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Oral health improvement for local authorities and their partners

About

What is covered

This interactive flowchart covers local authority strategies to improve oral health particularly among vulnerable groups. It is for local authorities, health and wellbeing boards, commissioners, directors of public health, consultants in dental pubic health and frontline practitioners working more generally in health, social care and education. The recommendations include undertaking oral health needs assessments; developing a local strategy on oral health and delivering community-based interventions and activities to:
  • promote and protect oral health by improving diet and reducing consumption of sugary food and drinks, alcohol and tobacco (and so improve general health too)
  • improve oral hygiene
  • increase the availability of fluoride (excluding water fluoridation)
  • encourage people to go to the dentist regularly
  • increase access to dental services.

Updates

Updates to this interactive flowchart

14 December 2016 Oral health promotion in the community (NICE quality standard 139) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on oral health improvement strategies for local authorities and their partners in an interactive flowchart

What is covered

This interactive flowchart covers local authority strategies to improve oral health particularly among vulnerable groups. It is for local authorities, health and wellbeing boards, commissioners, directors of public health, consultants in dental pubic health and frontline practitioners working more generally in health, social care and education. The recommendations include undertaking oral health needs assessments; developing a local strategy on oral health and delivering community-based interventions and activities to:
  • promote and protect oral health by improving diet and reducing consumption of sugary food and drinks, alcohol and tobacco (and so improve general health too)
  • improve oral hygiene
  • increase the availability of fluoride (excluding water fluoridation)
  • encourage people to go to the dentist regularly
  • increase access to dental services.

Updates

Updates to this interactive flowchart

14 December 2016 Oral health promotion in the community (NICE quality standard 139) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Oral health promotion in the community (2016) NICE quality standard 139

Quality standards

Oral health promotion in the community

These quality statements are taken from the oral health promotion in the community quality standard. The quality standard defines clinical best practice in oral health promotion in the community and should be read in full.

Quality statements

Oral health needs assessments

This quality statement is taken from the oral health promotion in the community quality standard. The quality standard defines clinical best practice in oral health promotion in the community and should be read in full.

Quality statement

Local authorities carry out oral health needs assessments to identify groups at high risk of poor oral health as part of joint strategic needs assessments.

Rationale

An oral health needs assessment can identify local groups of people who are at high risk of poor oral health, and determine their likely needs. This can be used as the basis for developing interventions for oral health improvement tailored to the local population. Including oral health in joint strategic needs assessments ensures it is a key health and wellbeing priority.

Quality measures

Structure
Evidence that oral health needs assessments are part of joint strategic needs assessments.
Data source: Local data collection.
Outcome
a) Identification of local groups of people at high risk of poor oral health.
Data source: Local data collection.
b) Development of an oral health strategy.
Data source: Local data collection.

What the quality statement means for public health practitioners and commissioners

Public health practitioners (working in local authorities) ensure that they include oral health needs data from a range of data sources (for example the Public Health England dental epidemiological programme, questionnaire survey data, feedback from community groups) when undertaking joint strategic needs assessments to identify groups at high risk of poor oral health.
Commissioners (working in local authorities and on health and wellbeing boards) ensure that oral health needs data are collected from a range of data sources (for example the Public Health England epidemiological programme, questionnaire survey data) so that oral health needs assessments to identify groups at high risk of poor oral health are included in joint strategic needs assessments. This should be as part of a cyclical planning process.

Source guidance

Oral health: local authorities and partners (2014) NICE guideline PH55, recommendation 2

Definitions of terms used in this quality statement

Groups at high risk of poor oral health
People living in areas that are described as socially and economically disadvantaged are often at high risk of poor oral health. Local authorities (and other agencies) define disadvantaged areas in a variety of ways. An example is the government's Index of Multiple Deprivation. This combines economic, social and housing indicators to produce a single deprivation score.
Based on the oral health needs assessment, local authorities may prioritise other population groups at high risk of poor oral health, such as looked-after children, people who misuse drugs, people with severe mental illness, frail elderly people, some ethnic groups, and people with physical, mental or medical disabilities.
[Adapted from NICE’s guideline on oral health: local authorities and partners, glossary and expert opinion]

Early years settings and schools

This quality statement is taken from the oral health promotion in the community quality standard. The quality standard defines clinical best practice in oral health promotion in the community and should be read in full.

Quality statement

Local authorities provide oral health improvement programmes in early years services and schools in areas where children and young people are at high risk of poor oral health.

Rationale

The risk of dental caries and periodontal disease is reduced by good oral health behaviour, such as reducing sugar consumption and brushing teeth with fluoride toothpaste twice a day. Giving clear advice about good oral health and providing services such as supervised tooth brushing schemes and fluoride varnish programmes encourages this behaviour and reduces the risk of dental decay.
To help support this statement, local authorities should also ensure that healthy food and drink options are displayed prominently in local authority and NHS venues, including early years services and schools (see quality statement 3 in the quality standard on obesity in children and young people: prevention and lifestyle weight management programmes).

Quality measures

Structure
Evidence of local arrangements to ensure that oral health improvement programmes are provided in early years services and schools in areas where children and young people are at high risk of poor oral health.
Data source: Local data collection.
Process
a) Proportion of early years services in areas where children are at high risk of poor oral health where oral health improvement programmes are provided.
Numerator – number in the denominator where oral health improvement programmes are provided.
Denominator – number of early years services in areas where children are at high risk of poor oral health.
Data source: Local data collection.
b) Proportion of schools in areas where children and young people are at high risk of poor oral health where oral health improvement programmes are provided.
Numerator – number in the denominator where oral health improvement programmes are provided.
Denominator – number of schools in areas where children and young people are at high risk of poor oral health.
Data source: Local data collection.
Outcome
a) Plaque on teeth of children.
Data source: Data on the presence or absence of plaque on the teeth of 5 year old children is recorded as part of the oral health survey of five-year-old children.
b) Tooth decay in children and young people.
Data source: Data on the prevalence and severity of dental decay in 5 year old children is recorded as part of the oral health survey of five-year-old children.
c) Tooth extractions in secondary care for children and young people.
Data source: Data on tooth extractions for children aged 10 and under admitted to hospital is included in the NHS Outcomes Framework 2016–17.

What the quality statement means for service providers, healthcare, education and social care practitioners, and commissioners

Service providers (such as school nursing services) ensure that oral health improvement programmes are provided in early years settings and schools in areas where children and young people are at high risk of poor oral health.
Healthcare, education and social care practitioners (such as school nurses, health visitors, social workers and family link workers) ensure that they provide oral health improvement programmes in early years settings and schools in areas where children and young people are at high risk of poor oral health.
Commissioners (local authorities and health and wellbeing commissioning partners) ensure that they commission oral health improvement programmes in early years settings and schools in areas where children and young people are at high risk of poor oral health.

What the quality statement means for children and young people

Children and young people in areas at high risk of poor oral health are told about the importance of looking after their teeth and are helped to do this. For example, they take part in a programme at school or nursery where teachers, teaching assistants or school nurses supervise them brushing their teeth or they are encouraged to reduce the amount of sugar they eat.

Source guidance

Oral health: local authorities and partners (2014) NICE guideline PH55, recommendations 14, 15, 16, 18 and 21

Definitions of terms used in this quality statement

Oral health improvement programmes
These include providing supervised tooth brushing schemes, fluoride varnish programmes or programmes providing advice to encourage brushing with fluoride toothpaste and reducing the amount and frequency of sugar consumption. Advice should be based on the information provided in Public Health England’s (Delivering better oral health 6).
[Adapted from NICE’s guideline on oral health: local authorities and partners, recommendations 14, 15, 16, 18, 19, 20 and 21]
Areas where children and young people are at high risk of poor oral health
Schools and early years settings in areas where children and young people are at high risk of poor oral health can be identified using information from the oral health needs assessment.
Children and young people living in areas that are described as socially and economically disadvantaged are often at high risk of poor oral health. Local authorities (and other agencies) define disadvantaged areas in a variety of ways. An example is the government's Index of Multiple Deprivation. This combines economic, social and housing indicators to produce a single deprivation score.
Based on the oral health needs assessment, local authorities may prioritise other population groups at high risk of poor oral health, such as looked-after children, some ethnic groups, and children and young people with physical, mental or medical disabilities.
[Adapted from NICE’s guideline on oral health: local authorities and partners, glossary, recommendations 3 and 4 and expert opinion]

Oral health in care plans

This quality statement is taken from the oral health promotion in the community quality standard. The quality standard defines clinical best practice in oral health promotion in the community and should be read in full.

Quality statement

Health and social care services include oral health in care plans of people who are receiving health or social care support and at high risk of poor oral health.

Rationale

Oral health is a key part of a person’s overall health and wellbeing. Including oral health in care plans for people receiving health or social care support and at high risk of poor oral health helps ensure that relevant needs are addressed. This may include day-to-day support to help people maintain good oral hygiene and referring to dental services if needed.

Quality measures

Structure
Evidence of local arrangements to include oral health in the care plans of people receiving health or social care support and at high risk of poor oral health.
Data source: Local data collection.
Process
Proportion of care plans that include oral health for people receiving health or social care support and at high risk of poor oral health.
Numerator – number in the denominator that include oral health.
Denominator – number of care plans for people receiving health or social care support and at high risk of poor oral health.
Data source: Local data collection.
Outcome
Tooth decay in people who are receiving health and social care support.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (health and social care providers) ensure that systems are in place so that oral health is included in care plans of people who are receiving health or social care support and at high risk of poor oral health.
Health and social care practitioners (such as GPs, nurses, care workers and social workers) ensure that they include oral health when developing care plans for people at high risk of poor oral health.
Commissioners (clinical commissioning groups and local authorities) ensure that service specifications need oral health to be included in care plans for people who are receiving health or social care support and at high risk of poor oral health.

What the quality statement means for patients and service users

People receiving health or social care support who are at high risk of poor oral health have oral health considerations included in the written plan of the care they agree with professionals.

Source guidance

Oral health: local authorities and partners (2014) NICE guideline PH55, recommendation 8

Definitions of terms used in this quality statement

High risk of poor oral health
Groups of people at high risk of poor oral health should be identified using information from the oral health needs assessment.
People living in areas that are described as socially and economically disadvantaged are often at high risk of poor oral health. Local authorities (and other agencies) define disadvantaged areas in a variety of ways. An example is the government's Index of Multiple Deprivation. This combines economic, social and housing indicators to produce a single deprivation score.
Health and social care services may prioritise other population groups at high risk of poor oral health, such as looked-after children, people who misuse drugs, people with severe mental illness, frail elderly people, some ethnic groups, and people with physical, mental or medical disabilities.
[Adapted from NICE’s guideline on oral health: local authorities and partners, glossary, recommendations 3 and 4 and expert opinion]

Routine attendance after emergency care

This quality statement is taken from the oral health promotion in the community quality standard. The quality standard defines clinical best practice in oral health promotion in the community and should be read in full.

Quality statement

Dental practices providing emergency care to people who do not have a regular dentist give information about the benefits of attending for routine care and how a local dentist can be found.

Rationale

People should be encouraged to attend a general dental practice routinely to help them maintain good oral health. This can reduce problems and the associated costs in the long term. For people who do not have a regular dentist, this contact provides an opportunity for the dental practice team to establish a positive relationship with them and to help them to find a local dentist to attend regularly. For example, dental practice teams can point people to information about local services on the NHS Choices website.

Quality measures

Structure
Evidence of local arrangements to ensure that dental practices providing emergency care give information to people who do not have a regular dentist about the benefits of attending for routine care and how they can find a local dentist.
Data source: Local data collection.
Process
Proportion of emergency attendances at dental practices of people who do not have a regular dentist where information about the benefits of attending for routine care and how to find a local dentist was given.
Numerator – number in the denominator where people were given information about the benefits of attending for routine care and how they can find a local dentist.
Denominator – number of emergency attendances at general dental practices of people who do not have a regular dentist.
Data source: Local data collection.
Outcome
a) Adults who were seen by an NHS dentist in the previous 24 months.
Data source: Local data collection. NHS Dental Statistics for England.
b) Children who were seen by an NHS dentist in the previous 12 months.
Data source: Local data collection. NHS Dental Statistics for England.

What the quality statement means for service providers, dental care professionals and commissioners

Service providers (general dental practices that provide emergency care) ensure information is available about the benefits of attending for routine care and how to find a local dentist.
Dental care professionals (such as dentists and dental nurses) ensure that they establish positive relationships with people not registered with a dentist and give information about the benefits of attending for routine care and how to find a local dentist.
Commissioners (NHS England) ensure that they commission services in which dental practices providing emergency care give information to people who do not have a regular dentist about the benefits of attending for routine care and how to find a local dentist.

What the quality statement means for patients and carers

People who visit a dentist as an emergency and do not have a regular dentist are given information about the benefits of going back for routine check ups and how they can find a local dentist.

Source guidance

Oral health promotion: general dental practice (2015) NICE guideline NG30, recommendations 1.2.2 and 1.2.3

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

NICE has produced resources to help implement its guidance on:

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Delivering better oral health

Below is an edited extract from: Delivering better oral health: an evidence-based toolkit for prevention (Public Health England 2014). This toolkit provides practical, evidence-based guidance to help dentists and their teams promote oral health and prevent oral disease among their patients.

Summary guidance for primary care dental teams: advice for patients

Prevention of caries in children aged 0-6 years
Children aged up to 3 years:
  • Breastfeeding provides the best nutrition for babies
  • From 6 months of age infants should be introduced to drinking from a free-flow cup, and from age 1 year feeding from a bottle should be discouraged
  • Sugar should not be added to weaning foods or drinks
  • Parents or carers should brush or supervise toothbrushing
  • As soon as teeth erupt in the mouth brush them twice daily with a fluoridated toothpaste
  • Brush last thing at night and on one other occasion
  • Use toothpaste containing no less than 1000 parts per million (ppm) fluoride
  • It is good practice to use only a smear of toothpaste
  • The frequency and amount of sugary food and drinks should be reduced
  • Sugar-free medicines should be recommended
All children aged 3-6 years:
  • Brush at least twice daily, with a fluoridated toothpaste
  • Brush last thing at night and on one other occasion
  • Brushing should be supervised by a parent or carer
  • Use fluoridated toothpaste containing more than 1000 ppm fluoride. It is good practice to use a pea-sized amount
  • Spit out after brushing and do not rinse, to maintain fluoride concentration levels
  • The frequency and amount of sugary food and drinks should be reduced
  • Sugar-free medicines should be recommended
Children aged 0-6 years giving concern (for example, those likely to develop caries, those with special needs). All advice as above, plus:
  • Use fluoridated toothpaste containing 1350-1500 ppm fluoride
  • It is good practice to use only a smear or pea-sized amount
  • Where medication is given frequently or long term, request that it is sugar free, or used to minimise cariogenic effects.
Prevention of caries in children aged from 7 years and young adults
All children and young adults:
  • Brush at least twice daily, with a fluoridated toothpaste
  • Brush last thing at night and on at least 1 other occasion
  • Use fluoridated toothpaste (1350-1500 ppm fluoride)
  • Spit out after brushing and do not rinse, to maintain fluoride concentration levels
  • The frequency and amount of sugary food and drinks should be reduced
Those giving concern (for example, those with obvious current active caries, those with ortho appliances, dry mouth, other predisposing factors, those with special needs). All the above, plus:
  • Use a fluoride mouth rinse daily (0.05% NaF-) at a different time to brushing.
Prevention of caries in adults
All adults
  • Brush at least twice daily with fluoridated toothpaste
  • Brush last thing at night and on at least 1 other occasion
  • Use fluoridated toothpaste with at least 1350 ppm fluoride
  • Spit out after brushing and do not rinse, to maintain fluoride concentration
  • The frequency and amount of sugary food and drinks should be reduced
Those giving concern (for example, with obvious current active caries, dry mouth, other predisposing factors, those with special needs). All the above, plus:
  • Use a fluoride mouth rinse daily (0.05% NaF-) at a different time to brushing.
Prevention of periodontal disease – to be used in addition to caries prevention
All adults and children:
Self-care plaque removal
  • Remove plaque effectively using methods shown by dental team. This will prevent gingivitis and reduce the risk of periodontal disease
  • Daily effective plaque removal is more important to periodontal health than tooth scaling and polishing by the clinical team
Tooth brushing and toothpaste
Brush gum line and each tooth twice daily (before bed and at least on 1 other occasion). Use either:
  • a manual or powered toothbrush
  • small toothbrush head, medium texture.
All adults and ages 12-17
Interdental plaque control
Clean daily between the teeth to below the gum line before toothbrushing:
  • For small spaces between the teeth use dental floss or tape
  • For larger spaces use interdental or single tufted brushes
  • Around orthodontic appliances and bridges use kit suggested by the dental professional.
Risk factor control
Tobacco
All adults and adolescents:
  • Do not smoke
  • Smoking increases the risk of periodontal disease, reduces the benefits of treatment and increases the chance of losing teeth.
Diabetes
Patients with diabetes should try to maintain good diabetes control as they are:
  • At greater risk of developing serious periodontal disease
  • Less likely to benefit from periodontal treatment if the diabetes is not well controlled.
Medications
Some medications can affect gingival health.
Prevention of peri-implant disease
All adults with dental implants:
  • Dental implants require the same level of oral hygiene and maintenance as natural teeth
  • Clean both between and around the implants carefully with interdental kit and toothbrushes
  • Attend for regular checks of the health of gum and bone around implants
All adolescents and adults:
Tobacco use, both smoking and chewing tobacco, seriously affects general and oral health. The most significant effect on the mouth is oral cancers and pre-cancers.
  • Do not smoke or use shisha pipes
  • Do not use smokeless tobacco (such as, paan, chewing tobacco, gutkha)
If the patient is not ready or willing to stop they may wish to consider reducing how much they smoke using a licensed nicotine-containing product to help reduce smoking. The health benefits to reducing are unclear but those who use these will be more likely to stop smoking in the future.
All adolescents and adults:
  • Drinking alcohol above the recommended levels adversely affects general and oral health with the most significant oral health impact being the increased risk of oral cancer.
  • Reduce alcohol consumption to low risk (recommended) levels.
Recommended levels (May 2014)
  • Men should not regularly consume more than 3 to 4 units per day
  • Women should not regularly consume more than 2 to 3 units per day
  • All drinkers should avoid alcohol for 2 days following a heavy drinking session to allow the body to recover
  • Pregnant women or women trying to conceive should avoid drinking alcohol but if they choose to drink they should limit this to no more than 1 to 2 units once or twice a week and avoid getting drunk.
All ages:
  • The frequency and amount of consumption of sugars should be reduced
  • Avoid sugar containing foods and drinks at bedtime when saliva flow is reduced and buffering capacity is lost.

Glossary

the result of a complex and wide-ranging set of factors including material disadvantage, poor housing, low educational attainment, insecure employment and homelessness; people who experience 1 or more of these factors are more likely to have problems with their health and are also likely to die earlier than average for the rest of the population
people at high risk of poor oral health generally live in areas that are described as socially and economically disadvantaged; local authorities (and other agencies) define disadvantaged areas in a variety of ways, an example of which is the government's Index of Multiple Deprivation 2010 (ID 2010) which combines economic, social and housing indicators to produce a single deprivation score (see 'Indices of English deprivation 2010' Department for Communities and Local Government, 2011)
teach parents and carers how to set effective boundaries and how to reward and praise children and young people in a way that promotes positive relationships and self-esteem; the aim is to improve children and young people's behaviour

Paths in this pathway

Pathway created: October 2014 Last updated: May 2017

© NICE 2017. All rights reserved. Subject to Notice of rights.

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