Free Health Essays - An investigation into dental caries: the effects of socio-economic status and deprivation in young children, and the implications for health visiting practice
In this paper we examine the evidence base for a purported linkage between dental caries and socio-economic depravation. Intertwined with this consideration is a discussion of the various indices of socio-economic depravation and how they impact on the literature base.
We consider evidence of a number of measures that have been instituted in order to tackle the incidence of dental caries in the more deprived groups and examine how they have affected the incidence of dental disease.
We consider the specific issue of fluoridation and its effect on the patients with the greatest risk of caries and we also comment on the lack of implementation of original Government policy relating to general fluoridation of the water supply which has been consequent on the privatisation of the Water Companies.
We consider the impact of these findings on the profession of Health Visiting and also consider the professional guidelines and Benchmarking standards that are relevant in this area.
We finish by drawing a number of conclusions from the work done and the literature reviewed.
Introduction
Outline the topic chosen for investigation with rationale for choice in terms of relevance to the student's learning needs within the specialist practice pathway and importance to contemporary policy and practice, for example the health needs of the community and locally and nationally determined priorities. Approx. 800 words
It has long been recognised that there is a direct statistical link between socio-economic depravation and a range of physical and psychological morbidity. (WHO 1996)
In part, this is due to factors such as poor diet, poor housing and sanitary conditions and poor working conditions, but it is also due to a comparative inability to access health care facilities to the same extent as the socio-economically well off (Parker and Lawton 2003). This can be demonstrated across a wide range of human pathology, most notable coronary heart disease, respiratory illness and some infectious disease process.
With specific reference to dental pathology, the link between socio-economic depravation and dental pathology in general and caries in particular, there are a number of studies which can point to the fact that the homeless, for example, are often not registered for dental care and make little use of the dental services that are provided in any event. They have a greater default rate for keeping dental appointments. (Bedi & Uppal 1995).
With specific reference to caries, further evidence comes from work that shows that people who have a substance abuse problem tend to have higher incidence s of poor dental hygiene. Methadone users, for example, tend to selectively choose sweet and sugary food, which is a prime independent risk factor for dental caries (Carter EF 1998)
As a general trend, the last few decades have seen a progressive improvement in the levels of child oral health and one would hope that this will eventually be translated into a trend in adult oral health. (Heller T et al 2001)
The inequalities in affluence appear to be translated into inequalities in both the use of the dental services as well as the general access to the dental services and this is potentially a major confounding factor in this argument. The elderly, the homeless and the poor all have their own difficulties in accessing appropriate dental care and this difficulty will translate into difficulties in the children of these groups with the appropriate consequences for these children
Main body Critical analysis of the literature available on the topic. This should provide an overview and then focus upon the evidence base for practice in relation to the topic, including critical appraisal of three key references as sources of evidence. This should include justification of the selection of the references. Approx. 4700 words (including 2200 words for critical appraisal of research articles)please show as critical analysis:- Paper one, paper two and paper three.
In any critical assessment of a topic such as this it is essential to establish a firm evidence base. (Sackett, 1996). There is a great deal of literature on the subject of dental caries and a fair proportion of this makes reference to socio-economic deprivation. The most important factor from our point of view is to be able to make a valid assessment of the weight to be placed on the evidence presented. Some of the studies considered for this review were discarded on the basis that they were statistically flawed or methodologically unsound. (Altman DG. 1991)
Although such studies may present firm conclusions or make apparently valid discussion points, they are of no value in an evidence base if the studies that they were based on were statistically unsound (Rogers et al 2000).
With this in mind we have selected three papers, each of which, in our judgement, makes a sound and important contribution to our understanding of the subject.
Paper one
The first is a review paper by Sweeny ( et al 1999) which is a commentary and assessment of the Scottish Health Board's dental epidemiological programme which specifically looked at the problem of depravation and dental caries.
It was carried out from the University of Dundee and it draws on, and compares its current results with the previous report of the SHBDEP in 1995/6 so trends can be identified (Pitts et al 1996). The report itself is a long, meticulous and complex document with a number of different sub-sections. We shall concern ourselves with the elements of the report that are specifically relevant to our considerations in this essay.
The report begins by detailing the various Government strategies (both local and National) that have an impact upon the dental health of the population in genera, including the fact that the Scottish office have previously made dental and oral health one of their five designated priority targets in the past (SO 1992)
The paper discusses the relationship between social deprivation and poor health and in specific consideration of dental health, it cites the fact that many features of the Scottish diet may give rise to specific illness patterns including alcohol misuse, high fat, low fruit and vegetable consumption being associated with various types of malignancy. In the field of oral health specifically, it comments on the increased frequency of smoking which may be responsible from the disproportionate significance of oral and pharyngeal malignancies seen in the north of England (SO 1993)
In its section on epidemiology, the paper points to the caries gradient across the UK. with the higher incidences occurring towards the north and west of the UK and the lowest incidences being found in the south east. These studies are done on a regular basis under the auspices of the British Association for the Study of Community Dentistry (BASCD) and, in Scotland by the Scottish Health Board's Dental Epidemiological Programme (SHBDEP)
The authors tell us that there is not only a geographical divide as mentioned above but that there is also the economic divide between the higher and lower social classes when it comes to the analysis of the incidence of caries. Children in the north of the country tend to have more caries disease than children of the same social class in the south of the country. But irrespective of geography, the children from the higher social class have less dental caries disease than those of a lower social class.(Davies C et al.2000)
The authors also tell us that their findings are corroborated by other studies, not least being the National Diet and Nutrition Survey of 1 to 4 Year Olds (Hinds & Gregory 1995)
They were able to identify a number of independent risk factors for dental caries including:
Head of the household is in a manual social class
Receipt of Income Support,
Receipt of Family Credit,
Lack of mother's educational qualifications
Lone parentage
Quite apart from the obvious socio-economic factors that we have discussed, the authors also point to other discriminatory factors such as studies that show that dental disease is more prevalent in families where the child has not had its teeth brushed with toothpaste by its first birthday (Elley et al 1993)
Other studies quoted in support of their findings include the Prendergast study (et al 1995) which was centred in Leeds and showed a clear link between material deprivation and the incidence of dental caries. The Attwood study (et al 1999) took a slightly different slant on the topic and showed that there was a material improvement in the dental health of a cohort of 12-15 yr. olds over a three year study period in the Glasgow area, but the percentage improvement in the more affluent groups was three times that demonstrated in the poorer groups
This particular paper is notable because it not only provides a wealth of good quality supporting evidence for the fact that there is a direct link between socio-economic groups and dental caries, but it has a large section on the methodology and rationale behind the techniques of assessment and measures of socio-economic depravation. We will not discuss this particular section in any great detail other than to point out the fact that the Registrar General's classification of the six social classes based on the occupation of the head of the family (Leete & Fox 1977) is no longer considered to be a socially useful tool.
There are a number of other models used by the social scientists including the Carstairs model, the Jarman scale and the Townsend index. (Jarman B 1984). All have their advantages and disadvantages. The paper is to be commended on its thorough analysis of the various indices of deprivation and the statement of the overall fact that irrespective of just what measure of deprivation is used, the incidence of dental caries is directly proportional to the degree of social deprivation.
The paper also is to be commended on its rather unusual approach of quantifying the degree of dental caries with the post code of the patients. Each post code was allocated a score which equated with its degree of social prosperity . It has long been known that there is a post code association with disease process such as coronary heart disease and certain cancers, but this paper was able to produce evidence that there is an equal relationship between the same post code degree of deprivation and the amount of dental disease. The authors felt able to comment that:
There is a sequential rise in the number of decayed and missing teeth on moving from the more affluent to the most deprived postcode sectors.
Five year old children from the most deprived areas, as determined by their postcode sector of residence, have more than 3 times the amount of dental disease experienced by those children living in the most affluent postcode sectors.
The authors illustrate this finding with an analysis of 5 yr. old children of the least deprived post code areas where 60% have already exceeded the National Target of no fillings cavities or extractions, whereas in the most deprived post code areas less than 20% are free of dental disease.
One of the reasons that this particular paper was chosen for this analysis, was the fact that unlike many other analytical papers on this subject, it has a large section of discussion on the general theme of What can be done. Many papers are content simply to present the facts of their research and rest on their laurels. The authors of this paper are to be commended for their stance of not only producing an exemplary analysis of the link between dental caries and socio-economic depravation but then to produce a rational list of suggestions on how to combat the situation. (Fairbairn G J et al 1993)
This particular section of the paper is both long and involved, but is of particular relevance to the subject of Health Visiting and the evidence base on which to structure professional practice so we shall present a concise but critical overview of the salient points raised.
The first point made is that although there is clear and irrefutable evidence of inequality of dental health care, there was very little in the way of National guidance on what should, or could be done. To a degree, this shortfall was both recognised and at least partly remedied by a working party that was set up by the Chief Medical Officer's office in 1994 with the prime remit of advising the NHS and the Dept. of Health just what measures could be employed to address the situation. this culminated in the publication of the Government White Paper Variations in Health - What can the Department of Health and the NHS do? (VIH 1995)
In broad terms, the report's strategy was To improve the health of the least healthy group to the levels of health attained by the most healthy groups. The implications of this statement are not immediately obvious. We have spent a considerable part of this discussion outlining the inescapable correlation between socio-economic deprivation and poor dental health. It follows from this precept, that the logical way to address poor dental health is to eradicate the areas of socio-economic deprivation. Clearly, it is beyond the power of the Department of Health and the NHS to do that. It follows than, that an alternative strategy must be adopted. (Hardey M 1998)
The Department of Health decided that a targeted programme of health education and intervention should be instituted. They identified the key problem behaviours in the 5 yr. old age group which were known to be associated with the early onset of dental caries. These are :
Poor diet
Poor oral hygiene
Build up of dental plaque
Lack of exposure to topical fluoride
Lack of attendance at the dentist for regular check-ups
Higher than average consumption of sugary food and drinks from an earlier than average start age.
(Hinds & Gregory 1995)
They also identified the fact that planned interventions and strategies to tackle these particular problem areas simply either did not exist or were generally lacking
Also, with particular relevance to our considerations here, they identified the features of the more successful interventions that did exist and quantified them as:
Planned systematic and intensive action
Multi-agency working
A combination of strategies/range of services
The provision of materials, support and resources
The development of skills in the target group
Precise and intensive focusing on the target group
Consumer involvement
Prompts to use services
In an appendix to the document, the Department of Health also recognised the beneficial role that other agencies could play in promoting dental health, thus strengthening the Multi-agency approach of the initiative. In particular they cited the following:
Government departments other than the Department of Health, Local Authorities, voluntary groups, the manufacturing and retail sectors, communities and individuals themselves.
The point relating to the individual is particularly significant. We have already discussed the importance of empowerment and education of the patient and their carers. (Howe and Anderson 2003). The government took the view that this was every bit as important as the simple provision of resources.
A confounding factor was thought to be the fact that when such measures had been used (in a piecemeal fashion) previously, it was found that the general take up and adherence to health promotion programmes in schools was much better in the schools with the most affluent catchment areas and they had little or no benefit in schools in the most deprived areas (Schou et al 1993). This was further evidence that such measures had to be targeted rather than universally applied since the universal application of such resources only therefore widened the social divide, not closed it. (Heller T et al. 2001)
A critical analysis of this particular paper would have to conclude that it represents an impressive tour de force on the subject. It is particularly strong in presenting the evidence that dental caries are related directly to poor socio-economic status. It is good at presenting the historical perspective on government strategy and an analysis of what measures can be employed. The Achilles' heel of this paper is the recommendation section. One could reasonably hope that, after such an erudite exposition of the situation relating to dental caries, the authors would feel able to actually recommend a strategy or course of action to combat the situation.
There is an implied recommendation from the material presented, but the only concrete measures presented are all to do with changes in the way that statistical information is to be collected in the future, which, in our opinion, is rather disappointing.
Paper Two
The second paper that we shall consider may be considered, at first sight, a strange choice. It does give considerable information relating to dental caries in the young, but it also considers the dental health of a specific sub-group of those patients who have additional special needs. Part of the rationale for choosing this paper is the specific relevance it has for the health visitor, who may very well tend to have a greater input into this type of situation than perhaps the average family.
The paper itself is by three respected authors (Davies et al 2000) whose names frequently appear in the peer reviewed journals, and this fact alone makes it worthy of consideration.
The authors start with the point that their definition of special needs is not actually the same as the definition more commonly heard in educational circles. They define special needs as being:
Those whose dental care is complicated by a physical, mental, or social disability.
Within this definition they suggest that such patients tend to receive less good quality dental health care than the rest of the population, yet the presence of oral problems that can affect their systemic general health are a more common finding in this particular group.
The authors also make the point early on in the paper that empowerment and education of the patient 's carers is a prime prognostic factor in the reduction of dental disease in this group. Good care is even more important in this group since operative intervention and extractions often tend to have greater problems than in the rest of the community. (Jones L 1994)
Psychological problems are encountered with greater frequency in this group, not the least being dental phobias. The authors describe how such patients can often be dealt with using behaviour modification techniques although sedation or anaesthesia may eventually be required in resistant cases.
The bulk of the article is extremely informative and of great value to the prospective (or even fully qualified) Health Visitor, as it deals with a number of unusual and rarely seen dental problems. These are clearly of professional interest, and therefore thoroughly commended to the Health Visitor reader, but they are otherwise beyond the prime thrust of this essay. We shall therefore confine our discussions here to the part of the article that deals with the issue of dental caries.
There is a higher incidence of cardiovascular abnormalities in this particular group. Dental caries represent a particular problem here, as the resultant bacteraemia that can be associated with caries and the associated gingivitis will always carry with it the danger of sub-acute bacterial endocarditis. Dental health is of considerably greater importance therefore in this group than (arguably) it is in the general population. Apart therefore, form the normal measures to be taken for the prevention of dental disease, the authors also recommend that regular use of 4.8% tranexamic mouthwash on a four times daily basis, to combat the build up of oral pathogens.
There is a large section of this paper that is given over to the rarer disease entities, but which are seen with greater frequency in this particular client group. The authors are at pains to point out the fact that there is an association with concurrent disease and a reduction in personal dental care. This can be due to intercurrent illness, or just simply increased patient debility. These factors should not be overlooked when professional advice is given as, in the immunocompromised patient, dental infection - particularly oral candidiasis - is far more common and this is one of the prime causative factors in dental caries formation.
The immunocompromised patient may be in that particular state either by illness or because of the treatment of a particular illness ( typically HIV or some malignancies). Very often the focus of treatment and therapeutic intervention is (quite properly) on the target illness. The authors make the point that it is part of the professional remit of the healthcare professionals involved, that they should also consider the other, less obvious, dental consequences of the treatment of illness concerned. (Mason T et al 2003)
Gingivitis and peridontitis are commonly seem in these situations as they occur with disproportionate frequency in the immunocompromised patient. They remind us that, although the thrust of the treatment must be targeted at the acute condition, one must not overlook the less acute consequences of dental decay.
In the light of our discussions with regard to the socio-economic disadvantages of access to dental health care, there is one particular subgroup of the special needs patients who have particular problems, and they are the mentally challenged. Poor oral health is a more normal state of health in this group than the general population. This is, to some extent, a vicious circle. Missing, discoloured or broken teeth and oral disease simply adds to the problem of social exclusion that is already experienced by this group. It worsens the problems of social acceptance that they may struggle with on a daily basis.
We have already established that these two factors are of major importance when it comes to the availability, and the ability of the patient to access appropriate dental care. Additional factors in this group will also include fear - which may be worsened by their inability to actually understand the need for treatment, the need to be accompanied and also, sadly, the attitude and even the lack of appropriate training on the part of the healthcare professionals involved. All these factors may militate against appropriate dental care, together with all the attendant consequences of the lack of that care.
(Wilkinson R 1996)
The authors point to the fact that it is not only the socio-economic depravation that is therefore relevant in these cases. If a patient has only a mild disability, then it may be quite practical to deal with their problems in a local dental surgery. If they have more severe problems, then sometimes the only realistic option is to be treated by the local community dental service or in very severe cases, in the local hospital under sedation or even general anaesthesia. This, by any appreciation, significantly reduces the availability of comprehensive dental care. (Jones L 1994)
Unlike the previous paper, which we criticised for a lack of practical recommendations for action, this particular paper is full of practical suggestions, recommendations and targets which adds to its overall value. In overview, it recommends, for the socio-economically deprived and the socially excluded, that there should be a general recognition that such groups tend to avoid regular dental care and as a result, their dental hygiene may often be impaired. This requires additional care and input from those that are charged with caring for them, both lay and professional. Their medication may well produce unwanted side effects such as xerostomia and this in itself carries an increased risk of caries. Those patients with any form of dyskinesia may have physical difficulty in brushing their teeth.
Healthcare professionals may well have to advise the delaying of appropriate dental treatment until a psychiatric equilibrium has been achieved and they may well find that frequent, short appointments are better than
delaying treatment until there is relative psychiatric equilibrium, keeping appointments short, and oral or intravenous sedation as required.
Paper three
As can be seen from the previous two papers that we have presented here, there appears to be no difficulty in establishing a causative linkage between socio-economic deprivation and poor dental health. The problem seems to revolve around just what exactly can be done. To some extent we have considered other measures, but it has to be said that these measures are primarily aimed at either trying to make the current services more responsive to the demands of the socio-economically deprived group, or to educate and empower this group to make more use of the services that are already available.
The third paper that we shall consider in this regard is the paper by Jones (et al 1997). We have specifically chosen this paper in favour of the other candidate papers because firstly, it uses data from the north west of England, secondly it examines some of the data that was presented in the first paper (Sweeny et al. 1999) and thirdly it also examines the issue of fluoridation (both natural and artificial) which is one of the measures employed that has no socio-economic demographic attached to it. (McIntosh J 1999)
The paper itself is well written and apparently statistically sound. It has a large entry cohort of over 10,000 children who are in the 5th year of life. The study design was to look at the dental health of the children from three areas, namely:
Hartlepool (naturally fluoridated)
Newcastle and North Tyneside (fluoridated)
Salford and Trafford (non-fluoridated).
This is both ingenious and comparatively original, as it allows natural populations to act as their own controls. The Hartlepool area has natural fluoridation and therefore the indigenous population has been receiving the perceived benefits of natural fluoridation throughout their lives. The incidence of dental caries can therefore be easily compared with the other regions which are either naturally free of fluoride or have it artificially added to their water supply.
Each of the children targeted had their teeth assessed and quantified on the Ward tooth decay scale. Each of the target areas were subdivided into smaller discrete areas and categorised by means of the Jarman Scale. (Jarman B 1984).
In broad overview, the results of the study showed a clear and statistically significant relationship between the Jarman score for the area, the number of teeth affected by decay (Ward score) and both types of fluoridation.
In the terms of our consideration here, this is clearly highly significant, as, particularly with natural levels of fluoridation, this measure is completely independent of social class, access to dental care or even quality of dental care. (Ellwood RP et al. 1995)
The corollary of this is that the greater the level of initial deprivation (and by extrapolation the greater the amount of dental caries) the greater was the statistical effect of the reduction in the number of caries by the fluoridation measures.
In specific terms, taking the figures slightly out of context, the study was able to show that when the Jarman score was at the National average ( the definition of Jarman value zero) there was a 44% reduction in decay in the fluorinated areas. This reduction increased to 55% in areas where the Jarman score rose to 40 (which equates with very deprived areas). This is further illustrated by the observation that in areas where there was naturally occurring fluoridation that was at a higher level than the artificial levels of fluoridation (up to 1.2 ppm) there was a 66% reduction in the levels of decay in the Jarman zero areas which rose to a staggering 77% reduction when the Jarman 40 areas were considered.
This improvement was sufficiently marked that the authors were able to conclude that
Tooth decay is confirmed as a disease associated with social deprivation, and the more socially deprived areas benefit more from fluoridation. Widespread water fluoridation is urgently needed to reduce the "dental health divide" by improving the dental health of the poorer people in Britain.
The comments relating to urgent need is clearly a reflection of the fact that this paper is seven years old and actually considers some figures which were derived from studies that are now fourteen years old. Despite this, the need for fluoridation is still great (say the authors). They point to the fact that:
Despite over a hundred studies consistently confirming the efficacy, non-discriminatory benefit, safety, and cost effectiveness of adjusting the level of fluoride in the water supply to 1 part per million (ppm), most of the British population does not have a fluoridated water supply, which would halve the amount of tooth decay in British children. (OIAM 1996)
The original drafting of the Water Fluoridation Act in 1985 (which was subsequently incorporated into the Water Industry Act of 1991) has proved to be virtually completely ineffective as there have been no new fluoridation schemes since the Act was originally introduced. The authors pass comment on the fact that the newly constituted water companies all have an eye to profit and the wording of the Act appears to give them the discretion to either ignore or override the wishes and legitimate requests of the local health authorities. (Taylor GO 1995).
The authors note that this state of affairs has allowed the study of a natural experiment in the way that the authors have exploited here. It effectively means that about 5 million people in the UK have had natural fluoridation of their water supplies for at least the past ten years, the rest of the population do not. The difference in the two groups is demonstrated in the paper itself with the non-fluoridation population acting as natural controls for the other sections.
The rest of the paper is a technical exposition relating to the statistical measures employed. One interesting point to note however, is the fact that the authors comment on the fact that other previous studies did not employ large enough entry cohorts to make their particular studies statistically valuable. They state that this is the first study that has recruited a large enough cohort to make the statistics both reliable and valuable. (Pitts NB et al 1994)
Review of best practice, clinical guidelines, benchmarks or equivalent relevant to the topic area. Evaluation of factors facilitating and \ or inhibiting evidence based practice including consideration of local arrangements for R & D, benchmarking and dissemination of evidence based practice within the frameworks for Clinical Governance. Approx. 1500 words
Professional practice and Benchmarks
A consideration of all of these factors suggests that socio-economic factors are still one of the prime determinants of dental health in the UK today. As we have presented each paper we have discussed the merits (or otherwise) of their recommendations in the implied context of best practice.
Best practice per se. is that practice which is founded on a firm evidence base. (Berwick D 2005). We have therefore been at pains to select those papers that are demonstrably well written, of sound construction, have a firm evidence base and will add to the practical professional knowledge in the area of the title of this piece. Each paper has set its own criteria with regard to patient selection and cohort size and distribution depending on the particular element of the problem that it wished to investigate.
Perhaps the most important factor that we can approach, having discussed these papers are the factors that militate both for and against the implementation of the various measures that have been identified as being significant.
Reflective practice is a vital ingredient of good professional practice.
(Dewey, J. 1933). The research that has had to be done, in order to select and present these three papers has been a fertile source of topics to reflect on.
For example, many of the issues raised in paper two that relate to the special needs client, are issues that, although a moment's thought may identify them, are not frequently encountered in every day professional practice. It is for this reason that one should perhaps familiarise oneself with them so that in the eventuality of coming across them on a professional basis, one is already familiar with the issues and also better able to provide a professional approach to any of the problems that may present.
As Health Visitors, we may not have considered the problems encountered by the patient with dyskinesia might have in simply brushing their teeth. It requires a paper such as this to bring such factors to one's professional attention. If one is unaware of the problem, it is not likely that one will enquire about it in the professional situation.
The whole spectrum of the dental and associated professions try to maintain the ethos of continuing education. The General Dental Council (GDC 2004) states that the primary qualifications for any dental healthcare professional should only be regarded as their first qualification of competence in an educational continuum which should last throughout their practising life. There should be therefore, a minimum level of continuing education that is consistent with continued competence.
Various benchmarks of educational competence are variously cited (GDC 2004) as
Recognise their role in and responsibility for improving the general and oral health of the community through treatment strategy, education and service
Understand the prevalence of oral disease in the UK adult and child populations.
And in terms of Dental Public Health promotion:
Recognise predisposing and aetiological factors that require intervention to promote oral health
Understand the pattern of oral disease in society and be able to contribute to health promotion
Assess the need for, and provide, preventive procedures, dietary advice and instruction in oral health methods that incorporate sound biological principles in order to preserve oral hard and soft tissues, and to prevent disease
The whole rationale of this essay is centred on these precepts. It has been the author's intention to identify the evidence base relating to the relationship between dental caries and socio-economic deprivation. It is clear that this relationship not only exists, but that it is surprisingly strong. We concede and accept that it is only by the professional evaluation of these types of association that the profession can move forward in a constructive and fruitful way. In general terms, the Health Visitor who has a firm knowledge of the subject, is far more likely to be able to apply that knowledge within the clinical situation.
It is by the identification of the at risk situation that the Health Visitor can actively seek out and positively identify, those clients who have potentially greater risk of dental disease. Having identified the target group, they are then in a better position to try to institute measures that will promote the individual's health and well being. (Fawcett J 2005)
If one considers the best practice guidelines for improving dental health with specific regard to the Health Visitor's remit, the Government White Paper - Choosing Better Oral Health (2004) makes a number of recommendations.
Improving the diet and reducing the amount of sugar in the diet are prime prerequisites of the promotion of good dental health. In this respect, the health Visitor should regard it as good practice to:
Promote breastfeeding and recommended weaning practices;
Reduce both the frequency and amount of added sugars consumed in line with Department of Health target (11% of energy from added sugars);
Increase the consumption of fruit and vegetables to at least 5 portions per day;
Reduce consumption of acidic soft drinks
Promote use of sugar free medicines.
These measures should be promoted in conjunction with the object of additionally improving general oral hygiene. The same paper also recommends that the Health Visitor promotes good oral hygiene by:
Encouraging the early adoption of oral hygiene practices in young children;
Promoting effective oral hygiene self care practices across the population; and
Supporting parents and carers of people who need help in maintaining their oral hygiene.
Conclusion Summary and conclusions to inform further enquiry and adoption evidence based approaches to practice. Approx. 500 words
Conclusion
In the preparation for the writing of this piece, we have explored a great number of papers in order to select the ones that were finally presented. We must express considerable surprise at the degree of variation that there was in the quality and the standard of the work which appeared in the peer reviewed journals. Clearly the majority was of a good standard, with clear, relevant and appropriate goals and good statistical analysis. Equally there appeared to be a substantial proportion that was of less good quality ( which was clearly discarded ) and showed the need for a critical evaluation of both the literature itself and the quoted sources. (Newell & Simon. 1992)
In the preparation, we have also accessed and considered the professional guidelines that have been produced by professional bodies and the Government. We also have to express surprise at the volume of both. Simply searching for guidelines on dental caries produces an enormous volume of literature in both areas. We have attempted to digest and assimilate what is available and have presented it and referred to it throughout this piece.
We have been able to draw a number of conclusions relating to the topic itself. It is clear that there is a strong and fundamental connection between the incidence of dental caries and socio-economic depravation. What is far more difficult to conclude are the means by which this connection can either be addressed or severed.
Most of the authors that we have discussed have found that the majority of the generally applied measures that have either been muted or instituted, have paradoxically had the opposing effect as they have been selectively taken up disproportionately by the more socially advantaged in the population. The one clear exception to this is the issue of fluoridation.
There is a wealth of literature (which space has not permitted to discuss in depth) which points to the relative benefits of general fluoridation of the water supplies. (Brechin A et al 2000). The benefits, with specific regard to dental caries, are both clear and dramatic. We have presented evidence to support the demonstration of positive benefit of fluoridation, and it appears to be the one measure which has a more startling impact on the socio-economically deprived than the comparatively well off. Clearly, this is not an indication of some selective ability of the fluoride, but simply a statistical manifestation of the fact that the measure is at its most effective in situations where the risk of dental caries is at its greatest, i.e. in the children of the greatest socio-economically deprived families.
It is also a matter of considerable regret ( on a Public Health level, ) that the water authorities have been allowed to place potential profits above the greater public good, and not institute the measures that were originally intended of general low level fluoridation of the water supply.
This does appear to be a particularly short sighted measure, as the impact on children's teeth has been both demonstrated and clear. It would also follow from this observation that the perceived improvement in children's teeth would, over a period of time, impact upon the overall dental health of the adult population of the country as a whole. (Davies C et al 2000)
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