| 4.1
Areas for Action to Achieve National Targets |
| 4.1.1 To
promote and improve oral health in Scotland and to
achieve the national targets will require preventive
action. The ultimate goal of prevention is to change
behaviour or to alter some factor in the environment so
that disease is prevented from developing. |
| 4.1.2 Diet
is an important factor in primary prevention of oral
disease. It will be addressed through health promotion
led by health boards, but action also needs to be taken
to directly influence the composition and marketing of
food and drink and the composition of meals in
institutional settings such as schools in order to reduce
their levels of sugar. |
| 4.1.3 Health
promotion is necessary to maintain and increase public
awareness of the principles of good oral hygiene and the
risk factors for oral diseases, and enable the population
to adopt healthy behaviour, thereby helping to improve
the current poor dental health record in Scotland. |
| 4.1.4
Fluoridation has the potential to make a substantial
impact on oral health. Fluoridation of public water
supplies is the most cost effective way of preventing and
reducing dental caries in the population. Fluoride
supplements and treatments can also be important to
specific at-risk groups and fluoridated salt could have a
useful part to play. |
| 4.1.5 The
role of the individual is of course central to this
process. The individual can achieve good oral health by
effective tooth cleaning, with fluoride toothpaste,
adopting and maintaining a healthy diet, and by regular
visits to the dentist for preventive dental and oral
health advice. |
| 4.1.6
Prevention aims to halt the onset of dental disease or
its progress once it has started. It also aims to reduce
the incidence of accidents which may damage the tissues. |
| 4.1.7 We
discuss each of these aspects below. |
| |
| 4.2
Diet |
| 4.2.1 The
importance of the link between the severity of carious
attack and the amount and frequency of sugar consumption
was emphasised by the Scottish Diet Report (Scottish
Office 1993). This Report pointed to the fact that
patterns of infant sugar consumption are related to those
of their mothers and to the correlation between the use
of sweetened comforters in infancy and the consumption of
sugar-containing snacks in later years (Silver 1992). It
also pointed to the particularly damaging effect on
dental enamel of carbonated drinks and to the fact that
rusks, commercially- prepared desserts, puddings, baby
foods and drinks nearly all have high added sugar
content. |
| 4.2.2 In its
response to the Report, the Government proposed a range
of dietary targets which included a target to reduce the
intake of sugar, and the establishment of a Scottish Diet
Action Group to develop a national strategy for
delivering the targets. |
| 4.2.3
Following consultation on its proposals, the Government
has adopted 2 targets for sugar. In relation to adults,
the average intake of sugar is not to increase above its
current level of around 10% of total energy. In relation
to children, the average intake of sugar is to reduce by
half to less than 10% of total energy. |
| 4.2.4 The
Scottish Diet Action Group consists of representatives
from the food production, processing and retailing
industries, health interests, schools, voluntary groups
and so on. The Group will look at ways in which sugar can
be reduced in food and in the national diet; and health
education and health promotion interests in health boards
will address sugars as part of their co-ordinated
approach to oral health and diet, paying particular
attention to the need to encourage a reduction in the
frequency of consumption of sugars. |
| |
| 4.3 Health
Promotion |
| 4.3.1 Health boards have
responsibility for purchasing health services for their
populations. The key aspects of purchasing are assessment
of health needs and health status, setting priorities and
targets, planning and contracting for services and
monitoring and evaluation. One of the key tasks of
purchasers is to assess the effectiveness and
cost-effectiveness of services, including health
promotion programmes. Most boards now have consultants in
dental public health who take the lead in needs
assessement and planning for dental and oral health. |
| 4.3.2 One of the key
functions of health boards in carrying out their
responsibility for improving health is the development of
joint working with other agencies and organisations. In
orde to ensure a co-ordinated and consistent approach
towards improving oral and dental health, health boards
should address all age groups and take the lead in
developing a local strategy together with the other key
agencies eg local authorities, schools, dentists,
medical, nursing and pharmacy professions. Boards will be
encouraged to develop their primary care strategies to
ensure that dental services are planned to respond to
need, and are integrated with other services. |
| 4.3.3 Boards should also
take the lead at local level in developing joint working
with those other organisations and groups, such as local
authorities, schools and employers, who can play an
active role in improving health through their spheres of
influence. For example, boards can work with local
authorities to develop lessons in oral hygiene for
children in local nursery schools. At the same time they
can work with local authorities to encourage the
provision of healthy food choices in school canteens and
tuck shops, which have potential benefits for oral
health. Some of the risk factors for other diseases such
as coronary heart disease and cancers are also common to
oral health, principally a poor diet, smoking and
excessive alcohol consumption. This argues for an
integrated approach by health boards to a reduction in
these risk factors. With the natural dentition being
retained longer in life, there is a growing need to
address the needs of the elderly. |
| |
4.3.4 Health promotion
therefore has an important and key role to play in
improving oral health in Scotland. Health boards and the
Health Education Board for Scotland are responsible for
leading health promotion activities. Key areas for action
include:
- encouraging education
departments and schools to include oral and
dental health as one of the aspects of the health
promoting school;
- developing health
education resources and training for staff to
ensure that messages about the importance of oral
and dental health are delivered to children in
schools, including the necessity of regular
visits to the dentist and regular tooth brushing;
- working together with
the education department to develop appropriate
material on oral hygiene for nursery schools and
play groups;
- working together with
schools to develop healthy food choices including
sugar free snacks in the school canteen and tuck
shop;
- encouraging the
dental team to play a more active health
promotion role in their dealings with
individuals. The delivery of simple, clear and
consistent advice, tailored to the individual's
circumstances, can do much to influence
behaviour. This can be particularly effective
with individuals who are unlikely to read written
materials or for whom written communications are
inappropriate. The dental team can also work with
schools and with general medical practitioners to
promote better oral health;
- encouraging health
visitors to encourage parents to teach their
children about the importance of looking after
their teeth, including proper tooth brushing.
Health visitors have a valuable health promotion
role, not least because they have contact with
mothers in that important period in a child's
life - between birth and the child's attendance
at nursery or primary school - when good oral
hygiene habits should become established. Health
visitors can do much to encourage mothers to
teach their children to brush properly with a
fluoride toothpaste from an early age; to exclude
sugary drinks in feeders; to reduce sugars in the
diet, particularly by less frequent sugar
consumption through sugar and carbonated drinks,
snacks, confectionery; and to register their
children with a dentist at least as soon as the
first teeth erupt. A major study being funded by
the Chief Scientist Office of the The Scottish
Office in the Dental Health Services Research
Unit and in conjunction with Dundee health
visitors, will throw valuable light on the role
which health visitors can play in improving the
dental health of very young children;
- encouraging general
medical practitioners and the primary care team
to take the opportunity of their contacts with a
large proportion of the population, particularly
mothers and young children, to stress the basic
oral hygiene message and the value of registering
with a dentist for regular care and treatment.
The development of multi-disciplinary health
centres could facilitate that cross-linking of
interests;
- encouraging
pharmacists to promote oral health in their
dealings with the public and to advise on
appropriate sugar-free medication.
|
| 4.3.5 The Health
Education Board for Scotland (HEBS) is the national
organisation with responsibility for undertaking health
promotion programmes at the national level, concentrating
on the national priorities which include dental and oral
health. It is the national centre for health education
expertise and information; for the production and supply
of materials; for the development of training and for
advice and assistance for local and national
organisations. HEBS is required to give a lead to other
organisations and to co-ordinate health education
programmes. HEBS will therefore have an important role to
play in campaigning at the national level to improve oral
health. |
| 4.3.6 Because children
represent our future and because at an early age they
have yet to acquire the health damaging habits of the
adult population, there is inevitably and rightly
concentration in this strategy on teaching children the
principles of good oral health. Here, schools can do a
great deal to help in the matter of sugar intake. Where,
for example, they seek to raise funds from the sale of
snacks and drinks, they should consider how this can best
be done without undue harm to pupils' dental health. The
sale of sugar confections either directly or through
vending machines are examples of actions harmful to
dental health. Schools, in co-operation with the health
board, should consider how to build the simple messages
of dental health both into general teaching and into
other policies such as food available for purchase within
school premises. |
| |
| 4.4 Fluoridation |
| 4.4.1 The fluoridation of
public water supplies is the single most effective public
health measure which can be taken to prevent dental decay
and has been consistently supported by the Government.
The fluoridation of public water supplies gives rise to
strongly held views, however, and the Government believe
that decisions about this issue should be taken at the
local level after appropriate consultation. |
| 4.4.2 At present a health
board must publish its proposals that public water
supplies be fluoridated and have regard to the results of
local consultation before making a proposal to the
regional council as water authority. Following local
government reform when responsibility for delivering
water services will pass to 3 new public authorities, the
health board will be required not only to publish its
proposals but also to give notice of its intentions to,
and consult, every local authority in its area and the
Scottish Water and Sewerage Customers Council (a body
which will represent the interests of customers of the
new water authorities). It must then, as now, have regard
to representations and consultation before making its
proposal to the water authority. |
| 4.4.3 In the absence of
fluoridation of public water supplies it will be very
much more difficult to achieve a significant improvement
in oral health in Scotland, and it is important therefore
that health authorities develop and support alternative
strategies within their areas to tackle oral and dental
health problems, with an emphasis on the younger age
group. |
| |
| 4.5 Alternative
Provision of Fluoride |
| 4.5.1 In the absence of
water treatment, the main vehicle for delivering fluoride
to the tooth is through fluoride toothpastes. Fluoride
toothpastes are widely available throughout the country.
They act protectively through their direct application to
the tooth surface. If used daily with a correct brushing
method, they can offer a high level of caries control
when linked with a reduction in sugary foods and drinks,
particularly between meals. |
| 4.5.2 Encouraging regular
tooth brushing with a fluoride toothpaste must be a major
plank of any oral health strategy. Its importance is
heightened by the continuing lack of fluoridation of
public water supplies. There is at present no reliable
data on the usage of fluoride toothpaste within the
population but there is sufficient evidence to show that
a significant proportion of children do not brush their
teeth at all. If oral health in Scotland is to be
improved this is an area which must be tackled as a
priority. Health promotion activity will have an
important part to play in encouraging the wider and more
regular usage of fluoride toothpastes but this will not
be enough to reach the children who do not brush at all. |
| 4.5.3 Fluoride
supplements also have a role to play in improving oral
health but where daily brushing with a fluoride
toothpaste and appropriate diet are being followed, it
should be unnecessary for additional supplements to be
taken. The main exception is high risk groups who are
predisposed to dental decay, inlcuding those with certain
medical conditions, many of those with disability and
those with a high decay rate due to salivary composition,
genetic, social and other factors. In those cases
fluoride supplements can be valuable but they should only
be taken under the direction of a dental or medical
practitioner. |
| 4.5.4 Clinical
applications of fluoride preparations can be effective
but costly in professional time. Topical fluoride
solutions, gels and varnishes are applied directly to the
teeth by dentists, dental therapists and dental
hygienists. They are principally of value in children who
may be particularly caries prone. Fluoride mouth rinses
also have their place in preventive programmes. |
| 4.5.5 Fluoride has been
added to cooking and table salt in several countries.
This should be available in Scotland to enable people to
use it if they wish to replace their existing salt
intake. |
| |
| 4.6 The Role of
the Individual |
4.6.1 Oral health is
determined largely by the actions or inaction of each of
us as individuals. Apart from those with certain
congenital or developmental conditions, each of us from a
very early age can maintain a health mouth by following a
very simple set of principles. These are:
- Brush at least once a
day using a fluoride toothpaste.
- Eat a sensible diet
and limit the intake of sugary foods and drinks,
particularly the frequency of their consumption.
- Visit the dentist
regularly for check-ups and preventive dental and
oral health advice and therapy. The dentist will
assess susceptibity to oral disease and advise on
appropriate preventive measures.
|
| 4.6.2 The key to oral
health lies in these simple preventive measures but too
many adopt a fatalistic attitude to dental decay and gum
disease. Individuals need to take charge of their own
destiny and it is one of the challenges for health
promoters to help people to make this change. |
| 4.6.3 A parent, or
someone who cares for young children, also has a
responsibility for the oral health of children in their
care. They can and should ensure that children learn how
to brush their teeth and that they should limit the
consumption of sugary foods, snacks and drinks in their
diet. They should also ensure that their child is
registered with a dentist at least as soon as the first
teeth appear and that the child has regular visits
thereafter. |
| |
| 4.7 Prevention |
| 4.7.1 Prevention is a
broad approach to disease. In the context of dental
disease, it includes the issues of halting the onset of
dental disease or its progress once it has started.
However it goes further, being a philosophy that should
be applied to all aspects of disease and accidents. It
implies changing behaviour or altering factors that have
an effect on disease. It includes a proper approach to
the early detection of disease and its eradication by
timely treatment; it includes an awareness of the
possibility of accidents and their consequences; and it
includes a reducing use of those substances that may be
implicated in producing disease. |
| 4.7.2 Aspects of
prevention that fall into the categories above would be
the early detection of oral cancer, the provision of
mouthguards for those involved in contact sports, and
reduced tobacco consumption and alcohol misuse as
predisposing factors in oral cancer. |
| |
| 4.8 Derangement
of Oro-facial Tissues |
| 4.8.1 Inherited anomalies
of jaw size and tooth size may require orthodontic
correction. Similarly, early loss of deciduous teeth can
cause dental irregularities in the positions of the
permanent teeth and these may also require orthodontic
correction. In assessing each child with such anomalies,
a judgement must be made of the need for intervention. If
intervention is judged to be necessary, treatment can be
planned to take place at the optimum age for the success
of that treatment. Treatment may include appliance
therapy, extractions, or the elimination of habits. |
| 4.8.2 Congenital clefts
of the lip and palate must be diagnosed at birth and
treatment planning instituted immediately. Some centres
in Scotland have built up special expertise in the
treatment of these children and it is desirable that
treatment planning and the treatment itself should be
provided in one of these centres. |
| 4.8.3 Traumatic injuries
to the teeth occur as a result of a wide range of
accidents from sports injuries to motor car accidents and
physical violence. Prevention of the majority of sports
injuries to the teeth could be achieved by the general
use of properly constructed mouthguards in all contact
sports. The Scottish Sports Council, sports governing
bodies and local authorities should increase their
efforts to encourage the regular use of mouthguards. The
prevention of other accidental injuries to the teeth must
rely on accident prevention measures in general. |
| |
| 4.9 Oral Cancer |
| 4.9.1 Cancer often has
early pre-malignant manifestations in the oral cavity.
The prognosis of oral cancer is greatly improved by early
detection of pre-cancerous and cancerous lesions during
routine dental examination. Regular examination by a
dentist is considered to be the most cost effective
option for screening for oral cancer(9). Prevalence of
oral cancer is increasing and many patients have advanced
disease before they are referred for specialist
treatment. Regular examination is considered to be the
most cost effective option for screening for oral cancer
and should increase the frequency of early diagnosis.
Health education campaigns about smoking should emphasise
that tobacco in all its forms is an imortant risk factor
for this disease, as well as for other cancers and that
the combination of smoking and excessive alcohol
consumption are particularly dangerous. Medical and
nursing professions also have an important role in the
detection of oral cancer. |
| |
| 4.10 Research |
| 4.10.1 Basic research
into the precise cause and treatment of dental decay and
peridontal disease is being undertaken by several
University departments in Scotland. The Chief Scientist
Office of The Scottish Office Department of Health is
prepared to consider well designed research proposals
which are relevant to The Oral Health Strategy for
Scotland. |
| 4.10.2 Dental
epidemiological information in Scotland is highly
developed and there are excellent dental reports within
the Scottish Needs Assessment Programme which make
recommendations on research. Research and Development
(R&D) is needed within primary dental care with a
concentration on the development end of the R&D
spectrum. Regional research may be of value and there
could well be much to be gained from linking this work
with this Strategy. |
