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Understanding and tackling oral health inequalities in vulnerable adult populations: from the margins to the mainstream


Vulnerable and socially excluded groups in society persistently experience significantly worse oral health and poorer access to dental services than the mainstream population. Action to tackle these unfair, unjust and avoidable inequalities in oral health needs to be informed by an understanding of the broad range of interacting factors that ultimately influence oral health across society and specifically the most vulnerable and marginalised. Failure to understand the underlying factors that create and perpetuate the oral health equity gap risks the development and implementation of ineffective interventions that do not achieve meaningful improvements in oral health for the most vulnerable. This paper presents a theoretical framework that combines a broad public health perspective on oral health inequalities, combined with more specific factors determining the oral health of vulnerable and marginalised groups. Actions to improve access to dental services and policies to combat oral health inequalities among vulnerable adult populations are then presented.

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  1. 1.

    The Royal College of Surgeons of England. Speciality Training Curriculum. Special Care Dentistry. 2009. Available at (accessed June 2019).

  2. 2.

    Schwendicke F, Dörfer C E, Schlattmann P, Foster Page L, Thomson W M, Paris S. Socioeconomic inequality and caries: a systematic review and meta-analysis. J Dent Res 2015; 94: 10-18.

  3. 3.

    Klinge B, Norlund A. A socio-economic perspective on periodontal diseases: a systematic review. J Clin Periodontol 2005; 32 (Spec Iss): 314-325.

  4. 4.

    Conway D I, Petticrew M, Marlborough H, Berthiller J, Hashibe M, Macpherson L M. Socioeconomic inequalities and oral cancer risk: a systematic review and meta-analysis of case-control studies. Int J Cancer 2008; 122: 2811-2819.

  5. 5.

    World Health Organisation. Closing the gap in a generation: Health equity through action on the social determinants of health. Geneva: World Health Organisation, 2008. Available at (accessed June 2019).

  6. 6.

    Lee J Y, Divaris K. The ethical imperative of addressing oral health disparities. J Dent Res 2014; 93: 224-230.

  7. 7.

    Marmot M, Commission on Social Determinants of Health. Achieving health equity: from root causes to fair outcomes. Lancet 2007; 370: 1153-1163.

  8. 8.

    Whitehead M. The concepts and principles of equity and health. Int J Heal Serv 1992; 22: 429-445.

  9. 9.

    Thomson W M, Poulton R, Milne B J, Caspi A, Broughton J R, Ayers K M. Socioeconomic inequalities in oral health in childhood and adulthood in a birth cohort. Community Dent Oral Epidemiol 2004; 32: 345-353.

  10. 10.

    Guarnizo-Herreño C C, Watt R G, Fuller E et al. Socioeconomic position and subjective oral health: findings for the adult population in England, Wales and Northern Ireland. BMC Public Health 2014; 14: 827.

  11. 11.

    Tsakos G, Demakakos P, Breeze E, Watt R G. Social gradients in oral health in older adults: findings from the English longitudinal survey of aging. Am J Public Health 2011; 101: 1892-1899.

  12. 12.

    Sabbah W, Tsakos G, Chandola T, Sheiham A, Watt R G. Social gradients in oral and general health. J Dent Res 2007; 86: 992-996.

  13. 13.

    Poulton R, Caspi A, Milne B J et al. Association between children's experience of socioeconomic disadvantage and adult health: a life-course study. Lancet 2002; 360: 1640-1645.

  14. 14.

    Peres M A, Peres KG, de Barros A J, Victora C G. The relation between family socioeconomic trajectories from childhood to adolescence and dental caries and associated oral behaviours. J Epidemiol Community Health 2007; 61: 141-145.

  15. 15.

    Bastos J L, Celeste R K, Paradies Y C. Racial Inequalities in Oral Health. J Dent Res 2018; 97: 878-886.

  16. 16.

    Parker E J, Jamieson L M, Broughton J, Albino J, Lawrence H P, Roberts-Thomson K. The oral health of Indigenous children: a review of four nations. J Paediatr Child Health 2010; 46: 483-486.

  17. 17.

    Keboa M T, Hiles N, Macdonald M E. The oral health of refugees and asylum seekers: a scoping review. Global Health 2016; 12: 59.

  18. 18.

    Joint Advisory Committe for Special Care Dentistry. A Case for Need: Proposal for a Speciality in Special Care Dentistry. London: JACSCD, 2003.

  19. 19.

    Faulks D, Hennequin M. Defining the population requiring special care dentistry using the International Classification of Functioning, Disability and Health - a personal view. J Disabil Oral Health 2006; 7: 143-152.

  20. 20.

    Department of Health. Valuing People's Oral Health. A good practice guide for improving the oral health of disabled children and adults. London: Department of Health, 2007. Available at (accessed June 2019).

  21. 21.

    Department for Work and Pensions. Family Resources Survey: financial year 2017/18. 2019. Available at (accessed June 2019).

  22. 22.

    World Health Organisation. World Report on Disability. Geneva: WHO, 2011. Available at (accessed June 2019).

  23. 23.

    Anders P L, Davis E L. Oral health of patients with intellectual disabilities: a systematic review. Spec Care Dentist 2010; 30: 110-117.

  24. 24.

    Navarro Azevedo de Azeredo F, Silva Guimarães L, Azeredo A. Antunes L, Santos Antunes L. Global prevalence of dental caries in athletes with intellectual disabilities: An epidemiological systematic review and meta-analysis. Spec Care Dent 2019; 39: 114-124.

  25. 25.

    Kisely S, Baghaie H, Lalloo R, Siskind D, Johnson N W. A systematic review and meta-analysis of the association between poor oral health and severe mental illness. Psychosom Med 2015; 77: 83-92.

  26. 26.

    Baghaie H, Kisely S, Forbes M, Sawyer E, Siskind D J. A systematic review and meta-analysis of the association between poor oral health and substance abuse. Addiction 2017; 112: 765-779.

  27. 27.

    Daly B, Newton T, Batchelor P, Jones K. Oral health care needs and oral health-related quality of life (OHIP-14) in homeless people. Community Dent Oral Epidemiol 2010; 38: 136-144.

  28. 28.

    Groundswell. Healthy Mouths: A peer-led health audit on the oral health of people experiencing homelessness. London: Groundwell, 2016. Available at (accessed June 2019).

  29. 29.

    Marshman Z, Baker S R, Robinson P G. Does dental indifference influence the oral health-related quality of life of prisoners? Community Dent Oral Epidemiol 2014; 42: 470-480.

  30. 30.

    Rouxel P, Duijster D, Tsakos G, Watt R G. Oral health of female prisoners in HMP Holloway: implications for oral health promotion in UK prisons. Br Dent J 2013; 214: 627-632.

  31. 31.

    Jones C M, Woods K, Neville J, Whittle J G. Dental health of prisoners in the north west of England in 2000: literature review and dental health survey results. Community Dent Health 2005; 22: 113-117.

  32. 32.

    Daly B, Thompsell A, Sharpling J et al. Evidence summary: the relationship between oral health and dementia. Br Dent J 2018; 223: 846-853.

  33. 33.

    Noble J M, Scarmeas N, Papapanou P N. Poor oral health as a chronic, potentially modifiable dementia risk factor: review of the literature. Curr Neurol Neurosci Rep 2013; 13: 384.

  34. 34.

    Nouaman M N, Meless D G, Coffie P A et al. Oral health and HIV infection among female sex workers in Abidjan, Côte d'Ivoire. BMC Oral Health 2015; 15: 154.

  35. 35.

    Edwards D M, Watt R G. Oral health care in the lives of Gypsy Travellers in east Hertfordshire. Br Dent J 1997; 183: 252-257.

  36. 36.

    Doughty J, Simons D, Pearson N, Evans P, Wright D. Challenges identified in a pilot outreach dental service for Traveller children in Hackney, East London. Community Dent Health 2016; 33: 185-188.

  37. 37.

    The Information Centre for Health and Social Care. Adult Dental Health Survey 2009 - Summary report and thematic series. 2011. Available at (accessed June 2019).

  38. 38.

    Faulks D, Freedman L, Thompson S, Sagheri D, Dougall A. The value of education in special care dentistry as a means of reducing inequalities in oral health. Eur J Dent Educ 2012; 16: 195-201.

  39. 39.

    Cumella S, Ransford N, Lyons J, Burnham H. Needs for oral care among people with intellectual disability not in contact with Community Dental Services. J Intellect Disabil Res 2000; 44: 45-52.

  40. 40.

    Baird W O, McGrother C, Abrams K R, Dugmore C, Jackson R J. Access to dental services for people with a physical disability: a survey of general dental practitioners in Leicestershire, UK. Community Dent Health 2008; 25: 248-252.

  41. 41.

    Leal Rocha L, Vieira de Lima Saintrain M, Pimentel Gomes Fernandes Vieira-Meyer A. Access to dental public services by disabled persons. BMC Oral Health 2015; 15: 35.

  42. 42.

    Bedi R, Champion J, Horn R. Attitudes of the dental team to the provision of care for people with learning disabilities. Spec Care Dentist 2001; 21: 147-152.

  43. 43.

    Craig P, Dieppe P, Macintyre S et al. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ 2008; 337: a1655.

  44. 44.

    World Health Organisation. A conceptual framework for action on the social determinants of health. social determinants of health: social determinants of health discussion paper 2. Geneva: World Health Organisation, 2010. Available at (accessed June 2019).

  45. 45.

    Watt R G, Sheiham A. Integrating the common risk factor approach into a social determinants framework. Community Dent Oral Epidemiol 2012; 40: 289-296.

  46. 46.

    World Health Organisation. International Classification of Functioning. Disability and Health (ICF). Geneva: World Health Organisation, 2001. Available at (accessed June 2019).

  47. 47.

    Schneidert M, Hurst R, Miller J, Ustün B. The role of environment in the International Classification of Functioning, Disability and Health (ICF). Disabil Rehabil 2003; 25: 588-595.

  48. 48.

    Luchenski S, Maguire N, Aldridge R W et al. What works in inclusion health: overview of effective interventions for marginalised and excluded populations. Lancet 2018; 391: 266-280.

  49. 49.

    United Nations General Assembly. Convention on the Rights of Persons with Disabilities: Resolution Adopted by the General Assembly. 2007. Available at (accessed June 2019).

  50. 50. Equality Act 2010. Available at (accessed June 2019).

  51. 51.

    NHS England. Guides for commissioning dentistry: Special Care Dentistry. London: NHS England, 2015. Available at (accessed June 2019).

  52. 52.

    Schou L, Wight C. Does dental health education affect inequalities in dental health? Community Dent Health 1994; 11: 97-100.

  53. 53.

    Qadri G, Alkilzy M, Franze M, Hoffmann W, Splieth C. School-based oral health education increases caries inequalities. Community Dent Health 2018; 35: 153-159.

  54. 54.

    The Health Foundation. A healthier life for all: the case for cross-government action. London: The Health Foundation, 2016. Available at (accessed June 2019).

  55. 55.

    International Centre for Oral Health Inequalities Research & Policy. Social inequalities in oral health: from evidence to action. London: UCL, 2015. Available at (accessed June 2019).

  56. 56.

    Sheiham A, Watt R G. The common risk factor approach: a rational basis for promoting oral health. Community Dent Oral Epidemiol 2000; 28: 399-406.

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Correspondence to Richard G. Watt.

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Watt, R., Venturelli, R. & Daly, B. Understanding and tackling oral health inequalities in vulnerable adult populations: from the margins to the mainstream. Br Dent J 227, 49–54 (2019).

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