essay on health promotion for oral health

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Home > Books > Insights into Various Aspects of Oral Health

Oral Health Promotion: Evidences and Strategies

Reviewed: 19 April 2017 Published: 20 September 2017

DOI: 10.5772/intechopen.69330

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Insights into Various Aspects of Oral Health

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Oral health promotion is for upliftment of oral health of community rather than an individual and has long‐term impact. Since Ottawa Charter for health promotion is implemented, significant advancements have happened in oral health promotion. Under comprehensive health programs, India has been running oral health promotion programs, and these evidences are shared here. Such examples are apt learning and execution to any part of world having similarities. The chapter put forward the strategic view points to consider further oral health promotion aspects and based on the needs. The authors have gathered various examples from national programs implemented in India. The authors discuss how these programs are linked to the Oral health promotion concept. For example, National tobacco control program which currently running across many states in India, how the banning on tobacco products near school premises helped to reduce the incidence is discussed. The worldwide literature and evidences of oral health promotion strategies are explained. The evidences and strategies mentioned can be significant for another region of world. Unless published, many programs remain hidden and are loss of valuable evidences to oral health science.

• oral health
• oral health promotion
• school health
• dental health

Author Information

Vikram r. niranjan *.

• Queen Mary University of London, UK and S.D. Dental College, Parbhani, India

Vikas Kathuria

• Consultant Dentist, Hadi Hospital, Jabriya, Kuwait

Venkatraman J

• Department of Pathology, Mahatma Gandhi Medical college and Research Institute, Puducherry, India

Arpana Salve

• Senior Registrar, Skin & VD Department, Government Medical College & Hospital, Aurangabad, India

*Address all correspondence to: [email protected]

1. Introduction

The twentieth century was noteworthy in dentistry for many epidemiologic advances that occurred in the study of oral diseases and conditions. These combined efforts of optimum personal, social, biological, behavioral and environmental factors contributed to better oral health. Hence, oral health promotion is a planned effort to build public policies, create supportive environments, strengthen community action, develop personal skills or reorient health services pertaining to influence above factors. Following are enlisted examples of effective oral health promotion:

Promotion of healthy eating

Training of relevant oral hygiene methods

Access to preventive oral health services at the earliest

Promotion of topical fluoride application [ 1 ].

Ottawa Charter principles form a sound base for oral health promotion. This suggest that individuals alone are not at risk but the entire population, which needs to be involved in directing action towards the causes of ill health. Importantly, three principles, that is, partnership, participation and protection, are taken into consideration while planning a public health program or intervention. Empowerment than compelling is the key for successful Oral health promotion while achieving good oral health [ 2 ].

The purpose of this article is threefold. First, it reviews the relevance of need of oral health promotion particularly through the public health surveillance of oral disease burden. Second, it puts forward the evidences from the various examples of oral health promotion programs integrated into general health promotion carried across the India. Finally, the authors briefly discuss the strategies for expanding frame of oral health promotion.

2. Oral health promotion through Ottawa Charter

Health promotion programs achieve success through actions that influence the social, physical, economic and political determinants of health. Health promotion irrefutably acknowledges the broader health determinants and focuses on risk reduction via sensitive policies and actions. Ideally, promotion of health in a day‐to‐day life setting having people live, work, learn and play is credible for efficacious and cost‐effective way of improving oral health and indeed the quality of life. Imperatively, actions that address the determinants of health should not be progressed in isolation. Research evidences suggests that isolated activities can have limited impact, particularly over the long term. For this reason, we suggest using the logic model based on Ottawa Charter to develop a comprehensive oral health promotion program, involving a range of interventions.

The Ottawa Charter was developed by the World Health Organization 1 (WHO) as a framework for constructing health promotion programs that address the wider determinants of health. The charter suggests that programs be built around the following five action areas:

Building healthy public policy

Creating supportive environments

Strengthening community action

Developing personal skills

Reorientating health services [ 2 ].

3. Need for oral health promotion

The remarkable improvements in oral health over the past half century reflect the strong science base for prevention of oral diseases that has been developed and applied in the community, in clinical practice and in the home. Yet, despite the remarkable achievements in recent decades, millions of people worldwide have been excluded from the benefits of socioeconomic development and the scientific advances that have improved health care and quality of life. Social and cultural determinants comprising poverty, lack of education, unsupportive traditions, cultures and beliefs increase the relative risk of oral disease and conditions. For instance, lack of safe water and sanitary facilities are the environmental risk factors for both oral and general health. While, access to high sugar containing foods and unhealthy dietary habits may lead to higher risk of dental caries in certain communities. Improvement in availability, accessibility and feasibility of oral health services can definitely cure and control oral diseases. However, strong evidences suggest that limiting the risks to disease is best possible when health services are primary care and prevention oriented. Clinically, oral health status is measured in terms of causal factors, that is, tobacco, sugar, micro‐flora, which have negative impact on quality of life. Emphasizing the risk behavior modifications, such as curbing use of tobacco and alcohol; restraining sugar intake in terms of quantity, intake frequency and nature; proper oral hygiene practices, is equally important incongruent to social and cultural determinants [ 3 ].

The Global Burden of Disease (GBD) 2010 Study produced comparable estimates of the burden of 291 diseases and injuries in 1990, 2005 and 2010. Pertaining to oral health, dental caries, aggressive periodontitis and tooth loss are considered as global burden, which compared from 1990 to 2010. Criteria used were disability adjusted life‐years (DALYs) and years lived with disability (YLDs) metrics to quantify burden. These oral diseases/conditions encroached 3.9 billion. Among all, prevalence of dental caries in permanent teeth was among the highest prevalent condition evaluated for the entire GBD 2010 study (global prevalence of 35% for all ages combined). Among the top 100 ranking as causes of DALYs, oral diseases also secured a ranking after some serious diseases. Oral diseases altogether affected 15 million DALYs globally with the breakdown as 1.9% of all YLDs; 0.6% of all DALYs. Statistical calculations imply that could be average health loss of 224 years per 100,000 populations. While there was reduction observed for other diseases from 1990 to 2010, DALYs due to oral conditions increased by 20.8%. This was due to population overgrowth and aging. DALYs due to aggressive periodontitis and dental caries increased, however due to extensive tooth loss has decreased. While DALYs differed by age groups and regions, those not by genders. The report revealed the challenging scenario of diversified oral health needs across the globe, with alarming needs in developing countries. Further, the burden of oral diseases has unevenly risen in the past 20 years.

As the noted prevalence of oral diseases is very high and has association with disability, it accounted for a substantial number of DALYs. Dental caries without any treatment was the most prevalent condition among all 291 conditions. Moreover, the disability weight in connection with extensive tooth loss (0.073) was marginally neared to those reported for moderate heart failure (0.068) and moderate consequences of stroke (0.074). Oral diseases received ranking of 31st, 34th and 35th of health outcomes causing YLDs in the category of non‐fatal outcomes. Compared to other non‐communicable diseases/conditions, such as maternal conditions, hypertensive heart disease, schizophrenia, hemoglobinopathies and hemolytic anemias, oral diseases/conditions were ranked higher. While oral conditions scored high index for more YLDs than 25 of 28 categories of cancer, shows its significance in terms of affecting individuals equal to lethal diseases. The other organ cancers, such as stomach, liver and trachea, and bronchus and lung cancers ranked higher than oral diseases [ 4 ].

The global burden of oral conditions is shifting from extensive tooth loss toward aggressive periodontitis and untreated dental caries. Tooth loss is a final common pathway when preventive or conservative treatments to alleviate pain fail or are unavailable. The social, economic, political and cultural determinants of health are significant, and it may be argued that better health can be achieved by reducing poverty. Poverty, poor education and inequality not only result in poor oral health but also affect the way in which people think about their oral health. In spite of excellent oral health care, oral diseases are prevalent. This suggests that improving healthcare services merely will not address the issue, oral health promotion is mandatory. Hence, health policymakers should be made aware of these evidences and directs themselves to restructure the policy framework. Health promotion policy acknowledges complimentary measures such as legislation, fiscal measures, taxation and organizational change altogether. These are best example of a coordinated effort towards creating supportive environments and strengthening community action. Ottawa Charter implementation for health promotion through establishing concrete and effective community actions in setting priorities, making decisions, planning strategies leads to achieve better health. Communities facilitate themselves with self‐help, social support, participation and ownership for development and empowerment. They are the best possible existing human and material resources of community and for community.

Oral health promotion through sensitive health policies and actions which already exist in some parts of world can address the global burden of oral diseases, essentially to improve oral health and quality of life.

4. Evidences: country examples from India

Identifying a significant health issue on the basis of prevalence, incidence, severity, cost, or impact on quality of life is preliminary step to design prevention programs. A combination of community, professional and individual strategies is the cost‐effective and creative methods for oral disease prevention. Incorporating public, practitioners and policymakers into strategic development of oral disease prevention and health promotion intervention is necessary. They should be liable to create a healthy setting, limit risk factors, inform target groups, generate knowledge and thus improve behaviors. This section includes a discussion of knowledge and practices of the public and healthcare providers regarding the oral health promotion. The purpose of this discussion is not to outline specific health promotion strategies to enhance knowledge and practices but to indicate the opportunities and needs for both broad‐based and targeted health promotion programs and activities.

4.1. Oral health promotion in health promoting schools (HPS)

Oral health education has been considered as one of the fundamentals in oral health promotion [ 5 , 6 ]. With education, a child receives training and encouragement especially to stimulate development of skills, aptitude formation and creation of values, which lead to act positively in relation to his oral health and other people’s oral health on a daily basis. High caries risk, change in dentition, ability to change bad habits and facilities to learn make oral health promotion for children a priority. The importance of oral health education programs in schools is significantly reported predominantly in the form of positive learning and behavior in children [ 5 – 11 ].

One‐fifth of the world’s population is adolescent, defined by WHO as a person between 10 and 19 years of age. The oral health promotion programs should primarily focus on this age group who become easy victims of excessive consumption of sweets, sugary beverages, tobacco and alcohol. Commonly, their main association is with home, school and community organizations. These three along with oral health professionals can form an effective alliance to control risks to oral diseases and form oral health promotion programs for young people [ 12 ]. Prevalence of dental caries and gingivitis is high in human populations throughout the world, and over 80% of schoolchildren are affected in some parts of the world. Dental erosion due to excessive carbonated beverages consumption is on rise, which was earlier noticed only among the late adulthood. Enamel defects due to malnourishments, dental trauma due to negligence and safety barriers are some of the increasing evidences in children. Moreover, youth became the easy targets of tobacco‐containing products. Eventually and unknowingly, early start of tobacco consumption manifolds risks of oral precancerous lesions and cancer in life ahead [ 8 , 10 , 13 ].

Strong arguments for oral health promotion through schools include the following:

Personal and social education aimed at developing life skills—Pupils and students can be accessed during their formative years, from childhood to adolescence. Students develop lifelong oral health‐related behavior, as well as beliefs and attitudes are being developed.

Schools can provide a supportive environment for promoting oral health. Access to safe water, for example, may allow for general and oral hygiene programs. Also, provision of mouth guards—accessible and affordable sports protection, a safe physical environment and school policy on bullying and violence between students reduce the risk of dental trauma.

The burden of oral disease in children is significant. Most established oral diseases are irreversible, will last for a lifetime and have an impact on quality of life and general health.

School policies on control of risk behaviors, such as intake of sugary foods and drinks, tobacco use and alcohol consumption.

Schools can provide a platform for the provision of oral health care, that is, preventive and curative services [ 14 – 18 ].

Common risk factor approach‐based oral health promotion policies in schools can lead to improvement in oral health and reduce oral health inequality [ 10 , 16 ].

The need to set up oral health promotion programs in schools is evident, and it can easily be integrated into general health promotion, school curricula and activities. One of the proposed examples has been shown in Figure 1 [ 13 ].

Figure 1.

Integration of oral health in health‐promoting schools: an example from Denmark.

Using the structures and systems already in place as a competent setting for the installation of vital facilities such as safe water and sanitation can instigate oral health promotion in schools. The HPS strategies are effective, leading to potential long‐term cost savings. For instance, Each key components of an HPS, that is, healthy school environment, school health education, school heath services, nutrition and food services, physical exercise and leisure activities, mental health and well‐being, health promotion for staff and community relationships and collaboration , incorporate equal opportunities oral health promotion as well as general health promotion. While oral health issue is specifically addressed, it can be admixed in general health promotion strategy. It is well illustrated in following examples of school health policies as shown in Table 1 [ 13 ].

Table 1.

Examples of oral health‐related school health policies to be promoted in HPS.

There is an association of socio‐economic, geographic factors and type of schools with school based health promoting activities. On an average, students attending private schools belong to more advantaged backgrounds than their counterparts in public schools. Privately managed schools achieve greater efficiency or academic value‐added than publicly‐managed schools [ 18 ]. According to one study, ten out of eleven participated countries (including India) had the large socio‐economic gap between private and public school pupils except Chile [ 19 ]. Moreover, students going to city/town schools generally belonged to more privileged backgrounds than their counterparts in village schools. All the school headmasters in this study reported that primary school student’s absenteeism rate decreased when the students received support in the form of school uniforms, textbooks, meals and various financial assistance schemes. For example, urban schools tend to have greater resources than those in rural. Also, students in private schools had higher levels of positive behavior than those in public schools, and these results were statistically significant for most countries [ 19 ]. Public and private school differ from each other in many ways as better amenities in school, extra‐curricular activities, outdoor and indoor sports, etc. The private school allots more fees from students for such activities/facilities. Consequently, children from upper and high middle socioeconomic status prefer private schools, while children with low socioeconomic strata attend public schools [ 20 ]. Students gain more attention when the student to teacher ratio is higher. Bruneforth et al. [ 19 ] also reported inferior pupil‐teacher ratios in village schools than in city/town schools in India. The children who do not have adult supervision after school are more vulnerable to indulge them into health hazarding habits like smoking, drugs and substance abuse and behavioral problems. The schools providing self care activities after school were found more effective in reducing the prevalence of smoking among ninth‐grade students in Los Angeles and San Diego Counties [ 21 ]. Smoking and chewing tobacco are systematically associated with socioeconomic markers [ 20 ].

4.2. Healthy food at school: Mid Day Meal Scheme of India

The whole school approach with availability of healthy food in school canteen, tuck shops, instructing parents for healthy food and school staff involved in planning for food and curriculum has amplified student’s knowledge. However, it has not led to change in behavior [ 22 , 23 ].

Providing healthy food in schools can meet the nutritional requirement of students and also guide the parents to deal with healthy diet chart for their children. In UK, campaigns like the ones conducted by famous chef, Jamie Oliver, are one example of actions in this area.

In India, Mid Day Meal Scheme in school started in 1925 from a single city, Madras (now Chennai) and now spread to all States. From April 1st, 2008, the program covers all children studying in Government, Local Body and Government‐aided primary and upper primary schools across the country. The Mid Day Meal Scheme is the world’s largest school feeding program reaching out to 0.84 billion primary students and 0.33 billion upper primary Students, in total about 1.2 billion children in over 9.50 ten thousands schools across the country during 2009–2010 [ 24 ].

Unhealthy eating habits and sedentary lifestyles are closely bound not only to various socioeconomic indicators such as the parent’s education levels, financial resources and professional situations, but also to living in economically deprived areas. This suggests significant contributions of gender, age and religion belief to the eating habit. Therefore, Schools should introduce healthy food policy and activity after consulting with school authority, nutrition expert and parents so as to maintain good eating habits among students [ 25 ].

4.3. National tobacco control program of India

Tobacco consumption either in smoke form or smokeless form has deleterious effect general and oral health. Tobacco abuse is the leading preventable cause of death and disease so far. Long list of diseases caused by tobacco abuse includes different cancers – lung cancer, oral cancer, cardiovascular disease, stroke and chronic lung disease. Pertaining to oral health, it causes aggressive periodontitis, tooth loss, wound healing complications and mainly pre‐cancerous or cancerous lesion leading to disfigurement of face. Risk of oral cancer is 10‐fold in smokers than no‐smokers and 11‐fold risk in smokeless tobacco users than non‐users. One can expect a normal life expectancy with early acknowledgement of tobacco health hazards and culminating tobacco use especially below 35 years. Prevention is the prime key factors, and at initial stage, most of the adverse effects of tobacco are reversible. This fact can be used to motivate tobacco using people to curb the use of tobacco [ 26 ].

India is the second largest consumer and producer of tobacco. India accounts for 10% of the world tobacco area and 9% of the production. 30% of cancer deaths, majority of cardiovascular and lung disorders; 40% of tuberculosis and other related diseases are attributed to tobacco consumption. Over 80% of oral cancers are caused due to tobacco use. As per the WHO Global Report on “Tobacco Attributable Mortality” 2012, 7% of all deaths (for ages 30 and over) in India are attributable to tobacco. Ministry of Health and Family Welfare (MoHFW), Government of India inaugurated The National Tobacco Control Program (NTCP) in 2007–2008, as included in 11th five year plan. The program includes objectives as:

Nationwide awareness regarding tobacco use harms and following tobacco control laws.

Necessary actions for strong implementation of the Tobacco Control Laws.

Effective primordial and primary level prevention strategies are planned under the National Tobacco Control Program (NTCP) .

The prime areas under the NTCP as targets are:

Training of trainers, that is, health and social workers, NGOs, school teachers and enforcement officers.

Information, Education and Communication (IEC) activities.

School Programs.

Monitoring tobacco control laws.

Co‐ordination at village level activities.

Medicinal treatment facility for cessation at district level.

Indian government implemented Cigarette and Other Tobacco Products Act (COTPA; addressing tobacco use in public places, tobacco advertising and sale and packaging regulations) since 2003 with comprehensive action in 2005 following the Framework Convention of Tobacco Control (FCTC). Following laws through the lobbying of anti‐tobacco advocates were successfully established by Indian judiciary.

Section 4: Prohibition of smoking in public places.

Section 5: Prohibition of direct and indirect advertisement, promotion and sponsorship of cigarette and other tobacco products.

Section 6a: Prohibition of sale of cigarette and other tobacco products to a person below the age of 18 years.

Section 6b: Prohibition of sale of tobacco products within a radius of 100 yards of educational institutions.

Section 7: Mandatory depiction of statutory warnings (including pictorial warnings) on tobacco packs.)

Section 7(5): Display of tar and nicotine contents on tobacco packs [ 27 ].

The achievements of this national program are examples of apt implementation. Increase in taxation had led to a reduction in self‐reported tobacco sales and consumption at the short‐term end‐point. The GATS data (2009) indicate that 54.7 and 62.9% are aware of health warnings on cigarette and smokeless tobacco packaging, respectively. Trials of school‐based education interventions demonstrated a positive impact on knowledge, advocacy skills and tobacco use. Teaching about the risks of tobacco use for health professional trainees appeared more widespread, but may have reduced slightly post‐FCTC. Community‐based education interventions and education interventions for adult tobacco users appeared beneficial. Moreover, the secondary outcomes of tobacco control programs observed as cleaner streets and air quality, preservation of forests, increased performance at school/work, reduction in fire hazards, healthy mother and infants and indeed a better quality of life. Tobacco‐use outcomes could be improved by school/community‐based and adult education interventions and cessation assistance that are facilitated by training for health professionals and schoolteachers [ 28 ].

4.4. National fluorosis prevention program

Fluoride is an essential mineral for human health. It widely exists in natural water and in foods such as tea, fish and beer. The twentieth century documented association among reduced level of dental caries with communal fluoridated water consumption. Soon, fluoride has become an effective preventive measure for dental caries. Easy incorporation into toothpaste has improved oral health in some parts of world, particularly in developing countries [ 26 ].

However, the other part of world suffers from excessive fluoride in natural environment. Fluorosis, a public health problem, is caused by excess intake of fluoride through drinking water/food products/industrial emission over a long period. Moderate‐level chronic exposure (above 1.5 mg/liter of water–the WHO guideline value for fluoride in water) is more common. Acute high‐level exposure to fluoride is rare and usually due to accidental contamination of drinking‐water or due to fires or explosions. It results in major health disorders like dental fluorosis, skeletal fluorosis and non‐skeletal fluorosis. The late stages of skeletal and dental fluorosis are permanent and irreversible in nature and are detrimental to the health of an individual and the community, which in turn has adverse effects on growth, development & economy of the country. There is no treatment for severe cases of skeletal fluorosis, only efforts can be made towards reducing the disability which has occurred. However, the disease is easily preventable if diagnosed early and steps are taken to prevent intake of excess fluorosis through provision of safe drinking water, promote nutrition and avoid foods with high fluoride content.

Fluorosis is worldwide in distribution and endemic at least in 25 countries. It has been reported from fluoride belts: one that stretches from Syria through Jordan, Egypt, Libya, Algeria, Sudan and Kenya, and another that stretches from Turkey through Iraq, Iran, Afghanistan, India, northern Thailand and China. There are similar belts in the Americas and Japan. In India, fluorosis is mainly due to excessive fluoride in water except in parts of Gujarat and Uttar Pradesh where industrial fluorosis is also seen. The desirable limit of fluoride as per Bureau of Indian Standards (BIS) is 1 ppm (parts per million or 1 mg per liter). High levels of Fluoride were reported in 230 districts of 20 States of India (after bifurcation of Andhra Pradesh in 2014). The population at risk as per population in habitations with high fluoride is 11.7 million as on 1.4.2014. Rajasthan, Gujarat and Andhra Pradesh are worst affected states. Punjab, Haryana, Madhya Pradesh and Maharashtra are moderately affected states, while Tamil Nadu, West Bengal, Uttar Pradesh, Bihar and Assam are mildly affected states.

Understanding the clinical manifestations of fluorosis

Dental fluorosis : It is categorized into mild, moderate and severe dental fluorosis depending on the extent of staining and pitting on the teeth. In severe dental fluorosis, unaesthetic & brittle enamel is found. Vitamins A and D deficiency or a low protein‐energy diet are also linked to enamel defects. Ingestion of fluoride after 6 years of age will not cause dental fluorosis. The teeth could be chalky white and may have white, yellow, brown or black spots or streaks on the enamel surface. Discoloration is away from the gums and bilaterally symmetrical.

Skeletal fluorosis : The early symptoms of skeletal fluorosis include stiffness and pain in the joints. In severe cases, the bone structure may change and ligaments may calcify, with resulting impairment of muscles and pain. Constriction of vertebral canal and intervertebral foramen exerts pressure on nerves, blood vessels leading to paralysis and pain.

Nonskeletal fluorosis/Effects of fluorosis on soft tissues/systems :

Gastrointestinal symptoms: Abdominal pain, excessive saliva, nausea and vomiting are seen after acute high‐level exposure to fluoride.

Neurological manifestation: Nervousness and depression, tingling sensation in fingers and toes, excessive thirst and tendency to urinate.

Muscular manifestations: Muscle weakness and stiffness, pain in the muscle and loss of muscle power, inability to carry out normal routine activities.

Allergic manifestation: Skin rashes, perivascular inflammation—pinkish red or bluish red spot, round or oval shape on the skin that fade and clear up within 7–10 days.

Effects on fetus: Fluoride can also damage a fetus, if the mother consumes water/food with high concentrations of fluoride during pregnancy/breast feeding. Abortions, still births and children with birth defects are common in endemic areas.

Low hemoglobin levels: Fluoride accumulates on the erythrocyte (red blood cells) membrane, which in turn looses calcium content. The membrane which is deficient in calcium content is pliable and is thrown into folds. The shape of erythrocytes is changed. Such RBCs are called echinocytes and found in circulation. The echinocytes undergo phagocytosis (eaten‐up by macrophages) and are eliminated from circulation. This would lead to low hemoglobin levels in patients chronically ill due to fluoride toxicity.

Kidney manifestations: Low volume, dark yellow to red color of urine is seen.

Calcification of ligaments and blood vessel: Forms unique feature of the disease helps in differential diagnosis.

With an aim to prevent and control fluorosis cases, Government of India initiated the National Program for Prevention and Control of Fluorosis (NPPCF) as a new health initiative in 2008–09. During the 11th Plan, 100 districts from 17 States were identified for program implementation. During the 12th 5‐Year Plan period, it is proposed to add another 95 districts for prevention and control of fluorosis. In the 12th Plan, the program has been brought under the Non‐Communicable Disease Flexi‐pool of National Health Mission (NHM).

4.4.1. Goal and objectives

To collect, assess and use the baseline survey data of fluorosis of Ministry of Drinking Water Supply for starting the project.

Comprehensive management of fluorosis in the selected areas.

Capacity building for prevention, diagnosis and management of fluorosis cases.

4.4.2. Strategy

Surveillance of fluorosis in the community and school children.

Capacity building at different level of healthcare delivery system for early detection, management and rehabilitation of fluorosis cases.

Diagnostic facilities in the form of laboratory support and equipment including ion meter to monitor the fluoride content in water and urinary levels at district/hospital/medical college for early detection and confirmation of fluorosis cases.

Health education for prevention and control of fluorosis: (a) Creating awareness about fluorosis disease, drinking water (safe/unsafe), diet editing and diet counseling through interpersonal communication, group discussions, media, posters and wall paintings. (b) Create awareness and skills among the medical as well as paramedical health workers to detect the disease in the community. (c) Provision of safe drinking water, water harvesting (rain water) and other measures in collaboration with Public Health Engineering Department.

Management Efforts are aimed to reduce the fluorosis induced disability and to improve quality of life of affected patients. Medical treatment is mainly supplementation of Vitamins C & D, Calcium, antioxidants and treatment of malnutrition. Treatment of deformity includes physiotherapy, corrective plasters and orthoses (appropriate appliances).

4.4.3. Expected outcome

The expected outcome of the National Program for Prevention & Control of Fluorosis in the districts will be:

Number of fluorosis cases managed and rehabilitated in the program districts.

Capacity for laboratory testing for fluoride in water, urine to be developed.

Trained health sector manpower in Government set up for measuring fluoride in urine and water.

Improve information base for the community and all concerned in the program districts [ 29 ].

Likewise, fluoride is double edge sword, that is, its deficiency and excess both affect the oral health. Hence, science based on effectiveness, safety and benefits should be implemented at different needs at different part of the world.

5. Strategies for oral health promotion

5.1. generation of strategies based on evidences.

WHO aim at building healthy populations involving all communities by combating every possible illness. The organization has recommended strategic framework which focuses and guide on oral health promotion activities/programs.

Reduction in oral disease/condition burden and disability, especially in poor and marginalized populations.

Promoting healthy lifestyles and reducing risk factors to oral health that arise from environmental, economic, social and behavioral causes.

Developing oral health systems that equitably improve oral health outcomes, respond to people’s legitimate demands and are financially fair.

Framing policies in oral health, based on integration of oral health into national and community health programs, and promoting oral health as an effective dimension for development policy of society [ 7 ].

Program goals are broad statements on the overall purpose of a program. For instance, “to eliminate racial disparities in oral cancer survival rates,” “to improve the oral health of nursing home residents” or “ to improve the oral health of country’s children under 5 years. Program objectives are more specific statements of desired endpoints of program.

Objectives of oral health programs should meet SMART criteria:

Specific —they should describe an observable action, behavior or achievement.

Measurable —they are systems, methods or procedures to track to record the action upon which objective is focused.

Achievable —the objective is realistic, based on current environment and resources.

Relevant —the objective is important to the program and is under the control of program.

Time based —there are clearly defined deadlines for achieving the objective [ 3 ].

Designing an oral health promotion program: step by step can be studied as shown in Figure 2 [ 1 ]:

Best practices in oral health promotion and prevention can take various forms, be it education, health promotion, integrating oral health promotion into general health promotion programs, policy changes which promote better oral health, the provision of care services, or programs specifically designed at addressing oral health inequalities. It is interesting to learn how oral health promotion and practices are implemented in through various interventions applying the Ottawa Charter guidelines.

Figure 2.

A step‐by‐step design of an oral health promotion program (based on Ministry of Health, New Zealand, 2006).

5.1.1. Building healthy public policy

Establishing healthy policies is integral in improving oral health. Based on the needs, evidences and situation analysis, National Government, health ministry, local governments, organizations, communities, schools, primary healthcare settings and local stakeholders forms or reforms the healthy policy. Health promotion advocates hold key responsibility to convey appropriate health needs of the population.

Examples of interventions that build healthy public policy

Campaigning to extend the coverage of optimal water fluoridation or water de‐fluoridation based on needs.

Supporting early childhood centers and school boards in developing healthy food and nutrition policies.

Working on policy options that eliminate the advertising of harmful food and beverages to children.

Working with organizations to promote injury prevention policies, for example, mouth‐guards in sport or safe play equipment.

Industrial approach to limit the marketing of carbonated & sugar‐containing drinks to children.

Working to study and develop standards for marketed harmful products to children.

Developing and implementing smoke free environment policies.

5.1.2. Creating supportive environments

Making the healthy choice easy choice is the aim of health promotion. This can be achieved by creating supportive social, physical, biological and cultural environments. These determinants of health directly and indirectly affect the oral health with or without general health consequences. Hence, the needs of local population should be considered in order to design and implementation of health promotion actions. Health promotion practitioners play a lead role in creating supportive environments along with public health units, government agencies, health organizations, NGOs, professional Dental Association, industry organizations and print and digital media.

Interventions that harness creating healthy supportive environments for oral health

Provision of fluoridated toothpastes at subsidized cost that low income group can also avail.

Reforming supermarket’s marketing policies for instance replacing sugary products like chocolates.

Encouragement for usage of smoke‐free environment advertisements and sponsorship for oral health promotion.

Media coverage of healthy food choices which enhance oral health.

Oral health awareness and promotion through social marketing campaigns.

Promoting safe water supply at all the public events.

5.1.3. Strengthening community action

Communities are a powerful force for achieving actions for any health promotion program where the key success factors are: partnership, participation and engagement . Encompassing all the communities for united efforts to understand their own oral health needs and ascertain to improve the oral health outcomes of their community. These health promotion programs may differ with age, society, culture and environment. Among the five actions themes of Ottawa Charter, community action is unique as concentrate on how particular health actions to be carried out. It eventually may turn out to be effective examples to be followed. Important factor for communities to have equitable access to resources to support the control they must have over their own health and development. Hence, strengthening community action is about providing and facilitating access to sufficient and appropriate resources.

Examples of interventions that strengthen community action for oral health

Engaging the community to support water fluoridation/de‐fluoridation and encourage safe water supply.

Engaging communities to participate in school oral health programs through leadership activities.

Empowering communities for healthy eating programs that enhance oral health.

Specific target‐oriented oral health improvement programs based on community cultures.

Community and school collaboration for establishing playgrounds with safe play equipment, barricades for children safety.

5.1.4. Developing personal skills

Personal skills can help individual to take control of his own health. Empowering people with appropriate knowledge and skills to improve and maintain their oral health is essential. Oral health literacy is the way that provides information, education and skills for oral health improvement. Such things help increases the resources available to people to exercise more control over their own health and environments. Health promotion programs needs to be updated that go collateral with changing environment and culture. Hence, continuum for health education, particularly for oral health, throughout life is necessary. Here, comes the role of oral health professionals who forms the bridge between health promotion advocates and health promotion program communities. At community level or at individual level, they create support system to ingress healthy personal skills to improve and maintain oral health. Oral health professionals fulfill this role of trainer by providing information, resources and training.

Interventions that help developing personal skills

Oral health promotion though guided tooth brushing using fluoridated toothpaste as self‐care habits.

Smoking cessation actions under the guidance of Oral health professionals.

Nutritional and dietary education programs which include oral health message.

Encouraging sports authorities for safe environment at sports events such as making sportsmen to put on mouth guards compulsory when required.

5.1.5. Reorientating health services

Health services carry the burden of all diseases by providing three tier cares. With advancing burden of new diseases and population explosion challenges, reorientation of health services is inevitable. The global burden of oral diseases had led to integrate oral health into general health. Indeed, it is giving a new direction for oral health services and recognizing that oral health is not merely a biomedical process. Health services should be reformed such that they not only treat the diseases but also find suitable solutions for health promotion. Strengthening of health services to analyze needs, to understand the socioeconomic determinants of health of the population is required. Such reformation which reduces oral health inequalities and improves oral health‐related quality of life is all about reorienting health services. While prime focus is on primary healthcare services, prevention, allocation, access and cost‐beneficial health services are obligatory to achieve this.

Interventions for reorientating health services

Establishing community‐led oral healthcare providers.

Extensive collaboration with NGOs and social services for oral health promotion, so the curative burden from Government is reduced.

Linking general health services and children oral health care under primary health centers.

Training the trainers, that is, training all health professionals about preventive and social components of oral health promotion.

Facilitating and building knowledge for diagnosing early caries detection programs by primary healthcare professionals.

Health care led healthy policies supporting access to oral health care.

Provision of professional fluoride lack and excess treatment facilities delivered by primary healthcare professionals and community [ 1 ].

Oral health should be an important agenda on the country’s health policy. The above international policy examples envision the challenges and opportunities for better identification, prioritization and integration of oral health services. Collaborative planning and organization may accelerate the process to arrest the global burden of oral diseases and pioneer the oral health promotion. Relevant international developments suggest that some other health promotion frameworks exists that are parallel to Ottawa Charter framework. Although their principles are same, the implementation may differ according to the needs and socio‐cultural environment of the region. One can develop or reform a different model based on above evidences for oral health promotion programs at their region.

5.2. Country examples for oral health promotion program

Investment in simple preventive programs is cost‐effective for prevention of oral diseases and promotion of good oral health which is already proven in Europe. Twenty eight examples of good practice are presented from across Europe as shown in Figure 3 . These cover all areas of oral health promotion across the life course and include programs aimed at pregnant mothers, children and adolescents, the elderly and disadvantaged groups. To solve the problem of poor oral health in other parts of world a thorough evaluation of existing successful policies and programs, identification of evidence‐based interventions can be learned from these programs.

Figure 3.

Examples of good practices in oral health promotion programs existing across the Europe.

These programs outline a number of successful initiatives that can help prevent oral diseases, which reduce the social burden and in turn reduce existing inequalities. This is done with various measures, for instance: prevention programs in communities; limiting social, economic, cultural and environmental risk factors for non‐communicable diseases, oral hygiene promotion, oral health literacy and an appropriate access to oral health care [ 30 ].

6. Conclusion

Gradient shift to rural population to urban area, issues of migrants, urbanization, socio, cultural and environmental changes alienate health promotion. Isolated intervention may not be successful at such circumstances. Oral health promotion actions with different approaches can only improve. Health for all is certainly efficient way than the target specific behaviors. It is evident that an effective and sustainable intervention combines health, society and individual through organization, policy and laws to create healthy living conditions which promotes better quality lifestyle.

WHO is considered as an accountable and reliable organization which provide necessary technical and policy support. Their evidence based guidance enable countries to integrate oral health promotion programs into the general health promotion. The organization has different expertise at Collaboration Centers across globe that is resourceful for oral health promotion guidance. However, most of the developed and developing countries utilize own resources and develop their own action program for health promotion. It is based upon local experiences and strengths, active communities to contribute participation facilitate community empowerment by creating sustainable supporting environment. WHO has given a vision to oral health promotion programs, that is, “think globally—act locally.” To conclude the chapter, an oral health promotion program should focus on following aspects:

Recognition of health determinants, capacity building for designing and implementing interventions to promote oral health.

Community led and based oral health promotion programs, having equal opportunity for marginalized segments of population.

Planning, monitoring and evaluation strategies to be implemented strictly for national oral health promotion activities/programs.

Methods and methodological development to analyze the processes and outcomes of national oral health promotion interventions.

Collaboration with strong of networks and alliances that strengthen local, national and international activities for oral health promotion. Every experience, whether success or failure should be counted and shared to acknowledge the cost‐effective and cost‐beneficial experience that yield to improve oral health quality of life.

Oral health promotion is one practice that involves strategic planning, integrative activities, evidence‐based concepts, evaluation, policy making and other related multifactor. Knowledge generation for oral health promotion through evidence‐based concepts is the goal of this chapter.

Abbreviations

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• WHO = World Health Organization.

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• Published: 15 July 2022

An introduction to oral health promotion

• Marjan Elyassi 1  

BDJ Team volume  9 ,  pages 26–27 ( 2022 ) Cite this article

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Marjan Elyassi , who has been a dental hygienist for seven years, provides an introduction to the role of the dental hygienist in imparting oral health advice.

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Introduction

According to the World Health Organisation (WHO), oral health is a key indicator of overall health, wellbeing and quality of life which encompasses a range of diseases and conditions that include dental caries, periodontal (gum) disease, tooth loss, oral cancer, and other less common oral diseases. 1

Oral health promotion

Oral health promotion is provided by dentists and dental care professionals (DCPs) for different groups of people, aiming to improve their oral health and general wellbeing. This is done by encouraging patients to carry out oral hygiene instructions while also addressing any dental health problems that are present.

The needs of the oral health promotion can be different from one person to another based on their oral health status and the presence of any underlying factors such as diabetes, cardiovascular disease, pregnancy, menopause, smoking, and the patient's socioeconomic background. Therefore, tailored oral health messages are required.

Regular visits to see the dental hygienist are part of oral health promotion, to keep a record of the patient's progression and motivation. Changes in the patient's behaviour towards oral health are important as they will affect the patient's perspective and commitment to oral hygiene for life.

Based on NICE guidelines there are different groups of people with specific dental needs in general dental practices in which a DCP educates the patients by providing oral health promotion. There are useful oral health promotion toolkits available through the NICE website. 2

Patient motivation and instruction in oral hygiene practices should be combined with professional mechanical plaque removal (PMPR) using hand scalers, sonic and/or ultrasonic scaling, and polishing based on 2-4 sessions per year. The frequency of these sessions should be tailored to a patient's risk and the level of compliance at home. 3

Target groups

1. early stages of gingivitis.

Gingivitis is the beginning of gum disease. It involves early inflammation (redness and swelling) of the gums induced by plaque as an irritating factor. It is reversible by effective toothbrushing technique, interdental cleaning, and removal of the plaque by DCPs. If not addressed this can progress to an irreversible stage of gum disease.

Explain the findings to the patient without using any dental jargon. Show the patient the findings, using disclosing tablets for patient motivation, and using visual aids to educate the patient.

Oral hygiene instructions given by the dental hygienist include taking a medical history and social history of the patient, performing external and internal dental examination, recording the patient's oral hygiene care at home, recording a Basic Periodontal Examination (BPE), distribution of the plaque, bleeding on probing, and presence of any plaque retentive factors.

Explain the findings to the patient without using any dental jargon. Show the patient the findings, using disclosing tablets for patient motivation, and using visual aids to educate the patient. You might also provide information leaflets, introduce useful dental apps, and issue a diet sheet.

Oral hygiene instructions include twice a day toothbrushing with a moderate bass technique, and daily interdental cleaning with floss, tape or interdental brushes. Mouthwashes can be advised as an adjunct as it is not a necessary part of oral hygiene.

2. Heavy smoker

Smoking has an adverse effect on general and dental health. It is one of the main risk factors in the progression of periodontal disease. Smoking more than ten cigarettes a day counts as heavy smoking. This can cause dry mouth, plaque build up, loss of gingival attachment and bone loss. Smoking also affects patients' confidence and commitment to comply with their oral hygiene regime at home. Quitting smoking is a cycle of change and needs willpower.

Oral hygiene promotion is the same as in the first group, plus providing smoking cessation advice for the patient in a non-patronising manner. Smoking cessation advice includes information on nicotine replacement therapy, e-cigarettes, trained community pharmacists who give smoking cessation counselling, reviewing oral hygiene instruction with regular dental hygienist visits and finally providing diet advice and issuing a diet sheet where possible.

3. Dentures

A denture is a prosthetic appliance replacing a missing tooth/teeth. It can be partial upper or partial lower or full top and bottom denture, removable or fixed. Acrylic or chrome cobalt are the main materials used to make a denture. Fixed dentures are usually attached to a set of implants. Patients who just commenced on wearing a new denture/s are usually those who require the most denture aftercare. It is important to remind patients that they still need to take care of their natural teeth which hold the denture, considering the patient's manual dexterity.

Oral hygiene promotion includes denture hygiene instructions ie denture cleaning materials based on manufacturers' instructions, advice on denture removal at night [left in cold water] and regular visits to the hygienist. For those who have implant-based dentures, an interspace brush, interdental brush and super floss, spitting and not rinsing are recommended, plus regular visits to the hygienist.

4. Patients with bridges and crowns

Bridges and crowns are restorations that either restore part of the tooth or a whole new set of teeth. Looking after the crowns and bridges is very important as they count as a plaque retentive factor and accumulation of plaque will affect the health of the restoration.

Oral hygiene instructions include twice daily toothbrushing with a modified bass technique, interdental cleaning including interdental brush, interspace brush and super floss, spitting not rinsing plus routine hygiene visit.

5. Patients with hypersensitivity

Hypersensitivity is a natural response of the dentine of the teeth to cold and hot temperature as a stimulus perceived by dentinal tubules. Acidity and sweetness are other factors that affect the sensitivity of the teeth in the same way.

Oral hygiene promotion includes gentle toothbrushing techniques, interdental cleaning, diet advice including eating more vegetables, replacing acidic fruits with non-acidic fruits, drinking plain water, cutting down on fizzy drinks, using straws, limiting fruits and fizzy drinks to mealtimes, and spitting not rinsing.

Data show 90% of the adults in the UK have some sort of gum disease, even if only a small amount 4 but also that oral health promotion is very important as it enhances individuals' quality of life. Delivering oral health messages in an appropriate manner makes a difference to people's lives and their wellbeing. There are different groups of patients with different needs based on their oral hygiene status. Maintenance and commitment to good oral hygiene by the patient enables a better response to treatment by DCPs. And never forget the importance of a proud smile!

World Health Organisation. Oral health. Available at: https://www.who.int/health-topics/oral-health#tab=tab_1 (accessed July 2022).

NICE. Oral health promotion: general dental practice. NICE guideline NG30. 1.1 Oral health advice given by dentists and dental care professionals. 15 December 2015. Available at: https://www.nice.org.uk/guidance/ng30/chapter/Recommendations#oral-health-advice-given-by-dentists-and-dental-care-professionals (accessed July 2022).

EFP. Guidelines for effective secondary prevention of periodontitis by professional mechanical plaque removal (PMPR). Guidance for dentist and dental hygienist. Available at: https://www.bsperio.org.uk/assets/downloads/Secondary-prevention-of-periodontitis-by-PMPR.pdf (accessed July 2022).

University of Birmingham. Nearly all of us have gum disease - so let's do something about it. 28 May 2015. Available at: https://www.birmingham.ac.uk/news/2015/nearly-all-of-us-have-gum-disease-so-lets-do-something-about-it (accessed July 2022).

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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

A systematic review of the effectiveness of health promotion aimed at improving oral health.

E Kay and D Locker .

Review published: 1998 .

• Authors' objectives

To examine the quality of oral health promotion research evidence, and to assess the effectiveness of health promotion aimed at improving oral health using a systematic and scientifically defensible methodology.

MEDLINE, CINAHL, the Social Sciences Citation Index, and Health Service Abstracts were searched using the keywords 'dental health education', 'oral health promotion', 'effectiveness' and 'evaluation'. A panel of experts in Europe and the USA, and members of an interest group, were contacted for additional studies.

The reference lists of retrieved papers were examined for additional studies, and any relevant journals identified were added to a list of journals to be handsearched. The handsearch included these journals and others known to publish material pertinent to the review.

Papers were included if they were published in the English language after 1979. Multiple reports from the same study only contributed once to the review, whereas papers which used a variety of outcome measures were included in each outcome category.

• Study selection

Study designs of evaluations included in the review

The studies had to report an evaluative component. Theoretical and purely descriptive studies were excluded.

Specific interventions included in the review

Studies reporting any oral health promotion intervention were eligible for inclusion. The following interventions were included in the review: tooth brushing programmes in schools; education of the parents on children's dental health; parental tooth brushing instruction; group and individual education sessions; mass media; prophylaxis; fluoride tablets, gels, drops and rinses; attending dental care; instruction or demonstration of denture cleaning; interview with psychologist; and computer games.

Participants included in the review

The authors did not report any inclusion criteria relating to the participants. The settings were clinical, community, schools or other institutions. The participants were children, the elderly, adults, and people with handicaps or disabilities.

Outcomes assessed in the review

The outcome measures assessed included caries, oral hygiene, oral health-related knowledge, attitudes and behaviours.

How were decisions on the relevance of primary studies made?

The authors do not state how the papers were selected for the review, or how many of the reviewers performed the selection.

• Assessment of study quality

Papers were scored using the criteria of Pettiti (see Other Publications of Related Interest). These criteria placed particular weight on the definition, reliability and validity of the outcome measures, and the drop-out rate.The authors do not state how the papers were assessed for validity, or how many of the reviewers performed the validity assessment.

• Data extraction

The authors do not state how the data were extracted for the review, or how many of the reviewers performed the data extraction.

Data were extracted on the following categories: study setting; main outcome; target population; number of participants; mean change in outcome, plus the standard deviation; study methodology; 'success' of the intervention; and any details regarding costs. The effectiveness of each intervention was calculated if there were sufficient data. The formula for this involved the weighted average at baseline (calculated from baseline scores in the intervention and control groups) and the separate baseline and final scores for the control and intervention groups.

• Methods of synthesis

How were the studies combined?

When sufficient homogeneity between a number of studies could be identified, a pooled estimate of the mean effect of the intervention was calculated together with the 95% confidence interval (CI). For studies that did not report sufficient data to be included in the formal meta-analysis, a qualitative synthesis of the results was undertaken.

If the majority of studies within each methodological group (RCT, quasi-experimental, single group or other) showed a positive outcome effect, the conclusion drawn was that there was robust evidence of a strong effect, which was not masked by poor research design or small numbers of participants. If, however, the majority of studies within each methodological group showed no intervention effect, the conclusion drawn was that there was no evidence that oral health promotion was effective.

How were differences between studies investigated?

Before pooling, homogeneity was considered in terms of study design, interventions, outcome and target groups.

• Results of the review

One hundred and sixty-four articles were included in the review. There were 36 randomised controlled trials (RCTs; n=3,353), 80 quasi- experimental studies (i.e. non-randomised clinical trials), 33 single-group pre-test post-test studies, 7 multiple baseline and 6 mass media studies; the number of participants for the other study designs was not reported.

RCTs (n=7): 4 RCTs reported a small non significant effect on the level of caries. Almost all of the oral health promotion initiatives which looked at caries involved the use of fluoride. The meta-analysis showed that the mean intervention effect was a caries reduction of 1.8 surfaces (95% CI: 0.38, 3.26).

Quasi-experimental studies (n=11): these studies indicated that the levels of caries could be reduced by daily brushing with a fluoridated toothpaste. The size of the intervention effect was dependent on the length of time that elapsed between the introduction and evaluation of the programme. Greater reductions in caries were observed in the longer-term studies. There was no evidence that the levels of caries were affected by interventions that did not involve daily brushing.

Single-group studies (n=3): these were poor studies and no conclusions could be drawn.

Oral Hygiene.

RCTs (n=23): the majority of studies used plaque levels in the participants' mouths as the outcome measure. The conclusions drawn in each individual study varied according to the follow-up period.

The majority of studies with short follow-up showed significant improvements in plaque levels, whilst studies with long periods of follow-up suggested that instruction and education about plaque control were not effective in the long term. The more elaborate and theoretically based interventions appeared to be no more successful in reducing plaque levels than the more simple approaches. A meta-analysis showed that the mean intervention effect was a 0.316 reduction in the plaque index (95% CI: -0.063, 0.695).

Quasi-experimental studies (n=33): there was no convincing evidence that school-based education programmes had any effect on the plaque levels in the participants' mouths, even when daily brushing at school was part of the programme. School-based programmes, whether run by dental professionals, teachers, or older pupils teaching younger pupils, have not been demonstrated to affect oral hygiene. In clinic- and work-based interventions, some experimental plaque control programmes with adults demonstrated dramatic reductions in plaque levels. Educating the parents about plaque control in their young children was effective.

Single-group studies (n=22): these were poor studies and no conclusions could be drawn.

Sugar consumption. Study designs not reported (n=8): the outcomes reported by these studies were behavioural intentions or reported behaviour. Thus, it was difficult to draw definitive conclusions from these studies.

Knowledge, attitudes and behaviours. Study designs not reported (n=37): these studies indicated that knowledge levels were invariably altered by the interventions described. Complex and technical educative methods added little benefit, and simple provision of information was sufficient to increase knowledge levels. However, the studies that included other outcome measures also suggested that alterations in knowledge, attitudes and beliefs were not related to changes in behaviour or health.

Mass media. Study designs not reported (n=7): these studies suggested that oral health promotion via the mass media was ineffective for promoting both knowledge and behaviour change. However, the authors stated that the evaluation methodologies in these studies were inadequate and, therefore, no specific conclusion regarding the role of mass media could be drawn.

• Cost information

Details of the costs were qualitatively recorded. However, the authors stated that few data were reported and, therefore, no statements about cost-to-benefit ratios could be made.

• Authors' conclusions

Oral health promotion which brings about the use of fluoride is effective for reducing caries. Chairside oral health promotion has been shown to be effective more consistently than other methods of health promotion. Mass media programmes have not been shown to be effective. The quality of research evaluating oral health promotion needs to be improved.

• CRD commentary

This was an average review of the area. A reasonable literature search was conducted. However, only studies published in English were included, thus important studies may have been missed and the results may be subject to publication bias. The inclusion criteria were mentioned in the methods and the abstract, but it would have been helpful if these had been presented more clearly. Details of the review process, such has how many authors were involved in each stage of the review, were not reported. Appropriate study details were presented in the article.

The authors stated that a validity assessment was performed, but this was not presented in the results section, or related to the results presented. It was therefore difficult to interpret the reliability of the individual studies included in the review. Given the heterogeneity in the studies in terms of intervention, design, populations and outcomes, it does not appear to have been appropriate to have pooled the results, especially as heterogeneity was not formally assessed. The pooled results should, therefore, be interpreted with extreme caution.

Overall, the authors' conclusions appear to be supported by the results presented. However, they should be interpreted with some degree of caution due to the limitations highlighted.

• Implications of the review for practice and research

The authors did not state any implications for further research and practice.

• Bibliographic details

Kay E, Locker D. A systematic review of the effectiveness of health promotion aimed at improving oral health. Community Dental Health 1998; 15(3): 132-144. [ PubMed : 10645682 ]

• Other publications of related interest

Pettiti DB. Meta-analysis, decision analysis and cost-effectiveness analysis. Oxford: Oxford University Press; 1994.

• Indexing Status

Subject indexing assigned by NLM

Adult; Aged; Attitude to Health; Cariostatic Agents /therapeutic use; Child; Dental Caries /prevention & control; Disabled Persons; Fluorides /therapeutic use; Health Behavior; Health Education, Dental; Health Knowledge, Attitudes, Practice; Health Promotion; Health Status; Humans; Mass Media; Oral Health; Oral Hygiene; Periodontal Diseases /prevention & control; Toothpastes /therapeutic use

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This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

• Cite this Page Kay E, Locker D. A systematic review of the effectiveness of health promotion aimed at improving oral health. 1998. In: Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

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The Oral Health in America Report: A Public Health Research Perspective

Jane a weintraub , dds, mph.

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Corresponding Author: Jane A. Weintraub, DDS, MPH, R. Gary Rozier and Chester W. Douglass Distinguished Professor, University of North Carolina at Chapel Hill Adams School of Dentistry, Department of Pediatric and Public Health, Koury Oral Health Sciences Building, Suite 4508, Chapel Hill, NC 27599-7450. Telephone: (919) 537-3240. Email: [email protected] .

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Peer Reviewed

Collection date 2022.

Preventing Chronic Disease is a publication of the U.S. Government. This publication is in the public domain and is therefore without copyright. All text from this work may be reprinted freely. Use of these materials should be properly cited.

Introduction

In December 2021, the National Institutes of Health, National Institute of Dental and Craniofacial Research, released its landmark 790-page report, Oral Health in America: Advances and Challenges ( 1 ). This is the first publication of its kind since the agency’s first Oral Health in America: A Report of the Surgeon General described the silent epidemic of oral diseases in 2000 ( 2 ). This new, in-depth report, an outstanding resource, had more than 400 expert contributors. Its broad scope is exemplified by its 6 sections ( Box ), each of which includes 4 chapters: 1) Status of Knowledge, Practice, and Perspectives; 2) Advances and Challenges; 3) Promising New Directions; and 4) Summary. In this essay, I provide a public health research perspective for viewing the report, identify some advances and gaps in our knowledge, and raise research questions for future consideration.

Box. Section Titles, Oral Health in America: Advances and Challenges ( 1 ).

1. Effect of Oral Health on the Community, Overall Well-Being, and the Economy

2A. Oral Health Across the Lifespan: Children

2B. Oral Health Across the Lifespan: Adolescents

3A. Oral Health Across the Lifespan: Working-Age Adults

3B. Oral Health Across the Lifespan: Older Adults

4. Oral Health Workforce, Education, Practice, and Integration

5. Pain, Mental Illness, Substance Use, and Oral Health

6. Emerging Science and Promising Technologies to Transform Oral Health

Data Needed

A recurring theme in the report is the need for many types of data, from microdata — the molecular, nanoparticle level — to macrodata — the population and global level. Data are needed to guide public health policies and programs at the federal, state, and local levels. Future research using big data from multiple sources (eg, community health needs assessments, surveillance systems, GIS mapping, electronic health records, practice-based research networks) will provide timely, population-based information to evaluate and drive changes to policy and delivery systems and oral health advocacy efforts.

This new report includes descriptive national data from 3 cycles of the National Health and Nutrition Examination Survey (NHANES). To continue monitoring national oral health surveillance data and trends, oral health data need to be included routinely in NHANES and in other large national studies. Too often, questions about oral health are missing from surveys, or clinical oral health data are not collected. For example, very little about oral health was included as part of the planned data collection protocol for the National Institutes of Health All of Us Research Program. This program aims to collect health information from 1 million people ( 3 ). Local and state data are often outdated, incomplete, or unavailable. Most oral health data are cross-sectional and are useful for studying trends and associations, but population-based longitudinal data to study causality and the effectiveness of interventions and policies are sparse.

How does oral health care improve other health conditions? Proprietary claims data from insurance companies ( 4 ) show the inter-relationship between treatment of periodontal disease and systemic conditions, but secondary data analysis has many limitations and confounding factors. Clinical trials show that periodontal treatment improves glycemic control among people with diabetes ( 5 ), but long-term outcome assessments are lacking. We need more answers to convince policy makers and payers about the importance of including comprehensive adult oral health services in publicly financed programs such as Medicaid, which is currently lacking in many states, and Medicare, where those services are missing altogether.

Health Disparities and Social Determinants of Health

Many examples of substantial oral health disparities and inequities are presented in Section 1 of the report. For some conditions and population groups, little improvement has been made, especially among adults and seniors. Section 1 also describes the adverse social, economic, and national security effects of poor oral health, barriers to care, social and commercial determinants of oral health, and related common risk factors. More than the clinical data collected in a typical dental history is needed to understand social determinants and employ local and upstream interventions. The report suggests obtaining social histories from patients to get information about where people live, learn, work, and play. For example, to learn about socioeconomic status, diet, and medications, we want to know not only “What’s in your wallet,” (as touted in a frequent television advertisement) but what’s in your refrigerator? What’s in your medicine cabinet? Telehealth has given clinicians a look inside patients’ homes. Collaboration with social workers, home health aides, and visiting nurses could inform us even more about the home environment. With integrated electronic medical and dental patient records, oral health professionals and medical colleagues can share information. Barriers to integration and assessment of population health outcomes affect many dentists who still use paper records or software specific to dental care that lacks diagnostic codes and interoperability with other health care records systems ( 6 ).

The report highlights the need for more information about adolescents and older adults and other understudied population groups. Section 1 describes many diverse, vulnerable populations (eg, people with special health care needs, low health literacy, mental illness, substance abuse disorders; victims of structural racism) who all need to be included in oral health research. Non-English speakers and hard-to-reach populations that have physical and/or financial barriers to traditional dental care are less likely to be recruited and represented in clinical trials, making results less generalizable and interventions less applicable. The applied research agenda being developed by the American Association of Public Health Dentistry ( 7 ) and the “Consensus Statement on Future Directions for the Behavioral and Social Sciences in Oral Health,” which is based on an international summit ( 8 ), are helpful in setting research and methodologic priorities, including qualitative, implementation, and health systems research.

Individual and Community Relationships

Knowledge about the interrelationships between oral and systemic health has greatly expanded since the 2000 report. About 60 adverse health conditions have now been shown to be associated with oral health ( 1 ), which is part of the rationale for the integration of oral health and primary care. Research will advance our understanding of the mechanisms by which oral and systemic conditions are affected by upstream environmental and social factors, epigenetic factors, and the aging process, both individually and communally. For example, how do external exposures change our microbiomes? Our oral microbiome may be exposed to air containing Sars-CoV-2, water containing protective fluoride, or many kinds of food, beverages, medications, illicit substances, smoked products, and sometimes the biome of close personal contacts. How does the health of a community’s high caries risk groups change with policies such as a tax on sugar-sweetened beverages, Medicaid reimbursement changes, or health promotion efforts to improve oral health literacy and dietary behaviors? To what extent will increased application of value-based health care reimbursement with emphasis on disease prevention, early detection, and minimally invasive care improve oral health? Will the World Health Organization’s addition of dental products (eg, fluoride toothpaste, low-cost silver diamine fluoride, glass ionomer cement) to its Model List of Essential Medicines ( 9 ) increase their use to prevent and treat dental caries for under-resourced populations without access to conventional high-cost dental care?

Scientific Advances and Equitable Distribution

The report’s Section 6 describes many exciting advances in biology, biomimetic dental materials, and technology. Rapid advances in salivary diagnostics are providing information about early, abnormal changes in remote organ systems in the body. Advanced imaging techniques and artificial intelligence can be used for early diagnosis of oral lesions before they are visible to the human eye. The validity and accuracy of these techniques need careful evaluation. Can these earlier clinical end points be used to shorten the length of expensive clinical trials? Guide new preventive strategies? At what point do providers intervene with early preventive or therapeutic strategies instead of letting the body heal itself?

Will populations at greatest risk for disease and the greatest barriers to accessing dental care be able to benefit from early intervention? Every intervention has a cost. If access to new prevention and therapeutic discoveries is not equitable, will health disparities worsen? We need community engagement in the research process and the tools from many disciplines to measure and facilitate the best outcomes. The national Oral Health Progress and Equity Network’s blueprint for improving oral health for all includes 5 levers to advance oral health equity: “amplify consumer voices, advance oral health policy, integrate dental and medical [care], emphasize prevention and bring care to the people” ( 10 ).

Educational Opportunities

Who will analyze all these data mined from many micro and macro sources, and who will interpret the data? Health learning systems and complex software algorithms are being developed to provide automated diagnostic information. Data analysts with knowledge of these and other sophisticated tools and modeling approaches are needed.

The dental, oral, and craniofacial research and practice communities increasingly need to be part of interdisciplinary research and educational programs with opportunities for collaboration and learning. Federally qualified health centers and look-alikes are good sites for medical–dental integration, but many of these facilities do not provide dental care.

More positions are needed for dental public health specialists who can lead advocacy efforts, interdisciplinary teams of researchers, clinicians, and community partners and conduct research. For example, the new Dental Public Health Research Fellowship at the National Institute of Dental and Craniofacial Research will provide more intensive research training to further advance dental public health and population-based research. Mechanisms are needed to promote, facilitate, and reward sharing of research and training resources across disciplines in our competitive environment.

Public health perspectives are an important part of interdisciplinary approaches to guide, conduct, and apply research and implement policies to improve oral health. Preventive approaches exist as do barriers to their dissemination and implementation. To prevent disease and improve population oral and overall health, systems change and policy reform are needed along with scientific advances across the research spectrum, more population-level data and analysis, and community participatory engagement. I am optimistic that the next Oral Health in America report will describe fewer inequities and more progress toward oral health for all.

Acknowledgments

This article is based on a presentation made in the webinar, Oral Health in America — Advances and Challenges: Reading the Report through a Research Lens , sponsored by the American Association for Dental, Oral, and Craniofacial Research. The author received no financial support for this work and has no conflicts of interest to declare. The statements made are those of the author. No copyrighted materials were used in this article.

The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.

Suggested citation for this article: Weintraub JA. The Oral Health in America Report: A Public Health Research Perspective. Prev Chronic Dis 2022;19:220067. DOI: https://doi.org/10.5888/pcd19.220067 .

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