Torbay Oral Health Framework 2025/30

Contents

• Foreword
• Our oral health framework             
• Framework development 
• What are we going to do? 
• Background
• Oral health, disease and quality of life 
• Organisation of dental services 
• Torbay Council’s role - policy context 
• Oral health in Torbay - where are we now?
• Impact of the COVID-19 pandemic 
• What works well for improving oral health: the evidence base 
• Challenges going forward
• Priority areas for Torbay and implementing our action plan 
  
  • Children and Young People 
  • Adults
  • Older Adults 
  • Vulnerable and high risk groups   
• Annex 1: Bibliography
• Annex 2: Action Plan     

Foreword

This framework has been created by Torbay Council and outlines our intent to improve the oral health of our population. It is informed and supported by a partnership action plan.

Good health is central to people’s happiness and wellbeing. Tooth decay is the most common oral disease affecting children and young people in England, and although preventable, a significant proportion of children and adults in Torbay still have tooth decay.

Oral health is an integral part of overall good health and wellbeing and allows people to eat, speak, smile, and show emotions. It also affects a person’s self-esteem, school performance and attendance at work or school. Torbay’s residents have different experiences of oral health with significant inequalities in oral health across the area.

We outline what oral health is like in Torbay and have set out plans for how it can be improved by further developing and building on evidence-based prevention work which may have been impacted by the Covid-19 pandemic. It is also important that we work together with our communities and partner organisations and strive to improve oral health for all residents through oral health promotion programmes with a particular focus on our residents who are most vulnerable to poor oral health.

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Our oral health framework

Our oral health framework will aim to improve the oral health of everyone living in Torbay. We will reduce oral health inequalities and create supportive environments by working with our communities and partner organisations to promote oral health and contribute towards maintaining good oral health throughout the life course.

We will work collaboratively with partner organisations and across services to integrate oral health considerations into policymaking and focusing on preventive interventions to improve the oral health of all communities.

Despite many positive changes to the landscape of oral health over the years, there is still more work to be done. Achieving twice-daily brushing, an excess of sugar in our food and drink, smoking and alcohol consumption remain difficult challenges to oral health. Many factors affect a person’s ability to care for their oral health, for example, poverty, isolation, poor mobility and poor physical or mental health. This framework looks at ways we can help to overcome some of the barriers to having good oral health and gives everybody the opportunity to access the information and support they need to improve their oral health.

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Framework development

• This framework was developed by working together with the multi-disciplinary Devon Integrated Care Board (ICB) Oral Health Steering Group with representatives from services and organisations who are interested in improving oral health for all residents of Devon. It included partners from NHS Commissioning, adults and health commissioning services, children and young people’s commissioning, education, local dentists, dental public health consultants and Torbay Healthwatch. This group will also share decision making over the period of the framework.
• It is based on what the data tells us about levels of dental disease within Torbay.
• It describes what works well to improve oral health. The preventive interventions included are based on evidence from national research.
• It focuses on adding to what is already being done. Oral health links to many existing programmes, for example, to best start in life with breastfeeding and weaning. Also, to healthy eating and to healthy food choices in schools. Therefore, we aim to link to existing programmes and promote and include oral health as part of these.
• It supports existing national and local strategies where there is a connection with oral health. For example, the Torbay Joint Health and Wellbeing strategy, ensuring that good oral health is seen as an integral part of good general health. We will ensure that oral health becomes embedded in all relevant Torbay strategies and frameworks.
• It outlines some of the challenges around dental services and the impact of the COVID-19 pandemic.
• It is designed for all residents of Torbay and for health and social care professionals working in the area.

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What are we going to do?

To achieve the ambitions of the framework, we have developed an action plan (see Annex) that reflects both local need and national NICE guidance and recommendations. It is also important that we work with our residents, recognising the individual strengths and assets of communities in different parts of Torbay. We will further develop the action plan by:

• Ensuring people living and working in Torbay and are provided with opportunities to play a role in the development of oral health promotion for themselves and their families.
• Empowering communities by listening to and acting on the feedback we gather.
• Reflecting on data, particularly about high-risk groups and develop services targeted towards these groups.
• Using existing information from research on what is good practice but also look at what works best locally. For example, working with early years settings, schools, residential homes and the homeless hostel to explore how interventions could be implemented.
• Guide service providers in how they can ensure their staff have the skills and knowledge required to improve oral health for service users.
• Build on existing assets within our communities. We will engage and work with community groups to ensure this. For example, linking with and supporting family hubs and the start for life programme.

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Background

Oral health is multifaceted and includes the ability to speak, smile, smell, taste, touch, chew, swallow, and convey a range of emotions through facial expressions with confidence and without pain, discomfort, and disease of the mouth, face or head (1). Oral health is a key indicator of overall health, well-being and quality of life. It encompasses a range of diseases and conditions that include dental caries (decay), periodontal (gum) disease, tooth loss, oral cancer, dental trauma, and birth defects such as cleft lip and palate.

Most oral diseases and conditions share modifiable risk factors with major long-term conditions and chronic diseases, including, cardiovascular diseases, cancer and diabetes. These risk factors include tobacco use, alcohol consumption and unhealthy diets high in sugar. There is a proven relationship between oral and general health. For example, diabetes is linked with the development and progression of gum disease (2). Moreover, there is a causal link between high consumption of sugars and diabetes, obesity and dental decay.

Tooth decay is the most common oral disease affecting children and young people in England, yet it is preventable.

The relationship between deprivation and poorer oral health is now well established. There is evidence for social gradients in the prevalence of dental decay, tooth loss, oral cancer, oral health related quality of life and service use (3). There are marked differences in dental decay experience of 5 year olds related to deprivation: in England in 2023 the prevalence of dental decay was 23.7% whilst in Torbay it was 21.3%, in both cases the level of decay is most severe in the more deprived communities. The COVID-19 pandemic is likely to have negatively impacted oral health and widened these oral health inequalities (4).

We also recognise that vulnerable groups, such as homeless people, those with learning disabilities and children in care are also more likely to suffer poor oral health and poorer access to dental services than the general population (4).

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Oral health, disease and quality of life

Good oral health contributes to overall health and wellbeing. Oral health is an important public health concern because oral diseases have a significant impact on society and individuals.

Poor oral health can lead to pain and discomfort, sleepless nights, loss of function and self-esteem, and in turn disrupt family life. It can also lead to time off work, either because a person is suffering pain or because they need to attend dental appointments or because their children are experiencing pain and they need to be taken to dental appointments. Consequently, children can miss time at school risking impacting on their educational attainment.

Experiencing tooth decay or having missing teeth or ill-fitting dentures can lead to an individual becoming socially isolated. Research has shown that such oral problems can negatively affect a person’s confidence and consequently their employment chances, including being promoted at work. The maintenance of oral health is a life skill that will have long term effects, not only on tooth decay but to a life free from disability (5). See Figure 1 which outlines how good or bad oral health effects quality of life (6).

Figure 1: Impacts of poor oral health

Good oral health contributes to overall health and wellbeing. Poor oral health can have negative impacts. These include:

• Time off work due to pain, attending dental appointments and accompanying children
• Pain and discomfort resulting in possible sleepless nights
• Disruption of family life
• Loss of function and self-esteem: cannot eat, smile or talk with confidence
• Ill-fitted dentures can be painful and affect an individuals ability to eat, talk and socialise
• Time off school due to toothache and attending dental appointments

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Diseases affecting the teeth, mouth and surrounding structures

There are a number of modifiable risk factors which can impact on oral health. These risk factors can cause diseases of the mouth, as described in the following sections and outlined in Figure 2 (6).

Figure 2: Risks of oral health

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Dental caries (tooth decay)

Dental caries is the most common non-communicable disease worldwide and, in the UK (7). Tooth decay is caused by having too much sugary food and drink and not cleaning teeth and gums properly. The disease is caused when sugars from our diet are broken down by micro-organisms in the plaque on a tooth surface, this produces acids that, over time, demineralise tooth enamel. When factors promoting demineralisation continue tooth decay progresses into dentine, the layer of tooth underneath the enamel, to a point where the tooth surface breaks down and cavities form.

Tooth decay can result in pain and will require dental treatment, severe tooth decay can require tooth removal. Dentists will always recommend restoring teeth wherever possible, however, once filled teeth will need ongoing maintenance throughout life. Therefore, preventing teeth from becoming decayed through regular toothbrushing with fluoride toothpaste and minimising the amount and frequency of consumption of sugar-containing foods and drinks is key.

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Periodontal disease

Periodontal diseases are the result of infections and inflammation of the gums and bone that surround and support the teeth. The mouth is full of bacteria; these bacteria, along with mucus and other particles, constantly form a sticky plaque on teeth. Periodontal disease is typically caused by poor brushing and flossing habits that allow the plaque to build up on the teeth and harden.

The first stage of the disease is called gingivitis; the gums can become swollen and red, and they may bleed. This can progress to a more serious form of the disease, called periodontitis, the supporting bone can be lost, the gums can shrink away from the teeth and as a result be teeth may loosen or even fall out. Periodontal disease is mostly seen in adults (7).

The number and types of treatment will vary, depending on the extent of the gum disease. Physical removal of plaque is the important element of toothbrushing for preventing or controlling periodontal diseases, therefore, self-care is important to maintain healthy gums and managing gingivitis. More advanced periodontal disease may require dental treatment alongside improved self-care.

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Oral cancer

Mouth cancer, also known as oral cancer, is where a tumour develops in a part of the mouth. It may be on the surface of the tongue, the inside of the cheeks, the roof of the mouth (palate), the lips or gums. Tumours can also develop in the glands that produce saliva, the tonsils at the back of the mouth, and the part of the throat connecting your mouth to your windpipe (pharynx). However, these are less common.

Factors which increase the risk of developing mouth cancer include smoking or using tobacco in other ways, such as chewing tobacco; drinking alcohol; and infection with the Human papillomavirus (HPV).

The latest figures show that 8,864 people in the UK were diagnosed with mouth cancer in 2023. The number of people in the UK getting mouth cancer has more than doubled (103%) in the last 20 years. The number of people in the UK getting mouth cancer has increased by more than a third (34%) in the last 10 years. Also, approximately 68% of mouth cancers diagnosed in the UK are in men (8).

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Organisation of dental services

Devon Integrated Care Board (ICB), supported by the NHSE Commissioning Hub, have direct commissioning responsibilities for primary dental and secondary dental care, for the population of Devon. Dental practices can offer both NHS and private dental care. NHS dental treatment has associated dental charges which will apply unless people are in an exempt group e.g. pregnancy, in receipt of certain benefits such as Income Support.

The NHS in England spends around £3.4 billion per year on primary and secondary care dental services (9). In 2018-19 the total funding for Primary care services alone was £292 million, of which £856 million were patient charges (9).                                    

Figure 3: Annual costs of dental care services

Specialised dental services are commonly provided by community dental services. Devon ICB also directly commissions this service. Community dental services are available in a variety of places to ensure everyone can have access to dental health.

People who may need community dental services include children with physical or learning disabilities or medical conditions, adults with complex needs.

In Torbay, these services are provided by Torbay Community Dental Service, which also includes an oral health promotion function. The service has specific criteria for referral of patients for assessment and treatment and it will be important for services caring for children and adults with specific dental needs that they are aware of the criteria and this referral pathway.  Service structure and pathways are available on the Torbay Community Dental Service website.

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Torbay Council’s Role - Policy Context

The Health and Social Care Act (2012) confers responsibilities on local authorities for health improvement, including oral health improvement for their residents. Local authorities are statutorily required to provide or commission oral health promotion programmes to improve the health of the local population, to the extent that they consider appropriate in their areas. They are also required to provide or commission oral health surveys to facilitate assessment and monitoring of oral health needs and the planning and evaluation of oral health promotion programmes and dental services.

There is guidance to help local authorities in providing their oral health function. In 2014 Public Health England published a toolkit to help local authorities fulfil their oral health responsibilities. NICE also have a quality standard relating to oral health promotion in the community and there is NICE Guidance, Oral Health Promotion in the Community, which covers improving oral health by developing and implementing a strategy that meets the needs of local people (10). This NICE Guidance contains 22 recommendations – as such it is the aim of this oral health promotion framework to address local need and meet these recommendations.

As well as NICE guidance, this framework also draws upon the Torbay Joint Strategic Needs Assessment and the Torbay Oral Health Needs Assessment completed in 2023.  Other policies including Commissioning Better Oral Health for Children and Young People, Delivering Better Oral Health and the PHE Oral Health Return on Investment Tool have also been used to develop this framework and action plan.

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Collaboration between the Integrated Care Board and Devon, Plymouth and Torbay Local Authorities

In June 2024, a new Devon Oral Health Steering Group was created as a collaboration of ICB commissioners, local authority oral health leads, dental public health consultants, Healthwatch, safeguarding teams, local authority Children’s  Services teams and wider stakeholders working together to make a long-term commitment to improve the oral health of everyone living in Devon.

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Links to other National and Local Strategies

Oral diseases share many risk factors with other chronic diseases. For example, excess sugar in the diet is risk factor for tooth decay and in obesity; alcohol is a risk factor in many cancers including oral cancer and smoking is the main cause of lung disease and periodontal (gum) disease. Therefore, this framework supports national strategies such as the Government Food Strategy 2022 and Smoke Free England ambitions. It also supports and is supported by Torbay strategies & programmes.

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Oral health in Torbay - where are we now?

Tooth decay in children

Tooth decay can start early in life – the national 2019 Oral Health Survey of 3 year olds found that 11% had visible tooth decay, with on average 3 teeth affected (11). Although oral health is improving in England, one of the most important data sets, the 2022 Oral Health Survey of 5 year olds shows nationally just under a quarter have tooth decay. Each child with tooth decay will have on average 3 to 4 teeth affected (12). There is regional variation in rates of tooth decay, inequalities and areas with greater need remain.

Several key indicators of oral health are monitored by the Office for Health Improvement and Disparities (OHID) and these provide a picture of oral health in Torbay. Figure 5 shows data from the national 2022 Oral Health Survey of 5 year olds where 21.3% in Torbay had obvious tooth decay (12). Though no further trend data is available at the time of writing this framework, this figure is lower than England average of 23.7% having seen a notable reduction from the last survey in 2018 where it was 28% and in 2012 when it was at its highest of 35.7%. The 2022 Torbay figure is higher than the Southwest average of 19.2% but lower than the highest figure in the region - Bristol at 27.2%.     

Figure 4: 2022 Oral Health Survey of 5 year olds

Source: Office for Health Improvement and Disparities, National Dental Epidemiology Programme

Tooth decay can start earlier than age 5, in fact as soon as first teeth start to appear in the mouth, they will be susceptible if the conditions promote decay, for example, residing in an area of health inequality and the associated prevalence of  poor nutrition, including higher levels of sugar intake. The national 2019 Oral Health Survey of 3 year olds, see Figure 6, shows a mean value for decayed, missing or filled teeth for 3 year olds in Torbay of .56 (11). This figure is significantly higher than the England mean value of .31 and remains consistent with the last Torbay survey in 2013 where the mean value was .58. The 2019 Torbay figure is higher than the Southwest average of .31 and equal highest value in the region with Bristol. These statistics reinforce the need for early intervention to give children the best start in life.

Figure 5: 2019 Oral Health Survey of 3 year olds

Source: Dental Public Health Epidemiology Programme for England: oral health survey of three-year-old children 2020

There is less data available for older children. The National Children’s Dental Health Survey has been carried out every 10 years since 1973. It includes data on children aged 5, 8, 12 and 15 years, and reports on a dental examination and questionnaires for parents and 12 and 15 year olds. The last survey took place in 2013. In 2013, a half (46%) of 15 year olds and a third (34%) of 12 year olds had “obvious decay experience” in their permanent teeth (13). This was a reduction from 2003, when the comparable figures were 56% and 43%, respectively.

A new survey, the Oral Health Survey of Children in Year 6 (aged 10-11 years) was carried out for the first time in 2023.  This survey shows that across England, 16% of Year 6 children who participated in the survey had visible tooth decay in their permanent teeth (14). Also that 3% of Year 6 children reported having had pain in their teeth or mouths often or very often and that Year 6 children living in the most deprived areas of the country were more than twice as likely to have experience of tooth decay (23%) as those living in the least deprived areas (10%).  In the South West as a whole, the percentage of Year 6 children examined with experience of dental decay in their permanent teeth was 12.1%.  Across the region, at higher tier local authority level, the percentage of children examined with experience of dental decay ranges from 3.4% in Bath and North East Somerset to 26.3% in Cornwall. The Torbay value was 11.2%, slightly above the Southwest average (14).

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Hospital admissions for tooth removal

The extraction of carious teeth has become the most common reason for hospital admission of under-18-year-olds in England.

Tooth removal in hospital is usually provided under general anaesthetic. Despite an overall improvement in recent years, the available evidence indicates that oral health improvement programmes implemented at primary care level have not improved the oral health of children in a number of clearly defined local areas, mostly in northern England. Young children in these areas are now three times more likely than children in other parts of the country to be referred to hospital for tooth removal.

Hospitals have faced unprecedented pressure due to the COVID-19 pandemic, increasing the burden on NHS services and resulting in long waiting lists for treatments, including tooth removal. Figure 7 shows that for the period 2022/23 Torbay’s hospital admissions rate for tooth decay requiring tooth removal for 0-5 year olds was 561.7 per 100,000. This is over three times the England and Southwest values and remains the statistic of greatest concern for Torbay (15). These children are receiving a general anaesthetic, which has inherent risks, for what is a preventable disease. At the same time, we must ensure that all children requiring this treatment are receiving the dental care they need.

Though it must be noted that the 6.8% increase from 21-22 is a lower % increase than England (15%) and the Southwest (10%). The direction of travel is improving but there is still much work to be done. Further analysis of the Torbay survey data shows 165 extractions in total during the period: 0-4 years 20 / 5-9 years: 105 / 10-14 years: 30 and 15-19 suppressed due to low numbers (15). The extraction levels in the 1-9 age group show the importance for oral health promotion activity in early years and through primary school.

Figure 6: Hospital admissions for dental caries (0-5 years) 2020/21-2022/23

Source: OHID, based on NHS England for Office for National Statistics data

Figure 7: Hospital admissions for dental caries (0-5 years) trends, 2015/16 - 2022/23

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Dental diseases among adults and older people

The National Dental Epidemiology Programme 2017/18 Oral Health Survey of Adults attending general dental practices in England found that in Torbay 29.2% of participants had untreated tooth decay with each having on average 1.5 decayed teeth. Most participants (70.8%) had ‘functional dentitions’ (comprising 21 or more natural teeth), The large majority of participants (92.3%) had at least one filling and 60% had bleeding on probing their gums, a sign of periodontal (gum) disease. Overall, 87.7% of the sample in Torbay had a treatment need (16). Figure 9 shows data for England with comparative levels of untreated tooth decay but a higher level of treatment need.

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Mouth cancer

Around 8,300 people are diagnosed with mouth cancer each year in the UK, which is about 1 in every 50 cancers diagnosed. More than 2 in 3 cases of mouth cancer develop in adults over the age of 55.

The reasons behind mouth cancer are numerous – including tobacco use, alcohol consumption, certain strains of Human Papillomavirus (HPV), having a weakened immune system and poor diet, lacking essential nutrients found in fruit and vegetables.

Figure 10 shows mouth cancer registrations for Torbay for the period 2017-19 were 17.9 per 100,000 - this is higher than the value for England (15.4) and the Southwest (15.6). Torbay also has the second highest rate of registrations behind only Plymouth at 19.1 (15). 

Figure 11 shows the trend data for mouth cancer registrations from 2007-2019. There has been a steady increase in registrations from 59 in 2007-09 to 84 in 2017-19 (15).

Late diagnosis, a lack of awareness of the symptoms, access to healthcare (including the impact of reduced NHS dentistry since the COVID-19 pandemic) and socio-economic factors have all likely contributed to the increase in mouth cancer registrations. 

Figure 9: Oral cancer registrations 2017-19

Source: OHID, based on NHS England and Office for National Statistics data

Figure 10: Oral cancer registrations trend data 2007-2019

As well as the steady increase in mouth cancer registrations, Torbay has also seen a notable increase in the mortality rate from mouth cancer.  We also have much more up to date data. Figure 12 shows that for the period 2020-22 Torbay’s mortality rate was 6.3 per 100,000 - this is higher than the value for England (5.2) and the Southwest (4.7). Torbay also has the third highest mortality rate behind Plymouth and Bristol joint at 6.5 (15). 

Figure 13 shows the trend data for mouth cancer mortality from 2008-2022. There has been a steady increase in mortality from 16 in 2008-10 to 34 in 2020-22 (15).

Figure 11: Oral cancer mortality 2020-22

Source: OHID, based on Office for National Statistics data

Figure 12: Oral cancer mortality trend data 2008-2022

It is difficult to gather information on the oral health of our more vulnerable older adults. The Quality Care Commission (CQC) reviewed the state of oral health care in care homes across England in 2019 and found that improvements were needed to maintain good oral health for older people in care homes (16). The report made several recommendations including the need to implement NICE guidelines, training for staff, assessment and daily mouth care for residents and better documentation and record keeping of oral health care delivered.

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Access to dental services in Torbay

The Dental Statistics Report 2023/24 includes information on the number of patients seen by an NHS dentist, as well as NHS dental activity presented down to dental contract level. It also includes data on clinical treatments, orthodontic activity, patient eligibility and charges, and dental workforce (17).

In England in 2023/24:

• there were 34 million courses of dental treatment delivered, 4.3% more than 2022/23
• there were 18 million adult patients seen in the 24 months up to the end of March 2024
• total units of dental activity increased by 3.4% from 2022/23, up to 73 million
• there were 6.6 million child patients seen in the 12 months up to the end of March 2024
• 31% of adult courses of treatment included scale and polish
• 56% of courses of treatment for children included fluoride varnish clinical treatment
• there were 24,200 dentists who performed NHS dental activity

The report also shows the percentage of adults who are NOT obtaining an NHS dental appointment in the last 24 months up to 31 March 2024 in Torbay was 66.7% (England value 59.7%) and for children it was 46.4% (England value 43.9%) (17). However, these figures need to be interpreted with some caution. They are taken from the GP survey where approximately 2.5 million surveys are sent out each year and the response rate is typically around 30 - 35 per cent.

Supporting data sources regarding dental access for vulnerable groups are limited, but we do have a clear picture of the % of children in care who have had their teeth checked since November 2023. The figure for Torbay stands at 52% against an England value of 79% (18).

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Impact of the COVID-19 pandemic

Inequalities in oral health are evident in the UK across the social spectrum and across the life course reflecting the socioeconomic inequalities that impact on general health. The COVID-19 pandemic is likely to have widened these inequalities as well as having a direct impact on dental care provision. Health behaviours, which also impact on oral health, such as smoking and alcohol consumption have increased during the lockdown periods associated with the pandemic (19).

During the first COVID-19 lockdown period in England all routine and non-urgent dental care stopped as practices were unable to operate safely. Resumption of services was gradual and slow as dental practices had to adapt to a new way of working with increased Personal Protective Equipment PPE and cross infection control procedures. Once NHS dental services were restored, uptake of care happened more quickly for adults than children. During the lockdown period secondary dental care was also affected as general anaesthetic tooth extraction lists in hospitals were either postponed or cancelled (19).

There may also be an impact on oral cancer rates. Routine dental examinations allow for screening of the mouth for early signs of oral cancer, however, during the pandemic there were also decreases in routine examinations and in urgent referrals for suspected oral cancer (20).

Many prevention schemes e.g. supervised toothbrushing were also halted during the lockdowns when schools and early years settings were closed. The suspension of these programmes and their slow re-establishment is likely to have negatively impacted the oral health of children (21).

The British Dental Association reported in December 2021 that 1000 dentists left the NHS in the previous year and that over half of dentists they surveyed stated they are likely to reduce their NHS commitment, putting further pressure on the NHS dental system and making it more difficult for patients to get an appointment (22).

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What works well for improving oral health – the evidence base

A number of community-based interventions are available to consider, however, we must ensure that any interventions put in place have robust evidence to understand their efficacy.

Water fluoridation

At a population level, water fluoridation is the most effective way of reducing inequalities, as it ensures that people in the most deprived areas receive fluoridated water and it does not require any behaviour change among the population. Public Health England, and now OHID, monitor the effects of water fluoridation schemes on the health of people living in the areas covered by these arrangements and reports its findings every four years. The findings of the 2022 health monitoring report are consistent with the view that water fluoridation at levels within the UK regulatory limit (<1.5mg/l) is an effective, safe, and equitable public health intervention to reduce the prevalence, severity, and consequences of dental decay. It reported strong statistical evidence for a clinically significant reduction in dental caries, indicated by prevalence, severity, and hospital admissions for extraction, with increasing fluoride concentration. The greatest benefit was seen in the most deprived areas, supporting previous conclusions that drinking water fluoridation is an effective public health intervention for tackling dental health inequalities (23).

According to Delivering Better Oral Health (an evidence-based toolkit which provides interventions and advice on how local authorities can improve and maintain good oral health) water fluoridation should form part of any overall oral health strategy as a potential intervention which should run alongside others such as a fluoride varnish application (24).

It must be noted Torbay Council, despite the low occurring levels of natural fluoride concentration across Devon (see Figure 14), cannot undertake direct action to improve levels in conjunction with the local water supplier as the Health and Care Act 2022 amended the Water Industry Act moving the responsibility for water fluoridation from local authorities to central government.  This change in responsibility may well see a  roll out of water fluoridation on a national basis, though which areas come first remains to be seen. There will need to be consultation process at public local authority and water provider level - as such any establishment of water fluoridation will be a long term process.

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Toothbrushing with fluoride toothpaste

We know that good oral hygiene, including toothbrushing with a fluoride toothpaste is the main way people can improve and maintain good oral health. Reviews of multiple research studies, show that the daily application of fluoride toothpaste to teeth reduces the incidence and severity of tooth decay in children (24). However, children in more deprived areas are less likely to brush their teeth at least twice daily (24).

Targeted childhood settings such as nursery and school settings can provide a suitable supportive environment for children to take part in a supervised toothbrushing programme, teaching them to brush their teeth from a young age and encourage support for home brushing. The evidence tells us that to maximise caries prevention children aged 3 to 6 years should brush their teeth at least twice, supervised by a parent or carer. This should be last thing at night (or before bedtime) and on at least one other occasion. The toothpaste should contain at least 1,000 ppm fluoride, only using a pea-sized amount and spitting out after brushing rather than rinsing, to avoid diluting the fluoride concentration. With children under 3, the evidence for toothpaste 500 to 1,000 ppm F is inconclusive, therefore a toothpaste containing at least 1,000 ppm fluoride should also be used but only a smear (24).

At a population, school or early years’ level, the evidence tells us that brushing each day at school over a two-year period is effective for preventing tooth decay and can establish life-long behaviour to promote oral health (10). It is also important that school based toothbrushing activity should promote and support toothbrushing in the home as well as the school or early years setting (10).

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Fluoride varnish schemes

Fluoride varnish is a highly concentrated form of fluoride that is applied directly to the tooth surface by a dental professional. It is a resin-based product that adheres to the enamel and releases fluoride over time. This controlled release enhances its effectiveness in preventing and even reversing early tooth decay.

Fluoride varnish has emerged as a key preventive measure in the fight against dental decay. Its widespread adoption is a testament to its effectiveness in promoting oral health, especially among vulnerable populations like children and individuals at high risk of dental caries. Fluoride works by interacting with the enamel (the outermost layer of the tooth) to enhance its resistance to acid attacks from bacteria in the mouth.

Figure 14 shows the returns on investment for various oral health improvements schemes and has been used to help inform action within Torbay at ICB level.  

Figure 14: Return on investment of oral health improvement schemes

Reviews of clinical effectiveness by NICE (PH55) and PHE (commissioning Better Oral Health for Children and Young People, 2014) have found the following programmes effectively reduced tooth decay in 5 year olds:

* All targeted programmes modelled on population decayed, missing or filled teeth, (dmft) index of 2, and universal programme on dmft for England of 0.8. The modelling has used the PHE Returns on Investment Tool for oral health interventions (PHER, 2006). The best available evidence has been used in this tool and where assumptions are made these have been clearly stated. PHE Publications gateway number: 2016321. @ Crown copyright 2016.

Regular dental attendance

It is recommended that children start to see a dentist as soon as their first tooth appears (25). NHS dental treatment for children is free, however, not all dentists will take on new NHS patients. There is essential oral hygiene and dietary advice that should be followed from an early age and this is important to instil good habits early, therefore, it is essential that there are opportunities for families to access this advice and guidance. There are some interventions which can only be provided by a dental professional for those at higher risk of dental decay e.g. fluoride varnish applications and fissure sealants (24).

There is also evidence for adults to have their mouths checked at regular intervals, not only to assess dental decay, but also to review any existing fillings or crowns and to screen the soft tissues of the mouth for early signs of oral cancer. The interval between check-ups can vary depending on the health of the mouth (19). We acknowledge that in promoting good oral health, with early identification of dental diseases we could potentially drive up demand for NHS dental services. This could be difficult for some residents where access is limited, however, we will continue to monitor the situation and will raise any concerns with NHS England and Healthwatch.

With our current reduced NHS dental capacity, dental care is becoming increasingly difficult to access and as a result, health inequality gaps are widening.

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Development and intervention by the wider workforce

Implementing a Making Every Contact Count (MECC) approach can give professionals an opportunity to provide brief advice to improve overall health and wellbeing. This can be supported through training and development to deliver appropriate evidence informed brief advice across the life course. Oral health messages can be included in current commissioned programmes such as the Public Health 0-19 Integrated Children’s Service, where health visitors can deliver advice on breastfeeding being beneficial to oral health along with general healthy eating messages and advice on oral hygiene. Current evidence suggests that breastfeeding up to 12-months of age is associated with a decreased risk of tooth decay (26).

Other examples would include in schools, where teachers or school nurses could be supported to provide oral health session as part of the Personal, Social, Health and Economic (PSHE) curriculum and the dedicated oral health content with Torbay Healthy Learning – our local healthy schools offer targeted to whole school teams.

Working together to safeguard children is everyone’s responsibility. Dental neglect is an important child protection issue. Signs include visible tooth decay, untreated trauma and multiple hospital admissions for dental care. All staff across healthcare, social care and education should have sufficient knowledge and understanding to recognise signs of poor oral health and neglect and take appropriate action.

We will work with partners to develop and offer a range of training packages to tackle these issues and enable staff to deliver oral health advice to residents of all ages across Torbay.

The importance of providing timely, opportunistic provision through trusted agencies in contact with populations must likley to benefit from intervention cannot be understated.   A good example is providing oral health guidance, toothbrushes and suitable fluoride toothpaste by health visitors at the regular child development checks as part of their programme of care. This is also true in regard to the wider workforce via appropriate settings such as Family Hubs.  They can also be provided by post to children in targeted areas.

Timely provision of oral health resources encourages parents to adopt good oral health practices and start toothbrushing as soon as the first teeth erupt. It is important to consider sustainability, as there may be limited benefit of one-off provision. Where health visitors are delivering oral health messages and distributing oral health packs it is important to ensure adequate training and consistency of messages. This method has been used in parts of the UK, as part of a wider approach, and was found to decrease decay prevalence in 3 and 5 year olds (27).

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Challenges going forward

The impact of COVID-19 has been felt more severely by those who were already more likely to have poorer health outcomes, including people from ethnic minority backgrounds, people with disabilities and those living in more deprived areas.

Many community based interventions were suspended during lockdown and it is taking time to re-establish these, particularly as there are so many competing priorities whilst recovering from the impact of the pandemic.

Access to dental services has been severely impacted by COVID-19 and the first national lockdown in the UK. It is likely to take some time to deal with the backlog of patients in need of oral treatment and care due to reduced capacity in the system.

The COVID-19 pandemic is causing a range of issues that are leading to greater uncertainty among dental professionals.  This uncertainty is leading to greater anxiety and stress amongst dental professionals, which could lead to more people leaving the profession and further strains on the system (21).

The Health and Care Act (2022) has seen the formation of Integrated Care Systems (ICS) across England on a statutory basis from 1 July 2022. The aims of this new way of more integrated working and operating will be to improve outcomes in population health and healthcare, tackle inequalities in outcomes, experience and access, enhance productivity, value for money, and help the NHS support broader social and economic development. How this will affect NHS dental practice remains unclear at this stage, however, the vital role dentists play in preventive health and wellbeing should be highlighted.

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Priority areas for Torbay and implementing our action plan

In order to improve oral health a whole systems approach is needed - partnership working with local services is vital to be able to support residents with their oral health through all stages of life. Working with partner organisations is also key to improving and maintaining oral health for our more vulnerable groups.

Torbay Council, in conjunction with the Devon Oral Health Steering Group, has identified several priority areas for delivery within this 5 year framework. These reflect the strategic direction outlined in the framework, including national best practice, the latest evidence based interventions and what the available data tells us. The priority areas are:

• Children and young people
• Adults
• Older adults
• Vulnerable and high risk groups

Priority area information includes key programmes for delivery, target groups and an overview of actions. High level summary included below (Figure 15).  Further detail, including additional actions, dates, milestones, key performance indicators and partners are included under Annex 2: Torbay Action Plan 2025-30.

Priority Areas

• Children and Young People
• Key Target Groups
  • Children in care, SEND, Young carers
  • Adults incl. Vulnerable and high risk groups
  • Older Adults

Key Programmes

• Children and Young people
  • Supervised Toothbrushing
• First Dental Steps
  • Fluoride Varnishing
  • Open Wide Step Inside
  • Torbay Level extraction under GA report
• Adults
  • Mouth cancer screening
  • MECC
  • Improved oral health & dental access pathways
• Older Adults
  • MECC
  • Survey of needs in care homes

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1. Children and Young People

Torbay has advocated for the re-investment of NHS Dental contract underspend (funds not utilised due to the declining take-up of the core NHS dental contract) to fund mitigating life course oral health promotion activity in our area. Devon ICB has agreed to commit £900k per annum, for 3 years, (total £2.7m) to provide support to further cohorts of children for supervised toothbrushing, fluoride varnish and a further schools-based intervention to go live on a phased approach over 2025-26.

Our primary focus will be on improving the oral health of children and young people living in Torbay. Implementing and expanding evidence-based oral health improvement programmes in schools and nurseries will be vital for ensuring that every child has the best start in life and to lay the foundations for future good oral health. These improvement programmes will be a mixture of universal programmes to address oral health needs of all children and targeted offers to areas of higher deprivation to address the needs of those at high risk of poor oral health.

Getting a good start in life and throughout childhood, building resilience and getting maximum benefit from education are important markers for good health and wellbeing throughout life. The objective of giving children the best start in life as highlighted by Marmot (28) remains key. Data for Torbay has shown that in some areas children as young as 3 years old have already developed tooth decay and just over a fifth of 5 year olds had tooth decay (11,12).

Marmot also described proportionate universalism, which is the resourcing and delivering of universal services at a scale and intensity proportionate to the degree of need. Services are therefore universally available, not only for the most disadvantaged, and are able to respond to the level of presenting need (28). This is particularly relevant when considering community water fluoridation, which would benefit all children, and it therefore remains a priority.

However, other targeted interventions will also continue to be part of this framework, for example, supervised tooth brushing and fluoride varnish schemes in early years settings. Tackling this level of tooth decay remains a priority to improve wellbeing among children and to reduce the number of children requiring clinical treatments, tooth removal under general anaesthetic and follow on orthodontics.

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Key programmes for delivery

Supervised toothbrushing

Programmes are currently underway to give children time and supervision to brush their own teeth at nursery and reception class in primary schools and nurseries in Torbay wards in Indices of Multiple Deprivation areas 1-6 (1 being most deprived) making brushing part of children’s everyday routine and helping to protect their teeth from decay.   Dental professionals employed by Home Dental visit primary schools and nurseries within IMD 1-6 to implement the programme. NHS Devon is working with the Local Authorities across Devon to invest in further cohorts of children within IMD 7-10 for extended delivery of supervised toothbrushing in 2025.

100% of schools in Torbay have signed up for supervised toothbrushing. The position of Devon, Plymouth and Torbay schools is outlined below.

First dental steps

NHS Devon is delivering an oral health improvement programme called First Dental Steps, in partnership with Torbay Council where health visitors and midwives are trained to give oral health care advice to families with children under two and have oral health care packs (toothbrushes and toothpaste) to give to families in need.  Torbay Families engaged in the programme also benefit from a referral through to This work is being undertaken in partnership with local authorities and will continue in 2025.

Fluoride varnish

Utilising the funding made available from NHS Devon, Torbay Council will scope and establish a fluoride varnish scheme to start early in 2026.  This scheme will cover all Year 2 children in primary schools in IMD areas 1-6.  The model and scope of delivery will depend on national guidance due out early in 2025.  

Open wide step inside

Open Wide Step Wide step inside is an animation, classroom based 45 min oral health promotion programme for primary school children with follow on resources for the home. Delivered to all Torbay primary schools in IMD 1-6 by the Dental Outreach Team at Peninsula Dental Social Enterprise last academic year, Open Wide Step Inside will continue in Plymouth and Torbay in 2024/25 as well as being extended to the whole county.  Alongside supervised toothbrushing and fluoride varnishing, this programme will be funded by the NHS Dental contract underspend.

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Target groups

Children in care

This particularly vulnerable group of children may have high dental needs. Oral health questions are included in the initial and review assessments for this group and they usually attend primary care dental practices to receive treatment (18). Children may live with foster carers or sometimes in a residential home. It is important that we ensure staff and foster carers are able to promote oral health, support children with their daily mouth care and recognise signs of neglect (18). Equipping children and young people with oral health knowledge and embedding good oral hygiene practices and habits will benefit them throughout life (18).

In 2024 the % of children in care who had their teeth checked was 52% against an England value of 79% (18).

• Following an expressions of interest process, NHS Devon have awarded two providers the new Children Looked After Dental Service.
• This service is a specialised dental care initiative designed to provide high-quality, clinically effective dental care for children and adolescents (aged 0-18, including unaccompanied asylum-seeking children) who are new to the care system or who have not seen a dentist in over 24 months. The service covers children under the care of all three local authorities in Devon.
• Two providers, located in Ilfracombe and Plymouth, are commissioned to deliver this service on a sessional basis until March 2025 while NHS Devon agrees longer term commissioning arrangements.
• Torbay Council will work with NHS Devon address barriers to Children in care attending the two out of area provider sites.

Children with special educational needs and disabilities (SEND)

There are two dedicated special needs schools in Torbay as well as many pupils with special needs attending regular state schools. The needs of this group can vary, some may have social, emotional and mental health needs, whilst others may have more sensory needs. These sensory issues may prevent children and young people from accessing mainstream dental services and impacting on oral hygiene.

Evidence from the National Oral Health Surveys of five-year-old children attending special support schools found that there was greater polarisation of dental decay among children attending special support schools than is typically seen among mainstream educated children. Put simply, fewer children have experience of decay, but those who have tend to have decay more severely, with more teeth affected than mainstream educated children (12).

• We recognise the needs of parents and carers and we aim to support them through providing the correct information and guidance to ensure they can support and improve their children’s oral health. This includes awareness and uptake of the specialist dental service for vulnerable children and adults provided by Torbay Community Dental Service at Castle Circus Health Centre.
• Ensure supervised tooth brushing schemes also reflect and consider the needs of children with special educational needs and disabilities.
• We will support SEND schools in providing oral health information, guidance and support through Torbay Healthy Learning.

Young carers

Young carers are children and young people under 18 years providing unpaid care to a family member. They often have a unique set of health needs that requires holistic support. It is important to provide them with resources and support to manage their physical and mental health, the former including good oral health, so they can lead healthy and fulfilling lives (29).

• We will include health professionals working with young carers within the Making Every Contact Count (MECC) approach to increase opportunities to provide brief advice.
• We will work with Home Dental, the supervised toothbrushing scheme provider in Devon, to ascertain whether young carers can be included in the service.

Children and Young People - further initiatives

• Scope the potential to disaggregate the oral health promotion funding of Community Dentistry Teams in Devon to potentially fund a Devon wide Oral Health Promotion Team to promote oral health throughout the lifecourse based on the outreach model currently being delivered in One Cornwall.
• Through the Devon Oral Health Steering Group, scope the establishment of a Devon wide tooth extraction under general anaesthetic report. Based on the current Plymouth model this provide a clearer picture of where there are higher levels of tooth extraction within Torbay and allow for the better targeting of oral health promotion interventions.
• Extend supervised toothbrushing activity via the NHS contract to include Family Hubs and children in care.    
• Continue to support breastfeeding – breastfed babies up to the age of one are less likely to have tooth decay. Whilst we advocate breastfeeding, we will also actively support all families who choose to formula feed their children and ensure they are provided with the best oral health advise to ensure good oral health for their babies.
• Support our Public Health Nursing Teams to deliver key oral health messages to families. We will ensure all information is delivered in easy to understand formats.
• Support Family Hubs in embedding oral health in the services they provide
• We will engage with groups who support children with learning disabilities to ensure they receive specialised oral health advice

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2. Adults

Routine dental check-ups alongside oral health promotion activity are the cornerstones for adults. Regular check-ups aim to detect the early signs of dental disease, including tooth decay and gum disease, and they also including screening of the mouth for early signs of oral cancer. NICE recommends the interval between oral health reviews should be determined specifically for each patient and tailored to meet individual needs, on the basis of an assessment of disease levels and risk of or from dental disease. It recommends that the shortest interval between check-ups should be 3 months and the longest is 2 years; based on individual risk assessment (25).

Dental access as discussed earlier can be an issue and has been impacted by the COVID-19 pandemic. There are a number of risk factors, including diet, oral hygiene, smoking, alcohol, stress and trauma, which are the same as for many chronic conditions, such as cancer, diabetes and heart disease. As a result, interventions that aim to tackle these risk factors, taking a ‘common risk factor approach,’ will improve general health as well as oral health (10).

• We will work with system partners to increase levels of mouth cancer screening both through NHS dentistry and outreach primary prevention models.
• We will work with partners e.g. OHID to fully understand data on access, which will allow interventions to be targeted to areas with reduced primary dental care availability.
• Scope the potential to disaggregate the oral health promotion funding of Community Dentistry Teams in Devon to potentially fund a Devon wide Oral Health Promotion Team to promote oral health throughout the lifecourse based on the outreach model currently being delivered in One Cornwall.  

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3. Older Adults

Along with dental caries, there are several other oral diseases and functional problems that are more common in older adults: periodontal disease, oral cancer, and tooth loss. Long term conditions such as arthritis and dementia can impact on a person’s ability to maintain their oral health. This can be compounded by medications, which often cause dry mouth and the lack of saliva promotes conditions for tooth decay to occur (30).

Older people in care homes are particularly at risk of poor oral health, therefore, we will focus on people in residential homes.

• We will work with residential homes to ensure staff have the knowledge and skills they need to support residents with their oral health and deliver care in line with NICE Guidance 48 Oral Health for Adults in Care Homes.
• Although NHS England commissions clinical domiciliary dental care, we will work with carers providing care for older people living more independently, to ensure they have the knowledge and skills to support older people with their oral health
• Support the development and roll out of the upcoming Epidemiological Survey for Care Homes. This survey, the first of its kind for adults will provide an evidence base for future work with this age group. Findings due for release early 2026.
• Scope the potential to disaggregate the oral health promotion funding of Community Dentistry Teams in Devon to potentially fund a Devon wide Oral Health Promotion Team to promote oral health throughout the lifecourse based on the outreach model currently being delivered in One Cornwall.

4. Vulnerable and high risk groups

People using Drug and Alcohol services

People who have a history of substance use problems are more likely to have poorer oral and dental health. This has been linked to a variety of potential contributory factors: smoking and tobacco use, dry mouth due to drug use and lifestyle factors e.g. poor diet often high in sugar, poor personal hygiene, less likely to attend dental appointments. The use of tobacco and alcohol is associated with increased risk of oral cancers (31).

• Opportunities to engage with this group will be explored to ensure any interventions are acceptable to both service users and service providers.

Homelessness and other inclusion groups

People with experience of homelessness or from other inclusion groups such as those accessing experiencing domestic abuse commonly suffer from poor general health (including oral health) and are likely to have low-level engagement with health and dental services.  They may not have access to toothbrushes or toothpaste or facilities where they can clean their teeth (32). Prioritising shelter, food, financial, health and social issues are likely to be above oral health, however, we recognise that this group may have specific oral health care needs.

• We will work with key partners to identify a pathway of oral health promotion and dental access for identified inclusion groups including those who are homeless or rough sleeping.

Adults with a learning disability

The evidence shows that people with learning disabilities have poorer oral health and more problems in accessing dental services than people in the general population (31). People with learning disabilities may need additional help with their oral care and support to get good dental treatment because of cognitive, physical and behavioural factors. Families, carers and staff who provide support to people with learning disabilities may require oral health training and information (33).

• We will work through the Devon Oral Health Steering Group to identify best practice and pathways for those with learning disabilities to develop tailored oral health guidance to meet their needs.

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Annex 1: Bibliography

1. M. Glick et al (2016), A new definition for oral health developed by the FDI World Dental Federation opens the door to a universal definition of oral health. BDJ: Vol 221 No 12
2. Casanova et al (2014), Diabetes and periodontal disease. A two way relationship BDJ Vol 217
3. PHE (2021), Inequalities in oral health in England: summary
4. Stennett and Tsakos (2022), The impact of the COVID-19 pandemic on oral health inequalities and access to oral healthcare in England. British Dental Journal volume 232, pages109–114 (2022)
5. OHID (2022), Adult oral health: applying All Our Health
6. Durham County Council (2023), Oral Health Promotion Strategy.
7. World Health Organisation (2017), Sugars and dental caries
8. Oral Health Foundation (2024), State of Mouth Cancer – UK Report
9. National Audit Office (2020), Dentistry in England
10. NICE (2016) Oral health promotion in the community
11. OHID (2019), Epidemiological Survey of Oral Health in 3-year-olds
12. OHID (2022), Epidemiological Survey of Oral Health in 5-year-olds
13. Health and Social Care Information Centre (2013), National Children’s Dental Health (CDH) Survey
14. OHID (2023), Epidemiological Survey of Oral Health in Year 6
15. OHID (2024), NHS England Hospital Episode Statistics (HES)/Office for National Statistics
16. CQC (2019), Smiling matters, oral health care in care homes
17. NHS (2022-23), Dental Statistics for England
18. DfE (2023), Children looked after in England, including adoption
19. PHE (2018), National Dental Epidemiology Programme for England Oral health survey of adults attending general dental practices
20. Arora and Grey (2020), Health behaviour changes during COVID-19 and the potential consequences: A mini-review. Journal of Health Psychology 2020, Vol. 25(9) 1155–1163
21. Stennett and Tsakos (2022), The impact of the COVID-19 pandemic on oral health inequalities and access to oral healthcare in England. British Dental Journal volume 232, pages109–114 (2022)
22. British Dental Association (2023), BDA News Centre
23. OHID (2022): Water fluoridation health monitoring report for England
24. OHID (2021), Delivering better oral health: an evidence-based toolkit for prevention
25. NICE (2004) CG 19 Dental checks: intervals between oral health reviews
26. PHE (2019), Breastfeeding and Dental Health
27. Rogers, J. G. (2011), Evidence-based oral health promotion resource. Prevention and Population Health Branch, Government of Victoria, Department of Health, Melbourne.
28. Marmot (2010), Fair society, healthy lives
29. Action for Children (2023), Young carers, who are they and why do they need support?
30. Mac Giolla Phadraig et al (2014), National levels of reported difficulty in tooth and denture cleaning among an ageing population with intellectual disabilities. Journal of Dentistry and Oral Health
31. DoH (2017), Drug misuse and dependence UK guidelines on clinical management
32. Paisi et al, British Dental Journal (2019), ‘Teeth Matter’: engaging people experiencing homelessness with oral health promotion efforts: https://www.nature.com/articles/s41415-019-0572-4
33. Wilson NJ, Lin Z, Villarosa A, George A. (2018), Oral health status and reported oral health problems in people with intellectual disability: A literature review, Journal of Intellectual & Developmental Disability
    

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Annex 2: Action Plan

Read the oral health framework action plan.

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