Richard G. Watt

Strategies and approaches in oral disease prevention and health promotion

Oral health is an important element of general health and well-being. Although largely preventable, many people across the world still suffer unnecessarily from the pain and discomfort associated with oral diseases. In addition, the costs of dental treatment are high, both to the individual and to society. Effective evidence-based preventive approaches are needed to address this major public health problem. The aim of this paper is to outline public health strategies to promote oral health and reduce inequalities. An extensive collection of public health policy documents produced by WHO are reviewed to guide the development of oral health strategies. In addition a range of Cochrane and other systematic reviews assessing the evidence base for oral health interventions are summarized. Public health strategies should tackle the underlying social determinants of oral health through the adoption of a common risk approach. Isolated interventions which merely focus on changing oral health behaviours will not achieve sustainable improvements in oral health. Radical public health action on the conditions which determine unhealthy behaviours across the population is needed rather than relying solely on the high-risk approach. Based upon the Ottawa Charter, a range of complementary strategies can be implemented in partnership with relevant local, national and international agencies. At the core of this public health approach is the need to empower local communities to become actively involved in efforts to promote their oral health.

Social Gradients in Oral and General Health

There are social gradients in general health and oral health. However, there have been few studies addressing whether similarities exist in the gradients in oral and general health in the same individuals. We set out to test, using data from NHANES III, whether there are social gradients in oral health, and whether they resemble the gradients in general health. Income, indicated by poverty-income ratio, and education gradients were examined in periodontal diseases, ischemic heart disease, and perceived oral/general health. Our analysis demonstrated consistent income and education gradients in all outcomes assessed. In the adjusted regression models, the probabilities of having poorer clinical and perceived health were attenuated, but remained significantly higher at each lower level of income and education for most outcomes. The results showed similar income and education gradients in oral and general health, implying commonalities of the social determinants of both oral and general health.

Toothbrushing, inflammation, and risk of cardiovascular disease: results from Scottish Health Survey

Objective To examine if self reported toothbrushing behaviour is associated with cardiovascular disease and markers of inflammation (C reactive protein) and coagulation (fibrinogen). Design National population based survey. Setting Scottish Health Survey, which draws a nationally representative sample of the general population living in households in Scotland. Participants 11 869 men and women, mean age 50 (SD 11). Main outcome measures Oral hygiene assessed from self reported frequency of toothbrushing. Surveys were linked prospectively to clinical hospital records, and Cox proportional hazards models were used to estimate the risk of cardiovascular disease events or death according to oral hygiene. The association between oral hygiene and inflammatory markers and coagulation was examined in a subsample of participants (n=4830) by using general linear models with adjustments. Results There were a total of 555 cardiovascular disease events over an average of 8.1 (SD 3.4) years of follow-up, of which 170 were fatal. In about 74% (411) of cardiovascular disease events the principal diagnosis was coronary heart disease. Participants who reported poor oral hygiene (never/rarely brushed their teeth) had an increased risk of a cardiovascular disease event (hazard ratio 1.7, 95% confidence interval 1.3 to 2.3; P<0.001) in a fully adjusted model. They also had increased concentrations of both C reactive protein (β 0.04, 0.01 to 0.08) and fibrinogen (0.08, −0.01 to 0.18). Conclusions Poor oral hygiene is associated with higher levels of risk of cardiovascular disease and low grade inflammation, though the causal nature of the association is yet to be determined.

Global Oral Health Inequalities Task Group—Implementation and Delivery of Oral Health Strategies

This paper reviews the shortcomings of present approaches to reduce oral diseases and inequalities, details the importance of social determinants, and links that to research needs and policies on implementation of strategies to reduce oral health inequalities. Inequalities in health are not narrowing. Attention is therefore being directed at determinants of major health conditions and the extent to which those common determinants vary within, between, and among groups, because if inequalities in health vary across groups, then so must underlying causes. Tackling inequalities in health requires strategies tailored to determinants and needs of each group along the social gradient. Approaches focusing mainly on downstream lifestyle and behavioral factors have limited success in reducing health inequalities. They fail to address social determinants, for changing people’s behaviors requires changing their environment. There is a dearth of oral health research on social determinants that cause health-compromising behaviors and on risk factors common to some chronic diseases. The gap between what is known and implemented by other health disciplines and the dental fraternity needs addressing. To re-orient oral health research, practice, and policy toward a ‘social determinants’ model, a closer collaboration between and integration of dental and general health research is needed. Here, we suggest a research agenda that should lead to reductions in global inequalities in oral health.

Integrating the common risk factor approach into a social determinants framework

The common risk factor approach (CRFA) has been highly influential in integrating oral health into general health improvement strategies. However, dental policy makers and oral health promoters have interpreted the CRFA too narrowly. They have focussed too heavily on the common behavioural risks, rather than on the broader shared social determinants of chronic diseases. A behavioural preventive approach alone will have minimal impact in tackling oral health inequalities and indeed may widen inequalities across the population. Based on recent WHO policy recommendations, this study presents the case for updating the CRFA in accordance with the social determinants agenda. The theoretical basis for a social determinants framework for oral health inequalities is presented, and implications for oral health improvement strategies are highlighted. Future action to address oral health inequalities in middle- and high-income countries requires a radical policy reorientation towards tackling the structural and environmental determinants of chronic diseases. In more equal and fairer societies, all sections of the social hierarchy experience better health and social well-being.

Evidence-based dentistry: an overview of the challenges in changing professional practice

reviews on interventions to improve professional performance have provided some useful insights.3,4 The aim of the first overview was to examine systematic reviews of different strategies for the dissemination and implementation of research findings to identify evidence for the effectiveness of different strategies.3 A detailed search of the relevant literature was conducted. The identified papers were then subjected to a rigorous quality assessment procedure. Eighteen reviews satisfied the inclusion criteria. In the second overview, information was collated on 44 systematic reviews of different dissemination and implementation interventions designed to change professional practice.4 Some of these interventions were Cochrane reviews. The interventions were categorised into reviews of broad strategies (continuing medical education; dissemination and implementation of guidelines); reviews of interventions to improve specific behaviour (preventive care, prescribing and other behaviours); and reviews of specific interventions (dissemination of educational materials, educational outreach, local opinion leaders, audit and feedback, reminders — manual or computerised and other interventions). The common findings from both overviews are summarised in Table 1. Most of the systematic reviews identified modest improvements in clinical performance as a result of the intervention, although no intervention was effective under all circumstances. The most effective interventions were educational outreach (though only specific for one area of practice), reminder systems, multi-faceted and interactive educational meetings. The passive dissemination of information either through the distribution of educational materials or attendance at didactic meetings were generally ineffective at changing clinical practices. Both overviews highlight that ‘no magic bullets’ exist to change clinical practice.5 The vast majority of studies considered in

Breast-feeding initiation and exclusive duration at 6 months by social class--results from the Millennium Cohort Study.

OBJECTIVES To assess breast-feeding initiation and rates of exclusive breast-feeding for the first 6 months after birth, and to examine social class differences in breast-feeding rates. DESIGN First sweep of a longitudinal population-based survey, the Millennium Cohort Study. SETTING Four countries of the UK. SUBJECTS Subjects were 18 125 singletons born over a 12-month period spanning 2000-01. Data were collected by parental interview on the initiation of breast-feeding and exclusivity at 1, 4 and 6 months after birth. RESULTS Overall breast-feeding was initiated for 71% of babies, and by 1, 4 and 6 months of age the proportions being exclusively breast-fed were 34%, 3% and 0.3%, respectively. There were clear social class differences and mothers with routine jobs with the least favourable working conditions were more than four times less likely (odds ratio (OR) 0.22, 95% confidence interval (CI) 0.18-0.29) to initiate breast-feeding compared with women in higher managerial and professional occupations. Women in routine jobs were less likely to exclusively breast-feed their infants at 1 month (OR 0.42, 95% CI 0.36-0.50) and 4 months (OR 0.5, 95% CI 0.31-0.77) compared with women in higher managerial and professional occupations. CONCLUSIONS Clear social class differences in breast-feeding initiation and exclusivity for the first 4 months were apparent in this large UK sample. By 6 months, less than 1% of babies were being exclusively breast-fed. A co-ordinated multi-faceted strategy is required to promote breast-feeding, particularly among lower-income women.

The role of health-related behaviors in the socioeconomic disparities in oral health

This study aimed to examine the socioeconomic disparities in health-related behaviors and to assess if behaviors eliminate socioeconomic disparities in oral health in a nationally representative sample of adult Americans. Data are from the US Third National Health and Nutrition Examination Survey (1988-1994). Behaviors were indicated by smoking, dental visits, frequency of eating fresh fruits and vegetables and extent of calculus, used as a marker for oral hygiene. Oral health outcomes were gingival bleeding, loss of periodontal attachment, tooth loss and perceived oral health. Education and income indicated socioeconomic position. Sex, age, ethnicity, dental insurance and diabetes were adjusted for in the regression analysis. Regression analysis was used to assess socioeconomic disparities in behaviors. Regression models adjusting and not adjusting for behaviors were compared to assess the change in socioeconomic disparities in oral health. The results showed clear socioeconomic disparities in all behaviors. After adjusting for behaviors, the association between oral health and socioeconomic indicators attenuated but did not disappear. These findings imply that improvement in health-related behaviors may lessen, but not eliminate socioeconomic disparities in oral health, and suggest the presence of more complex determinants of these disparities which should be addressed by oral health preventive policies.

Racial/Ethnic differences in breastfeeding initiation and continuation in the United Kingdom and comparison with findings in the United States?

OBJECTIVE. Patterns of breastfeeding vary considerably across different racial/ethnic groups; however, little is known about factors that might explain differences across and within different racial/ethnic groups. Here we examine patterns of breastfeeding initiation and continuation among a racially/ethnically diverse sample of new mothers and compare this with patterns seen in the United States. The effects of demographic, social, economic, and cultural factors on racial/ethnic differences in breastfeeding practices are assessed. METHODS. The sample includes all singleton infants whose mothers participated in the first survey of the United Kingdom Millennium Cohort Study. Missing data reduced the sample to 17474 (96%) infants with complete data. RESULTS. After adjustment for demographic, economic, and psychosocial factors, logistic regression models showed that Indian, Pakistani, Bangladeshi, black Caribbean, and black African mothers were more likely to initiate breastfeeding compared with white mothers. Further adjustment for a marker of cultural tradition attenuated these relationships, but all remained statistically significant, suggesting that some of the difference was a consequence of cultural factors. After adjustment for demographic, economic, and psychosocial factors, Indian, Pakistani, Bangladeshi, black Carribbean, and black African mothers were more likely to continue breastfeeding at 3 months compared with white mothers. Additional adjustment for a marker of cultural tradition attenuated the relationship for Indian, Pakistani, Bangladeshi, and black African mothers, but all remained statistically significant. Models run for breastfeeding continuation at 4 and 6 months were consistent with these results. CONCLUSIONS. We have shown that in the United Kingdom the highest breastfeeding rates are among black and Asian mothers, which is in stark contrast to patterns in the United States, where the lowest rate is seen among non-Hispanic black mothers. The contrasting racial/ethnic patterns of breastfeeding in the UnitedKingdom and United States necessitate very different public health approaches to reach national targets on breastfeeding and reduce health disparities. Those who implement future policies aimed at increasing breastfeeding rates need to pay attention to different social, economic, and cultural profiles of all racial/ethnic groups.

Effects of allostatic load on the social gradient in ischaemic heart disease and periodontal disease: evidence from the Third National Health and Nutrition Examination Survey

Introduction: Psychosocial stress and allostatic load have been postulated as a mechanism explaining socioeconomic inequalities in general and oral health. This study tested whether markers of allostatic load are associated with both ischaemic heart disease and periodontal disease and whether they affect education and income gradients for both conditions. Methods: Data are from the Third National Health and Nutrition Examination Survey, conducted in the United States from 1988 to 1994. Ischaemic heart disease was determined by the presence of angina or diagnosis of heart attack. Four variables were used for periodontal disease. Individual and aggregate markers of allostatic load were used. Results: Allostatic load (both aggregate and most individual markers) was associated with higher probabilities of all examined health outcomes. Adjusting for markers of allostatic load attenuated education and income gradients in both ischaemic heart disease and periodontal disease. The relationship between socioeconomic position and the examined health outcomes remained significant. Conclusion: Indicators of allostatic load were associated with ischaemic heart disease and periodontal disease and had a mediating effect partly explaining the social gradients in both diseases. The results suggest a possible common stress pathway linking socioeconomic position to both conditions.