Introduction

Saving lives: Our healthier nation1 outlines the Government's intention to improve health of the whole population, but particularly of the most socioeconomically disadvantaged. Cancer and circulatory diseases (coronary heart disease and stroke) were identified as two of the five main causes of premature death. A broad-based approach was described to address inequalities with initiatives on education, welfare to work, housing, transport and the environment. It asserted that people could also improve their own health through physical activity, better diet and quitting smoking and stressed that individuals and families would benefit from health education to enable lifestyle choices. Such changes in lifestyle would also contribute to a reduction in diabetes and obesity.

A key development from Saving lives: Our healthier nation was the creation of a National Service Framework (NSF) for Coronary Heart Disease (CHD).2 General medical practitioners (GMPs) and primary care teams were to identify people with established, or at risk of, CHD and offer them appropriate advice or treatment. The document did not specify which primary care teams should be involved in this work. The Health Development Agency (HDA) produced guidance for the 'downstream' preventive aspects for CHD; health education and behavioural change techniques could be carried out on a one-to-one basis, through group work or family counselling with a key element being regular contact with clients.3 Although these approaches could be within the remit of general dental practice, the HDA did not include them as potential partners, despite including pharmacists and ambulance trusts.

Concurrently the Government's strategy for NHS dentistry was outlined in Modernising NHS dentistry: Implementing the plan,4 which included broader health issues. Smoking cessation and prevention of excess alcohol consumption were highlighted due to their established aetiological role in periodontal disease and oral cancer.5,6,7 It emphasised dental health care workers involvement in multisectoral approaches to health improvement through a common risk factor approach,8,9 especially via healthy eating messages.

Options for change10 built on Modernising NHS dentistry: Implementing the plan. As well as recommendations to reform general dental practitioners' (GDPs) remuneration, it recommended the introduction of an oral health assessment, which would involve lifestyle advice on smoking and oral health education. New oral health promotion services provided by practices might also include smoking cessation services and blood pressure checks, possibly led by professionals complementary to dentistry (PCDs).

Through the legislative changes proposed in the Health and Social Care Act,11 the present single contract for GDPs across England will be replaced with Primary Care Trusts (PCTs) commissioning services locally in line with policy across healthcare. Theoretically this will allow PCTs to secure locally appropriate, high quality services and address inequalities from April 2006. In 2002 the then Secretary of State announced the intention to develop the public health role of primary care dental teams.12 Local commissioning of services may provide opportunities for dental teams to be involved in partnerships for health promotion, particularly where there is high circulatory disease and cancer morbidity and mortality.

Present health policy emphasises the Government's commitment to evidence-based commissioning through organisations such as the National Institute for Clinical Excellence and the ongoing development of clinical governance. Equally, the dental profession has increased the emphasis it places on evidence-based practice; the establishment of the Cochrane Oral Health Group, as part of the Cochrane Collaboration and consequent increased activity in systematic reviews is evidence of this. It is essential that the effectiveness of dental teams in the delivery of public health interventions is reviewed so that any future commissioning decisions made by PCTs are based on the best available evidence.

The aim of this study was to review the evidence of effectiveness of brief public health interventions that could be undertaken by dental teams and that might contribute to the Government's aims of reducing the prevalence of circulatory disease and cancer.

Method

The brief public health interventions that might contribute to circulatory disease and cancer targets set in Saving lives: Our healthier nation and that could be undertaken by dental teams are:

  • Smoking prevention

  • Smoking cessation

  • Advice on alcohol consumption

  • Diet counselling

  • Advice on physical exercise

  • Advice on skin cancer prevention

  • Blood pressure monitoring.

A generic approach was adopted to undertake a series of reviews, performed systematically, of the evidence supporting the use of dentists, PCDs and other healthcare workers in these public health interventions. For each intervention, the search question was:

What is the evidence that a brief intervention undertaken in a primary care setting by dentists, PCDs and other health care workers will achieve behavioural change?

The databases searched for each intervention were:

  • Cochrane Database of Systematic Reviews

  • Cochrane Central Register of Controlled Trials

  • Medline (1966-2003)

  • Embase (1980-2003).

Although there were minor alterations made for each database, each included a search under the medical subject headings (MeSH) of 'primary prevention', 'health promotion', 'health education' and combined them with MeSH headings of 'smoking', 'smoking cessation', 'smoking counselling', 'alcohol drinking', 'food habits', 'diet', 'exercise', 'skin neoplasms' and 'blood pressure'. These were also combined with a series of alternative terms for the subject areas on a free text search. This search was run separately for dentists, PCDs and for other healthcare workers. For reasons of practicality, if systematic reviews were identified on a particular intervention, that search was terminated. However if a high quality randomised controlled trial (RCT) was published after a systematic review, this would be included. Failing this, the best level of evidence available was reported.

The strength of the evidence to support each intervention is indicated using the following hierarchy, modified from that adopted by Davies et al.:13

Type 1 Systematic review

Type 2 At least one RCT

Type 3 Non-randomised intervention studies

Type 4 Observational studies.

Findings

Details of the studies identified are provided in Tables 1, 2, 3, 4, 5, 6, 7, 8, 9, 10. Critical appraisals of each study are summarised in the Tables. The following provides a summary of the findings for each intervention, an indication of the level of evidence found and any conclusions that can be drawn.

Table 1 Smoking prevention: effectiveness of other healthcare workers
Table 2 Smoking cessation: effectiveness of dentists
Table 3 Smoking cessation: effectiveness of dental teams (dentists and PCDs)
Table 4 Smoking cessation: effectiveness of hygienists
Table 5 Smoking cessation: effectiveness of other healthcare workers
Table 6 Alcohol consumption counselling: effectiveness of other healthcare workers
Table 7 Dietary advice: effectiveness of dental teams
Table 8 Dietary advice: effectiveness of other healthcare workers
Table 9 Physical exercise: effectiveness of other healthcare workers
Table 10 Skin cancer prevention: effectiveness of other healthcare workers

Smoking prevention

The search revealed no studies of the effectiveness of dental teams in smoking prevention. However, there is limited evidence that other healthcare workers can have some effect in preventing smoking in young people as part of wider community initiatives14 (Table 1).

Evidence: Type 1

Discussion: Although much has been written on the involvement of the dental team in smoking cessation, there is very little in the literature on involvement in smoking prevention. As dental teams regularly see a large proportion of the adolescent population at least every 15 months,15 they seem the ideal healthcare workers to be involved in this work. As other healthcare workers have been shown to have a small effect in prevention, it is likely that dental teams could have a similar effect. As the cost and risk of adverse outcomes of dental teams being involved in smoking prevention are both low, it would be reasonable for dental teams to be involved as part of wider community initiatives, particularly as the oral consequences of smoking could be used as additional motivating factors for prevention.

Smoking cessation

The small numbers of studies that exist for dentists and dental teams provide limited evidence of effectiveness in smoking cessation. All these studies have methodological weaknesses16,17,18,19,20,20,21 (Tables 2,3,4).

Evidence: Type 2,3,4

There is good evidence that physicians, nurses and health visitors have a small but significant effect on smoking cessation rates that will have demonstrable benefit on the public's health22,23 (Table 5).

Evidence: Type 1

Discussion: Accepting the limitations of the dental studies, those that do show an effect suggest quit rates similar to those produced by other healthcare professionals in high quality systematic reviews. As the risk of any adverse consequences is low and the public health benefits of involvement are high, dental teams should be involved in smoking cessation using a brief intervention as is widely recommended.5,24,25,26,27,28,29

Alcohol consumption counselling

The literature search was unable to identify any studies reporting the effectiveness of dental teams delivering alcohol consumption advice.

Evidence: nil

There is some evidence that brief interventions carried out in primary care by a range of healthcare workers can deliver moderate reductions in alcohol consumption30,31 (Table 6).

Evidence: Type 1

Discussion: It has been recommended that dental teams provide advice on alcohol consumption as part of primary prevention measures for oral cancer.7,32,33 Although there is no evidence of the effectiveness of dental teams, other healthcare workers appear to have an effect. It would be reasonable for dental teams to deliver such messages.

Dietary counselling

There is little quality evidence for the effectiveness of any member of the dental team in diet counselling, and the evidence that exists shows only a weak and transient effect.34,35 (Table 7).

Evidence: Type 1

There is some evidence that other healthcare workers can produce moderate changes in diet for up to 18 months through brief interventions36 (Table 8).

Evidence: Type 1

Discussion: Although there is little or no evidence of effectiveness of dental teams in delivering dietary advice, systematic reviews of the effectiveness of dental health education reported that the quality of the studies included were generally poor.34,35 Many of the studies were able to demonstrate a change in knowledge but not behaviour. As there is evidence that other healthcare workers can produce moderate changes,36 better designed and executed studies may demonstrate an effect. Furthermore, in the past dietary advice delivered by dental teams has had a narrow focus, which was not always consistent with general health advice. Effectiveness might be increased if advice provided is integrated into general health advice as previously recommended37,38,39 using a common risk factor approach8,9 and which is congruent with oral health messages and appropriate to a dental setting.

Physical exercise

The literature search found no studies of dental teams' effectiveness in increasing physical activity.

Evidence: nil

There is some evidence that brief interventions delivered by other healthcare workers can increase physical activity levels in the short to medium term. Changes were not maintained without recurrent contact. Intensive interventions tended to be more effective40,41,42 (Table 9).

Evidence: Type 1

Discussion: Although not traditionally regarded as part of the dental team's work, other healthcare workers can increase levels of physical activity. Dental teams may be able to provide the recurrent contact required to maintain increased activity levels.

Skin cancer prevention

There are no studies on the effectiveness of dental teams in health education for skin cancer prevention.

Evidence: nil

There is little or no evidence of effectiveness of other healthcare workers43 (Table 10).

Evidence: Type 1

Discussion: Undergraduate teaching for dental students considers the aetiology and prevention of oro-facial cancers. Although there is no evidence of effect, dental teams are well placed to provide such advice.

Blood pressure monitoring

The literature search did not identify any studies on the effectiveness of blood pressure monitoring alone in reducing circulatory disease levels. One US study evaluated a protocol in which patients identified by dentists as hypertensive were then referred to their medical practitioner. The programme successfully established a referral pattern44 but no details of long-term health gain were provided.

Evidence: Type 4

No studies were identified involving other healthcare workers on the effectiveness of blood pressure screening providing long-term health gain.

Evidence: nil

Discussion: There are moral and ethical barriers to undertaking a clinical trial to investigate the effectiveness of blood pressure screening in reducing circulatory disease levels. As a consequence, there is no evidence that blood pressure screening per se reduces levels of disease. However all prospective follow-up studies of large populations in westernised countries have demonstrated a close association between height of blood pressure and circulatory disease incidence.45 Once diagnosed there is good evidence that the treatment of hypertension reduces the incidence of circulatory disease.46 Dental teams are well placed to monitor blood pressure of their patients. Indeed, in the US dentists have been involved in national education and prevention programmes for more than two decades.47,48,49 Also US PCD organisations endorse their involvement.50 UK dentists who undertake conscious sedation must measure blood pressure as part of the patient assessment51 but involvement in routine blood pressure monitoring as part of a broader prevention strategy would be reasonable, as has been previously recommended.52

Concluding discussion

This review has revealed that there is minimal evidence of effectiveness of dentists or dental teams in delivering any of the public health interventions identified. However it found that other healthcare workers have some effect in most of them.

Dental teams could play a part in current preventive approaches to tackle key chronic diseases as outlined by the HDA.3 In so doing they would have a true public health role and contribute to reaching the targets set in Saving lives: Our healthier nation. Such an approach is commensurate with the shift of emphasis toward prevention expressed by Options for change and a more holistic view of oral care. The main reason for a lack of evidence is the paucity of studies undertaken investigating the effect of the dental team in these activities. Nevertheless, evidence that other healthcare workers are effective suggests that dental teams could have similar effects. The population approach to prevention53 using a common risk factor approach8,9 means that small effects delivered by dental teams may not have significant health benefits for the individual, but could deliver significant benefit for general and oral health at the population level. As the relative cost and risk of any adverse consequences of dental teams' involvement is low, it would be reasonable to include dental teams in broader health promotion strategies.

However it is widely accepted that such strategies should follow the five principles of the Ottawa Charter for Health Promotion:54 building healthy public policy; creating supportive environments; strengthening community action; developing personal skills and re-orienting health services. The brief interventions described only contribute to one or two of these principles (developing personal skills and re-orienting health services) and it is therefore not surprising that they are of limited effect in isolation of other measures. Indeed this has been suggested as one of the reasons for the lack of evidence of effect of dental health education in systematic reviews.55 Arguably, dental teams would be more effective in achieving dietary change through counselling if the other principles are considered. For example, advertisements aimed at children could be proscribed (healthy public policy); confectionery and carbonated drinks vending machines could be removed from schools and replaced with healthier snack options (creating supportive environments); community-based parental support groups could be established to consider the risks of foods with high refined sugar and fat content (strengthening community action) and all dental services should emphasise and reward prevention rather than mainly intervention (re-orienting health services).

Although the dental team is well placed to undertake public health interventions, involvement would mean a radical change of approach to practice for most dentists and their teams. The adoption of such changes is likely to be determined by two main factors: firstly, whether the profession sees dental teams as having a more general public health role, and secondly, whether it is economically possible for dental teams to make this change. If the Government wants dental teams to deliver public health interventions as part of wider health promotion approaches, it is essential that their views are sought on their involvement. Part 2 of this series explores and describes the factors that might influence dental teams' public health intervention activity in the general dental services using qualitative and quantitative methodologies.