The present British government has made a commitment to reduce health inequalities and address the underlying social, economic and political factors that create unacceptable health differences within the UK.1 An independent inquiry into inequalities in health under Sir Donald Acheson has collected together evidence on health inequalities and has reviewed recommendations for tackling this public health problem.2 This paper will summarise the evidence on oral health that has been submitted to the inquiry and will outline recommendations for action to reduce oral health inequalities.

Evidence on inequalities in oral health

A wealth of high quality epidemiological data has been collected in the UK over the last 30 years in both national and district surveys amongst children and adults. It is therefore possible to assess the changing trends in oral diseases within the population and identify regional and social class differences. Recording of the ethnicity of subjects has however not been included in many epidemiological surveys.

Social class and deprivation

Inequalities in oral health in children

There are inequalities in caries by social class and deprivation in the primary dentition. Among toddlers of 1 to 4 years, 40% from manual social classes had decay experience compared with 16% in those from non-manual.3 In children aged 5–15 years, the only variable strongly and independently associated with the number of decayed and/or filled primary teeth was the pattern of the child's dental attendance. For both 12 and 15 year olds there was an association between social class and decay.4 In 12 year olds there was a strong independent association with dental attendance and decay. For both 12 and 15 year olds there was an independent association between social class and the number of DMF permanent teeth. For 12-year-olds, the children of skilled manual workers had a mean DMF a little lower than the overall mean and there were significant differences between children from manual and non-manual households. The DMF for children of non-manual parents was 1.1, skilled manual 1.4, and children of semi-skilled and unskilled workers 2.0. At 15 years the DMF children from non-manual classes had scores of 2.0 compared with 2.7 among children of social class III manual, and 3.4 among those from social classes IV and V.4 Despite the social class inequalities O'Brien found that '...these social and background variables together explained very little of the variation between children in the mean numbers of decayed primary teeth. For five and eight year olds, the combination of these variables explain only 8% of the variation in the level of known decay in the primary dentition, and for twelve and fifteen year olds they explain 7% and 8% respectively of the variation in the decay experience of the permanent dentition'.4 Dental caries decreased in all social classes in the United Kingdom between 1983 and 1993. The greatest improvements were among 12 and 15 year old children from skilled manual households and the least was among children from semi-skilled and unskilled households, so the gap between the classes has widened from 0.9 teeth in 1983 to 1.4 in 1993 among 15-year-olds.4

The Acheson Report2 The Acheson Report was published in 1998. The range of areas for future policy development which they judged on the scale of their potential impact on health inequalities and based on scientific and expert evidence include peoples' living and working conditions, food supplies and access to essential goods and services; a health promotion approach. The preventive approach is directed to changing risk factors by encouraging people to give up smoking and changing diet. "Policies need to be both 'upstream' and 'downstream'". There are 39 recommendations in the Report; 24 of them relate directly or indirectly to oral health. In addition to the specific recommendation to fluoridate the water supply, there are recommendations on health promoting schools, improvements in foods provided at school and to the community at large, elimination of food poverty, increasing breast feeding, programmes on smoking cessation, reducing accidents, access to services for older people, extending the remit of the National Institute for Clinical Excellence (NICE), and policies to achieve a more equitable allocation of NHS resources. It is encouraging to see how many of the recommendations made in the submission on oral health have been included in the report to the Secretary of State for Health. We made specific recommendations on health promoting schools, school meals, smoking and accident prevention policies, fluoridating the mouth, government policy to improve diet and nutrition, smoking policy, developing personal skills, equity based goals, targeting of resources to areas of greatest need and the facilitation of healthy alliances with agencies and organisations outside of the NHS, dental services for disadvantaged groups and community development programmes.

Two other dental conditions, periodontal disease and dental trauma vary by social class and ethnicity.4 People in the lower social classes (IIIM, IV and V) have more severe periodontal disease than those in the higher classes (IIINM, II and I). Children of Asian and Afro-Caribbean origin have more severe periodontal diseases than Whites. Trauma to teeth, a condition which affects 17% of 8–15 year olds, is more common in lower than upper classes, although the trend appears to be changing.

Inequalities in oral health in adults

In adults the differences in decay experience is less unequal than in children but there are marked social class inequalities in edentulousness of adults. In the latest national adult survey carried out in 1988, whereas 14% of social classes I, II, III NM had no natural teeth, 24% of IIIM and 32% of IV and V had no natural teeth.5 The large social class differences in edentulousness did not exist in the dentate. More lower social classes had 18 or more sound and untreated teeth; 41% in social classes IIIM, IV and V compared with 33% in I, II, III NM. And, despite the higher percentage of social classes I–IIINM (39%) with filled teeth than those in social classes IV and V (18%), the difference in missing teeth by social class was only 1.4 — the mean numbers of missing teeth in social classes IV and V was 8.6 compared with 7.2 in social classes I, II, III NM. Higher percentages of social classes IV and V had decayed/unsound teeth (59%) than in social class IIINM but the mean numbers of teeth was not great: 1.8 compared with 1.4.5 An encouraging trend is that the mean numbers of decayed/unsound teeth decreased more in social classes IV and V between 1978 and 1988 than in the highest classes — from 2.7 to 1.8 compared with 1.5 to 0.8 in the upper social classes.5

Periodontal diseases prevalence and severity varies by a number of social conditions. People from higher social classes, those with more education, people living in urban areas and females have less severe periodontal disease than their lower social class counterparts who are less educated, male and live in rural areas.5

Oral cancer is relatively rare in the United Kingdom.6 In England, oral cancer for both tongue and mouth in males showed a graded increase in rates and mortality from the most affluent to the most deprived areas.7 The Standard Registration Ratios (SRRs) in 1986–1991 for cancer of the mouth in males was 142 for the most deprived and 61 for the most affluent wards in North-East England.7 The differences were less marked in females; 127 compared with 44.7 O'Hanlon, Forster and Lowry concluded that their study cannot provide answers to whether the differences were due to differential awareness and access to health care or whether social deprivation was merely a marker for lifestyles rooted in known risk factors and lower protective factors.7 In the USA, level of employment was more strongly associated with risk of oropharyngeal cancer than educational status suggesting that social and economic instability, as indicated by lack of employment and being unmarried, and their attendant behaviours may increase risk of oral cancer more than social disadvantage.8

Inequalities in oral health amongst minority ethnic groups

Being a member of an ethnic minority in the UK does not necessarily correspond to having poorer oral health. Caries experience in the primary dentition is higher in children of Asian origin than in White children but when matched for social class and mothers ability to speak English there were no differences.9 In the permanent dentition, children of Asian origin had less caries than Whites.9,10 Children of Asian and Afro-Caribbean origin had similar permanent teeth decayed scores as Whites.11,12,13,14 There are no differences in oral health among minority ethnic groups of the same socio-economic status. The inclusion of ethnicity as a variable for dental caries may no longer be relevant as it could divert attention from more important variables such as income and social class.15

National, regional and district inequalities

Area-based indicators are better predictors of oral health status than measures of socio-economic status. Moreover they add additional explanatory power to models of health inequalities.16 Wide regional differences exist in prevalence of caries. Children in the north-east Region had more decay than those in other parts of England. Fourty three percent of the 3Þ–4Þ year-olds in the north-east had decay compared with a quarter in the rest of England.3 The regional and national inequalities persisted in older children. In the United Kingdom, there is nearly a threefold difference in the dental health of 5-year-old children from the relatively prosperous region in the south-west and the relatively deprived regions of the north-west. At 6- years-old the dmf levels were 1.8 and 2.6 respectively.4 In 1992–93 the mean DMFT scores of the 12-year-olds in the two north-west regions were 1.9 and 1.5 compared with 0.8 in South West Thames. The regional and district differences in caries are related to deprivation. Jones et al17,18 showed correlation's of from r =0.88 and r =0.46 between caries levels in 5-year-olds and Jarman scores. In adults there are marked regional inequalities in dental status. Mainly in relation to edentulousness. For example, in the southern region of England 19% of females were edentulous compared with 33% in the northern region.5 The incidence of mouth cancer in males was worse in the northern region of England than in England and Wales as a whole.7

Inequalities by gender

No differences by gender exists in the proportions of adult dentate males and females with 21 or more teeth; the percentages are identical — 80%. Unsurprisingly, the mean numbers of missing teeth in males and females is similar — 7.6 compared with 7.9. There is a consistent trend at all ages for a higher percentage of females to have fillings. For example, at ages 35–44, 43% of males compared with 56% of females had 12 or more fillings. Females generally had less periodontal disease than males.5 More females than males are edentulous. Twenty five percent of females in the UK were edentulous compared with 16% of males.5

The cases of inequalities

The main reasons for the dramatic decrease in dental caries and periodontal diseases in the past 20 years are the wide scale use of fluoridated toothpastes, change in diet and infant feeding patterns, a reduction in smoking, an improvement in oral cleanliness and lastly a change in broad socio-economic factors (an oral health illustration of the McKeown theory19).

In addition to numerous publications, the declines in caries have been reviewed and discussed at length at six conferences on the subject.20 The generally held reason for the decline, the one where there is a consensus, is that the wide scale use of fluoridated toothpastes were a major reason for the decline. In a survey of 55 experts, most authors and experts agreed that the widespread use of fluoride, especially fluoride in toothpastes, was the main reason. There is little doubt that fluoride in toothpastes made a contribution to the declines in DMFT. There is little evidence that better treatment or preventive care or increased availability of dental manpower has contributed significantly to the improvement in dental caries. Dental services explained 3% of the variation in changes in 12-year-olds in 18 industrialised countries caries levels in the 1970s whereas broad socio-economic factors including fluoridated toothpastes explained 65%.21,22 So it appears that the increase in allocation of the budget spent on traditional dental care has only a marginal effect on the population's oral health status.

There is overwhelming evidence to support the link between sugars consumption and dental caries. It has now reached the status of an unequivocal axiom.23 Sugars consumption varies by social class. National food surveys reveal a higher consumption of sugar and sugar containing foods and drinks amongst low income groups.24,25,26 Explanations for this pattern are complex but economic and structural factors play a significant role.27

Inequalities in the prevalence and severity of periodontal disease are mainly related to health behaviours such as oral cleanliness and smoking.28,29 Social class is strongly associated with tooth cleaning.5 Belonging to a high social class was associated with cleaning the teeth more effectively and frequently and with using more oral hygiene aids than those of low social class.30

Notions about periodontal diseases are in a state of flux. Concepts about the epidemiology of the diseases have been challenged and the new theories on the epidemiology and in particular, the natural history of periodontal diseases, have important implications for preventing and controlling periodontal diseases. In both industrialized and underdeveloped countries the prevalence and severity of severe destructive periodontal diseases is very low and rates of progression of periodontal destruction, very slow. Contrary to earlier beliefs, susceptibility to periodontal diseases is not universal; the prevalence of destructive periodontal diseases is lower than previously estimated and is declining.31,32,33,34,35 In particular, the prevalence of severe periodontal disease is very low.31,34 Periodontal disease is not a major cause of tooth loss in adults. Contrary to the view that destructive periodontal disease was widespread and that The Ottawa Charter

  • Creating supportive environments:

     recognising the impact of the environment on health and identifying opportunities to make changes conducive to health

  • Building healthy public policy:

     focusing attention on the impact on health of public policies from all sectors, and not just the health sector

  • Strengthening community action:

     empowering individuals and communities in the processes of setting priorities, making decisions, planning and implementing strategies to achieve better health

  • Developing personal skills:

     moving beyond the transmission of information, to promote understanding, and to support the development of personal, social and political skills which enable individuals to take action to promote health

  • Reorienting health services:

     refocusing attention away from the responsibility to provide curative and clinical services towards the goal of health gain.

everyone is susceptible to advanced destructive periodontal disease, current epidemiological evidence indicates that mild gingival inflammation is common and many adults have mild to moderate loss of periodontal attachment at some sites of some teeth.34 The severity and rate of the loss of some periodontal support in the majority of populations does not lead to much tooth loss nor significant psychological and social impacts.36,37,38 Gingival inflammation seldom causes discomfort, social embarrassment or loss of function.39

The WHO-FDI Joint Working Group on Periodontal Health Services recognized that there are many deficiencies in knowledge about screening, monitoring, professional care and on the information for individuals and groups.40 Current theory suggests that progression of periodontal disease is slow. Most of the disease is at the gingivitis or early destructive stages. The tenuous basis for the effectiveness of current dental care for these stages of periodontal disease has been highlighted.41 Frandsen (1986) carried out an extensive review of professionally administered mechanical periodontal procedures. His main conclusions cast severe doubts about the effectiveness of most periodontal procedures such as scaling and oral hygiene instruction, the usefulness of removing calculus, the importance of root planing, polishing and the removal of plaque at intervals longer than four weeks.41

The risk factors for oral cancer are tobacco and alcohol use. Vitamins C and A are considered to have a protective effect.42,43 The risk and protective factors are inversely related to socioeconomic status, and it is therefore not surprising that oral cancers, as other cancers, occur more frequently among the poorer social classes. The 5-year survival rate for oral cancer was about 30% and has not improved despite changes in treatment.44

The causes of dental caries, periodontal diseases, oral cancer and dental trauma vary by social class; sugars ingestion, cleanliness and cigarette smoking and accidents respectively. Nevertheless the main social class differences in oral status are from the treatment for caries in the permanent dentition. In the upper social classes; more teeth are filled and less extracted than in the lower classes.5

In most countries the socio-economic gradient in use of dental services is well documented, not only in terms of relatively lower frequency of dental visits for low-income and less-educated children and adult groups, but also in relation to lower consumption of preventive services.45

Policy options for effective action

Treatment services will never successfully tackle the underlying cause of oral diseases.

Oral health inequalities will only be reduced through the implementation of effective and appropriate oral health promotion policies.46 Treatment services will never successfully tackle the underlying cause of oral diseases.47 Improvements in oral health that have occurred over the last 30 years have been largely a result of social, economic and environmental factors.21,22 To extend these improvements further and thereby reduce widening oral health inequalities therefore requires a strategic oral health promotion approach.

Recent systematic effectiveness reviews of dental health education have highlighted the limitations of existing dental health education interventions.48–50 Interventions were shown to be ineffective at producing long term sustainable changes in oral health behaviours and failed to address inequalities. Indeed the narrow individualist approach adopted actually increased oral health inequalities.51 A more progressive health promotion approach which recognises the importance of tackling the underlying social, political and environmental determinants of oral health is therefore needed. For this approach to be successful in achieving sustainable changes in oral health, multisectoral working is an essential requirement.

The Ottawa Charter provides a useful framework outlining the five strategic aims of health promotion.52 This framework will now be used to review the available options to reduce oral health inequalities.

Creating supportive environments

Fluoridating the mouth

Water fluoridation. Fluoridation of public water supplies is a proven public health measure that has been demonstrated to reduce caries experience, especially amongst socially deprived communities. Water fluoridation has led to an overall 44% reduction in caries in 5-year-old children. The greatest benefit was in the most deprived areas. Water fluoridation reduced oral health inequalities amongst the child population.17 This finding is supported by studies in the UK and Australia.53,54 Water fluoridation provided benefits for all social classes but the effects were more pronounced in lower social class children, particularly in the primary dentition.54

Since the Water (Fluoridation) Act 1985 was passed, no new fluoridation schemes have been introduced in the UK. Over 60 health authorities have completed the consultation required by the Act, but implementation of their fluoridation policies is being frustrated by the water undertakers. Amendment of the Water Fluoridation Act 1985 is urgently required to facilitate the extension of this proven public health measure in the UK.

Removing VAT on fluoride toothpastes. Fluoride toothpaste is the single most important reason for the dramatic decline in caries in the past 20 years. Patterns of consumption of toothpaste vary by social class.55 Fluoride in toothpastes made a marked contribution to the caries decline in most industrialized countries.20 The Treasury should remove the VAT currently levied on fluoride toothpastes to reduce the cost of this proven preventive agent. A reduction in cost would facilitate the increased use of fluoride toothpaste amongst socially deprived members of society many of whom have high levels of caries.

Health Promoting Schools. The WHO Health Promoting Schools initiative aims at 'achieving healthy lifestyles for the total school population by developing supportive environments conducive to the promotion of health. It offers opportunities for, and requires commitments to, the provision of safe and health enhancing social and physical environment'.56 Of particular relevance to oral health promotion would be nutrition, smoking and accident prevention policies. In addition, efforts such as the Schools Meals Campaign and School Nutrition Action Groups (SNAG) are initiatives which aim to provide students with a range of food choices within schools including nutritional options.57,58 Such initiatives recognise the importance of increasing the availability of cheap and appealing nutritious foods and drinks within school canteens, tuck shops and vending machines.

The Departments of Education and Health should expand the Health Promoting Schools programme to include all schools in socially deprived locations. Dental professionals and oral health promoters should ensure that any opportunities to promote oral health are adopted within these programmes.

Building healthy public policy

National and Local Food Policies.

The Minister of Public Health should create an Inter-Departmental forum to integrate Government policy to improve diet and nutrition. The Food Standards Agency should play a key role in this process. A reduction in the frequency and total consumption of non milk extrinsic sugars (NMES) will only be achieved through a national food policy, supported by regional and local initiatives. Such a policy requires Government support to facilitate legislative, fiscal, educational and organisational policies. Elements of this policy could include nutritional guidelines on the content of nursery school meals, school meals, and guidelines for food in residential homes.57,59,60

Consultation with major supermarkets to provide a wider range of low and no sugar confectionery, drinks, biscuits, cereals, and to introduce clear shelf, as well as product labelling of NMES content of all products would also be needed. Developments in welfare and social policies which focus upon the impact of food poverty which is affecting an increasing proportion of the population, are also urgently required.27

Smoking Policy

The Minister of Public Health should review and extend Government action on preventing and reducing smoking, especially amongst young people. Stricter controls on the advertising and marketing activities of the cigarette industry would be an essential element of such a policy. Smoking is an aetiological factor associated with periodontal diseases and oral cancer. Currently the dental profession is not actively involved in the prevention of smoking. Reducing smoking rates especially amongst young people requires a co-ordinated strategic policy that addresses the underlying reasons behind teenage smoking and deals with the social, economic and political determinants of this behaviour.61 The dental profession has an ethical and professional obligation to become actively involved in smoking cessation interventions.

Paan Policy

Regulations on the importation, labelling and sale of paan and associated products should be enacted and enforced alongside the regulations on sale and promotion of tobacco. Oral cancer rates amongst South Asian communities in the UK are higher than in the indigenous community. Effective prevention is dependent upon developing culturally sensitive interventions that address the social and structural basis of tobacco use amongst high risk populations. Sale of tobacco containing Paan (betel nut) is largely unregulated and many teenagers use these products.62

Developing personal skills

Oral health education

Health education supports personal and professional development through providing information, education for health, and helping people to develop the skills needed to make healthy choices. Integrated oral health education input into the national curriculum is essential to foster the development of the necessary knowledge, attitudes and skills to promote oral health. In particular skills training such as decision making, assertiveness training and cooking should be included in personal and social development courses. Overall the health education components of the National Curriculum need to be strengthened and incorporated across appropriate aspects of the curriculum.

In addition to school based health education many opportunities exist to promote oral health through professional training and education. Health visitors, GP's, pharmacists, teachers and Local Authority staff all can play an important role in educating their clients about oral health.63

Reorienting health services

The role of service commissioners.

The NHS has a key role to play in promoting and developing purposive policies to tackle oral health inequalities. In particular commissioners of services have a major contribution to offer.64 The development and implementation of local Oral Health Strategies which include equity based goals, targeting of resources to areas of greatest need and the facilitation of healthy alliances with agencies and organisations outside of the NHS are all important commissioning functions. Population preventive programmes such as fissure sealant programmes targeted at schools with high dmf/DMF levels are an effective preventive measure to reduce occlusal caries in high risk child populations.

Prescription of sugar free medications.

Frequent use of sugar based paediatric medicines is associated with increased risk of caries in vulnerable chronically sick children. Caries can be prevented by using sugar free medicines.65 Greater use of sugar free medicines is dependent upon action by medical and pharmaceutical professions together with the pharmaceutical industry. For example, the computerised labelling of Sugar Free options on GPs IT prescribing systems will encourage GPs to select these healthier choices.

Dental services for disadvantaged groups.

There is definitely inequitable access to dental care by area, ethnic group, or socio-economic group. There is no evidence that increasing the provision of care decreases inequity in oral health except that the disadvantaged groups may have fewer teeth extracted and more filled. The cost/benefit ratio of this approach is poor. For example, the cost of services to reduce tooth loss in disadvantaged groups by one tooth per person is unacceptably high and funds would be better used on public preventive approaches. Reducing inequities in care has a low priority in improving oral health. The one group who would benefit from more care are older people. Here the improvements in oral quality of life measures are significant and their food choices increase because they can chew better.66

Strengthening community action

Community development programmes

Community development strategies aim to improve the capacity of less powerful groups by developing collective social networks and thus accessing resources. This approach recognises the strengths and capabilities collective action can achieve to create healthier conditions for poor communities.67 Such an approach has been rarely applied directly to oral heath issues. However an oral health promotion programme in Newcastle and North Tyneside is using community link workers to facilitate improvements in oral health amongst socially deprived groups.68

Another example of a community development initiative directly relevant to oral health are food co-operatives. The establishment of fruit and vegetable food co-operatives within deprived neighbourhoods lacking access to cheap and appealing healthy foods increases the food choices available to these communities.69


Although oral health has dramatically improved overall in the last 20 years, oral health inequalities have widened. The most stark oral health inequalities are found in dental caries levels amongst pre-school children. A reduction in oral health inequalities will only be achieved through the implementation of effective and appropriate health promotion policies which focus action on the underlying social, economic and environmental causes of dental disease.