveness reviews.3,4,5,6,7

What does this all mean for dentistry and oral health? It places dental public health and oral health promotion more firmly upon the NHS policy agenda. It is essential therefore that the dental profession are informed and able to contribute to the forthcoming debate within the NHS over the future direction of oral health policy.

This paper therefore aims to take a fresh look at what oral health promotion can offer and how it can be implemented effectively, whether in the community or in the surgery. This will involve revisiting the scientific foundation of oral health promotion, acknowledging the contribution of other auxiliary members of the dental team and taking a critical look at evaluation of oral health promotion.

Importance of oral health promotion

Most general dental practitioners are keen to teach their patients to care for their teeth. Sadly, experience often tempers this initial enthusiasm. As Blinkhorn pointed out recently, the factors affecting patients' oral health should be quite easy to control: how often they eat sugars – specifically non-milk extrinsic sugars, their exposure to fluoride, their oral hygiene, their smoking habits and their use of dental care.8 So what goes wrong? Why do so many practitioners feel frustrated by their lack of success in improving their patients' oral health?

The problem is that a range of external factors affect individual patients' behaviours. These may be physical – such as the availability of healthy snacks or the presence of fluoride in toothpaste. Less obvious, but equally influential, are social pressures such as whether all the other mothers meet their children from school with sweets,9 or whether there is peer pressure to keep teeth clean.10 Social norms tend to support both sweet eating and toothbrushing.

Health education for individual patients is important, as well as being an ethical duty of the profession.8 It is effective in the short term in improving oral hygiene. It should come as no surprise that effectiveness reviews do not show longterm improvements in how patients clean their teeth, nor much success in changing diets.7 To change ingrained habits and customs, our patients need support. They need to be able to buy sugar-free snacks and drinks in their schools or workplaces; they need social support from their friends and families. Where such support has been forthcoming, for example when sugar-free drinks became available, or when public opinion shifted against syrupy baby drinks, then social norms and individual behaviour have changed in favour of health.

Effective oral health promotion demands far more than instruction to individuals

If complex and expensive restorations are to survive, the patient must do their part by restricting sugars in their diet and maintaining good oral hygiene. Only through the combination of high clinical standards and effective oral health promotion will the population achieve good dental health. As has been shown, effective oral health promotion demands far more than instruction to individuals. It requires changes in the physical or social environment in which our patients live, work, play or study. This is the shift in emphasis that has been heralded by the Green Paper, Our healthier nation.1

The scope of oral health promotion

Oral health promotion is any planned effort to build healthy public policies, create supportive environments, strengthen community action, develop personal skills or reorient health services in the pursuit of oral health goals (fig. 1).11

Figure 1
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Fig. 1

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Health promotion is often confused with health education. Health education is the process by which people are given the knowledge and awareness needed for them to take greater control over their own health; this process includes developing personal skills. The dental team impart to their patients the knowledge and skills necessary to care for their teeth, for example to identify sugar-free snacks, or to brush teeth effectively. Dental health education is an important part of the dentist's responsibility to their patients. Dentists and their staff are ideally placed to give individually tailored advice and to reinforce this at subsequent visits. Their advice on mouth care can be reinforced by health visitors, nurses, doctors, pharmacists, teachers and playgroup leaders. One important aspect of health education is helping patients to have confidence in their abilities to care for their own, or their children's teeth, otherwise known as self-empowerment.

However, it has been shown repeatedly that acquiring knowledge and skills alone are insufficient to change behaviour long-term. Health promotion is about making healthy choices easier choices.12 Building healthy public policy can achieve this. This can operate on a national level, for example legislation to fluoridate the water supply. At a local level it may include for example, individual primary schools only allowing pupils fruit and water or milk at break time rather than sweets and fizzy drinks.

Creating healthy environments, such as building public policy, can affect patients' behaviour directly. Many people apply fluoride to their teeth twice daily; they do this because the toothpaste they buy contains fluoride, even though few of them understand how it works. If the proportion of sugar-free drinks in vending machines in secondary schools increases, then children are more likely to buy them, whether they care about their teeth or not.

The 'chuck sweets off the supermarket check-outs' campaign is a good example of strengthening community action. Displays of confectionery at child height used to provide an irresistible temptation to harassed parents queueing to pay for their groceries, even for those who were highly motivated to care for their children's teeth. In response to public opinion, most major supermarket chains have removed these. The success of this campaign was largely because of effective media advocacy. This style of work should not just be confined to CDS dental personnel. General dental practitioners, either individually or collectively through local BDA groups can act as advocates for oral health. Our medical colleagues have been very successful in their efforts to the change the public and political agenda associated with smoking.

The introduction of the capitation scheme was an example of reorienting health services to promote oral health. It aimed to provide an incentive to general dental practitioners to maintain their child patients' dental health.

Oral health promotion is a combination of these five different strategies. As individual's behaviour is complex and influenced by a range of social, psychological and political factors, it will rarely change on the basis of good advice alone.

Scientific basis of oral health promotion

Whatever strategy is adopted in order to improve oral health it should be based on the Health Education Authority's Policy Document, The scientific basis of dental health education.13 This is an important report as it is a distillation of published evidence on effective preventive strategies. It is a consensus document, finalised only after wide and thorough consultation with leading figures in oral health science.

The document can be summarised as follows:

  • Reduce the consumption and especially the frequency of intake of sugar-containing food and drink.

  • Toothbrushing: clean the teeth thoroughly twice every day with fluoride toothpaste.

  • Fluoridation: request your local water company to supply water with the optimum fluoride level.

  • Dental attendance: have an oral examination every year.

If some groups emphasise parts of this message at the expense of others, then the credibility of all those involved in promoting oral health becomes undermined. The general public is extremely sensitive to contradictions and confusion in health messages. If they believe that the experts disagree then the health message quickly loses credibility. Elements of the food industry have been quick to seize on the opportunities for spreading doubt and confusion in respect to recommendations to reduce both fat and sugar intakes. A consistent and correct message, whether explicit in what we say or implicit in what we do, is essential from all of those involved in promoting oral health. Otherwise those groups whose behaviour we seek to change, including politicians and policy makers, will simply not listen to us.

Team approach

If the dental team are to convince their patients of the importance of effective self care, then they must agree a practice policy between team members. This will cover who gives advice, who they advise, what information they include, when and where they discuss oral health with patients and what teaching aids or leaflets they use for reinforcement. Team work is the key to effective and efficient health education; dentists' time is expensive. While dentists are best placed to diagnose the health education needs of particular patients or groups of patients, it may be more cost effective for an auxiliary to actually give the advice. A staff meeting provides a good opportunity for developing practice policy on health education.

Once the team has agreed a policy it should be included in the induction training of new staff. Regular review and updating is important. When considering the role of the dental team in oral health promotion the importance of the dentist as team leader should not be underestimated. To draw a parallel, a patient may be more impressed by a doctor explaining the importance of giving up smoking than by a leaflet from the receptionist.

Primary dental care focuses on the dental health of individual patients. The Community Dental Service (CDS) is responsible for improving the dental health of communities. Support for general dental practitioners is an important part of this. The CDS can provide training for practice staff in health education messages and techniques, and good quality dental health education materials.

In addition, the CDS works with a wide range of groups within the population who can support dentists in improving oral health. Groups such as health visitors, teachers, voluntary workers, pharmacists and the primary health care team have many opportunities for giving advice on oral care. They can set a good example to patients, clients, customers and pupils, such as doctors who prescribe sugar-free medicines or pharmacies that sell only sugar-free confectionery. They can also provide environments that support oral health, for example through developing policies on snacks in schools.

Skills base

When dentists seek to modify their patients' behaviour however, they must acknowledge that the patient themselves are the ones that know best.

Working in oral health promotion requires very different skills from clinical dentistry. When a dentist performs some clinical procedure the patient has only limited means of judging the dentist's clinical work. The dentist is considered to be the professional expert. When dentists seek to modify their patients' behaviour however, they must acknowledge that the patient themselves are the ones that know best. Only the patient knows about the constraints on and opportunities for change that exist within their everyday lives. To be successful in changing behaviour requires the development of a wide range of communication skills so that the advice given to the patient is appropriate to the exigencies of their everyday life. It is important to understand the patient's perspective. They are more likely to follow advice that is tailored to their needs, than a standard list of do's and don'ts issued to all patients.

Well-defined stages have been identified in the processes leading to a successful and sustained change in behaviour.14 The dental team need therefore to be able to assess at what stage their patients are at in changing a defined behaviour, and provide the appropriate assistance. In addition understanding the difficulties many people experience when they attempt to change behaviours such as their eating patterns or smoking habits is essential. The dental team therefore need a range of behavioural management skills. These may include interview techniques to motivate patients into changing their behaviour, goal setting to focus efforts on realistic and appropriate challenges, and evaluation skills to monitor effectively the changes taking place.15 Dealing in a supportive and positive way with unsuccessful attempts at change may be a particularly important skill for the dental team to develop.

Effectiveness debate

Pressure to evaluate the effectiveness of clinical interventions has gradually become accepted if not fully acted upon within the clinical professions. The same pressures are now being placed upon evaluating health promotion interventions. This move should be welcomed by anyone interested in promoting oral health. An improved understanding of what works, when and how is essential for developing good practice and using existing resources for their maximum benefit.

Several recent effectiveness reviews of oral health promotion have been published.3,4,5,6,7 These have received a good deal of attention and have caused a fair degree of controversy. What do these reviews reveal?

The published reviews have all adopted a systematic approach to assessing the effect of mostly traditional dental health education interventions. Common findings include a poor design of many interventions, a limited reference to relevant theoretical frameworks and inadequate evaluation of the effects of programmes. These findings are no surprise to those working in this field. However it is important that the debate focusing upon these reviews does not lose sight of certain fundamental issues.

Firstly, it has been known for a long time that educational interventions alone have only a very limited capacity to achieve long-term sustained changes in individual behaviours. Professor Leonard Syme, a renowned American epidemiologist who has been involved in developing, implementing and evaluating the most expensive and elaborate heart disease prevention programmes ever designed has already reached this conclusion.16 If millions of US dollars spent educating people to reduce their risk of heart disease produced little effect, what could one expect from our dental health education efforts!

Secondly, the methodology employed by the oral health effectiveness reviews has been challenged as inappropriate by placing an overemphasis upon outcomes of individual behaviour change.17,18 It has been proposed that the effects of health promotion should be measured across the breadth of its activities and settings, using a broader range of research methods.

Thirdly, it should be noted that because of the complexity and strategic nature of many health promotion interventions, their design will often not match the criteria used for inclusion within a meta analysis.

Lastly, the positive evidence from reviews of dietary interventions should not be overlooked.19,20 For example, it has been shown that a single health check with a nurse, supplemented by take-home materials, brief follow up and referral, resulted in positive dietary changes and a reduction in blood cholesterol. In addition, significant changes in dietary habits have been achieved when tailored and personalised interventions are implemented within primary care settings.21

Conclusions

The new government has made health promotion a priority. The new political climate demands that we address the determinants of health using evidence-based strategies. Health improvement programmes provide an opportunity for the promotion of oral health at a local level.2 A firm theoretical basis for interventions, better design and evaluation and strong links with the wider world of general health promotion must underpin future initiatives.

Healthy public policy, supportive environments and public participation are essential elements of effective oral health promotion, but are often neglected

Healthy public policy, supportive environments and public participation are essential elements of effective oral health promotion, but are often neglected at the expense of improving individuals' knowledge and skills or, to a lesser extent, reorienting dental services. Community-based oral health promotion programmes use the whole range of health promotion strategies.

Effective oral health promotion programmes can support the work of general dental practitioners by improving the oral health of targeted populations. General dental practitioners have a key role to play: only they can identify the particular needs of each patient and tailor dental health education accordingly. The synergy between preventively oriented general dental practitioners and oral health promotion teams offer the best opportunity for improving the nation's oral health.