Childsmile after 10 years part 1: background, theory and principles

Common and Multiple Risk Factor Approach

Diseases of the oral cavity such as dental caries, periodontal disease and oral cancer are classified by the World Health Organization (WHO) as Non-Communicable Diseases (NCDs), sharing risk factors such as smoking, alcohol and a high sugar diet with other chronic diseases. A common risk factor approach is therefore advocated as an effective and cost-effective approach to the prevention of such diseases,⁴ with sugar control being particularly important in relation to dental caries. Risk factors also cluster together and are socially patterned, indicating the need for multifaceted interventions.⁵

Social determinants of health

Traditionally, much of the activity associated with the prevention of caries in children has focused on clinical prevention and dental health education, targeted towards parents and the child. However, systematic reviews have shown that the latter approach on its own has very limited impact on health improvement,⁶ and can lead to increases in health inequalities. Those least likely to need support are more likely to access dental services − and this inverse care law is well recognized.⁷ Moreover, dental health education approaches have been singled out as increasing inequalities as they are taken up by those with higher socioeconomic status, education and resources,^{8, 9} while those from more disadvantaged circumstances find it much more challenging.

It is important to realize that the promotion of oral health, particularly in disadvantaged communities, will best be achieved by understanding the circumstances in which people live on a day-to-day basis, and creating supportive environments conducive to promoting oral health.

The publication of the Ottawa Charter in the 1980s¹⁰ was very influential in recognizing the need to shift away from the emphasis being on individuals and their behaviour to a more public health approach encompassing the social and environmental conditions in which people live. Important principles of the Ottawa Charter include: creating supportive environments, strengthening community action and developing personal skills. Figure 1 shows how material and social circumstances can impact on health and health inequalities. Economic, social and welfare policies at government level can affect living and working conditions, community cohesion and support, and psychosocial factors in individuals such as coping abilities, resilience and stress. The latter in turn can result in responsive behaviours such as comfort eating, smoking and excessive alcohol consumption. Additionally, financial, commercial, social and community circumstances can influence access to health promoting foods and resources (such as fluoridated toothpaste) and health services.

Watt highlights the importance of acknowledging that future actions to tackle inequalities in oral health may be very different from the strategies used previously.¹¹ He states that a social determinants approach to tackling oral health inequalities is essential and that reductions in oral health inequalities are more likely to be achieved by working in partnership across sectors and disciplines, through population-based public health measures.

Upstream approach

Thus health improvement, with associated reductions in health inequalities, requires a multifaceted approach. This involves implementing interventions at the structural (policy/regulation), community and individual levels, a methodology often referred to as the upstream/midstream/downstream approach.¹²

Reviews have shown that the upstream approach is likely to have a greater reach, effectiveness and cost-effectiveness, at a population level, than more downstream interventions. An example of this can be seen in relation to tobacco control, where pricing policies and clean air regulations have had a much more significant impact on reducing smoking attributable deaths than one-to-one or small group smoking cessation clinics.¹³ Health professionals, including those from dentistry, have been providing education and advice to the public on sugar control for many decades with very limited impact on levels of consumption. It is now recognized that more radical upstream approaches are also required to make a significant difference in this area.

The WHO advocates combining the strategy for child caries prevention with actions against childhood obesity and with breastfeeding initiatives.¹⁴ Other upstream and common risk factor approaches recommended include the implementation of comprehensive programmes that promote the intake of healthy foods and reduce the intake of sugar-sweetened beverages and foods. These include the introduction of sugar sweetened beverage (SSB) taxation policy, sugar product reformulation, school food policies and implementing recommendations on marketing of foods and unhealthy drinks to children. The SSB tax is to be welcomed − modelling work shows that it is likely to be effective in preventing childhood decay.^{15, 16}

Community-based midstream approach

In addition to upstream policies and regulations, there is good evidence that work at the community level can improve resilience, self-esteem, health behaviours and health. It is also recognized as a means of engaging the most vulnerable communities.^{17, 18, 19} Ensuring people from local communities, community/voluntary sector organizations and statutory services work together to co-produce, plan and deliver initiatives relevant to local circumstances is considered an overarching principle of good practice; and the more stages of the work people are involved in, the greater the benefits.²⁰ The importance of a ground-up approach is emphasized, ie working with, not doing things to, communities. Time and opportunities to build good working relationships amongst all stakeholders are required. This includes discussions relating to power, decision-making authority and responsibility.¹⁷

Examples of approaches include community-run food initiatives (‘co-operatives’) and opportunities to integrate oral health improvement into other voluntary programmes and action groups. Such programmes can also support families via the provision of skills and advice in a range of areas, such as parenting, resilience, welfare benefit and debt management, as well as providing a local social network of support. Community-based approaches can also involve integrating oral health into existing health services, such as ante-natal classes, breastfeeding initiatives and universal child development checks. These can be linked to community-based oral health workers. Free provision or sales of subsidized toothbrushes and toothpastes can take place through community clinics. Nurseries and schools also provide opportunities for oral health to be integrated into the curriculum as part of health and wellbeing plans. Initiatives include healthy food policies, daily supervised toothbrushing and fluoride varnish programmes.

Examples of ways of promoting child oral health via community action have been outlined in a toolkit for local authorities prepared by Public Health England,²¹ and those with existing or emerging evidence of effectiveness, and included in Childsmile, are summarized in Table 1.