Improving oral health and related health behaviours (substance use, smoking, diet) in people with severe and multiple disadvantage: A systematic review of effectiveness and cost-effectiveness of interventions.

BACKGROUND: People experiencing homelessness co-occurring with substance use or offending ('severe and multiple disadvantage' SMD) often have high levels of poor oral health and related health behaviours (particularly, substance use, smoking, poor diet). This systematic review aimed to assess the effectiveness and cost-effectiveness of interventions in adults experiencing SMD to improve oral health and related health behaviours. METHODS AND FINDINGS: From inception to February 2023, five bibliographic databases (MEDLINE, EMBASE, PsycINFO, CINAHL, and Scopus) and grey literature were searched. Two researchers independently screened the search results. Randomized controlled trials (RCTs), comparative studies and economic evaluations were included that reported outcomes on oral health and the related health behaviours. Risk of bias was assessed and results narratively synthesized. Meta-analyses were performed where appropriate. This review was registered with PROSPERO (reg. no: CRD42020202416). Thirty-eight studies were included (published between 1991 and 2023) with 34 studies reporting about effectiveness. Most studies reported on substance use (n = 30). Interventions with a combination of housing support with substance use and mental health support such as contingent work therapy appeared to show some reduction in substance use in SMD groups. However, meta-analyses showed no statistically significant results. Most studies had short periods of follow-up and high attrition rates. Only one study reported on oral health; none reported on diet. Three RCTs reported on smoking, of which one comprising nicotine replacement with contingency management showed improved smoking abstinence at 4 weeks compared to control. Five studies with economic evaluations provided some evidence that interventions such as Housing First and enhanced support could be cost-effective in reducing substance use. CONCLUSION: This review found that services such as housing combined with other healthcare services could be effective in improving health behaviours, particularly substance use, among SMD groups. Gaps in evidence also remain on oral health improvement, smoking, and diet. High quality studies on effectiveness with adequate power and retention are needed to address these significant health challenges in SMD populations.

Factors influencing implementation and sustainability of interventions to improve oral health and related health behaviours in adults experiencing severe and multiple disadvantage: a mixed-methods systematic review.

OBJECTIVES: Among people experiencing severe and multiple disadvantage (SMD), poor oral health is common and linked to smoking, substance use and high sugar intake. Studies have explored interventions addressing oral health and related behaviours; however, factors related to the implementation of these interventions remain unclear. This mixed-methods systematic review aimed to synthesise evidence on the implementation and sustainability of interventions to improve oral health and related health behaviours among adults experiencing SMD. METHODS: Bibliographic databases (MEDLINE, EMBASE, PsycINFO, CINAHL, EBSCO, Scopus) and grey literature were searched from inception to February 2023. Studies meeting the inclusion criteria were screened and extracted independently by two researchers. Quality appraisal was undertaken, and results were synthesised using narrative and thematic analyses. RESULTS: Seventeen papers were included (published between 1995 and 2022). Studies were mostly of moderate quality and included views from SMD groups and service providers. From the qualitative synthesis, most findings were related to aspects such as trust, resources and motivation levels of SMD groups and service providers. None of the studies reported on diet and none included repeated offending (one of the aspects of SMD). From the quantitative synthesis, no difference was observed in programme attendance between the interventions and usual care, although there was some indication of sustained improvements in participation in the intervention group. CONCLUSION: This review provides some evidence that trust, adequate resources and motivation levels are potentially important in implementing interventions to improve oral health and substance use among SMD groups. Further research is needed from high quality studies and focusing on diet in this population. PROSPERO REGISTRATION NUMBER: CRD42020202416.

Interventions to improve oral health and related health behaviours of substance use, smoking, and diet in people with severe and multiple disadvantage: a systematic review of effectiveness and cost-effectiveness.

BACKGROUND: Homelessness overlapping with substance use and offending is described as severe and multiple disadvantage (SMD). People experiencing SMD have poor oral health along with high levels of related behaviours such as substance use, smoking, and poor diet. Existing evidence largely describes the prevalence of oral health problems, substance use, and smoking in SMD groups. Little is known about interventions that can address these conditions in SMD groups. We aimed to review the effectiveness and cost-effectiveness of interventions on oral health and related health behaviours in adults experiencing SMD. METHODS: For this systematic review, we searched bibliographic databases (MEDLINE, EMBASE, PsycINFO, CINAHL, EBSCO, Scopus) and grey literature for papers published from inception to February 2023. Two researchers independently reviewed the searches. Randomised controlled trials (RCTs), comparative studies and economic evaluations were included. Risk of bias was assessed. Population included adults experiencing SMD (including homelessness and substance use or repeat offending). Outcomes included oral health, and related behaviours (substance use, smoking, poor diet). Results were narratively synthesised. This review was registered with PROSPERO, CRD42020202416. FINDINGS: The review included 38 studies (published between 1991 and 2023), with 34 reporting effectiveness. These studies comprised of 23 RCTs and 11 quasi-experimental studies conducted in the USA (25 studies), Canada (seven studies), France (one study), and Spain (one study). The interventions involving multiple components, such as housing services with substance use and mental health support, effectively reduced substance use in SMD groups; these were mostly individual-level interventions. However, these studies had short follow-up periods and high attrition rates. Only one study addressed oral health outcomes, none focused on diet, and three RCTs covered smoking, with one intervention showing smoking abstinence at 4 weeks. Some limited evidence suggested cost-effectiveness of substance use interventions. INTERPRETATION: This review found that integrating services such as housing with other health-care services together could be effective in improving health behaviours, especially substance use among SMD groups. More evidence is needed specifically on oral health, smoking, and diet-related interventions. The generalisability of findings of this review is limited to high-income countries and shorter-term outcomes. FUNDING: National Institute for Health and Care Research (NIHR) Policy Research Programme.

Trends and inequalities in realised access to NHS primary care dental services in England before, during and throughout recovery from the COVID-19 pandemic.

Introduction The COVID-19 pandemic triggered unprecedented disruption to NHS dental services in England. This work describes changes in realised access to NHS primary care dental services between 2019 and 2022, with a particular focus on geographic and deprivation-based inequalities.Methods Data from the NHS Business Services Authority and Office for National Statistics were combined to calculate the proportion of resident populations utilising NHS primary care dental services. These data were compared over multiple six-monthly time periods between 2019 and 2022, across several levels of geography and by quintiles of area-level deprivation.Results The proportion of the England population utilising services fell substantially after the start of the COVID-19 pandemic, recovering to 75-80% of pre-pandemic levels in the first half of 2022. Substantial geographic variation was observed in the pre-pandemic time points and re-emerged as the recovery period progressed. Deprivation-based inequalities in service use were persistently present, although these were consistently greater in child than adult populations. While inequalities for children increased in the initial post-pandemic period, this pattern returned almost to pre-pandemic levels by 2022.Conclusions Socioeconomic inequalities and geographic variations in the use of NHS primary care dental services, seen before the COVID-19 pandemic, have re-emerged afterwards.

Urgent dental care use in the North East and Cumbria: predicting repeat attendance.

Introduction Around one-third of the UK population are 'problem-orientated dental attenders', only seeking care when suffering with dental pain and often on a repeated basis to secondary care. Little is known about attendance in primary care. The aim here was to examine the period prevalence of repeat urgent care attenders and establish predictors of repeat attendance in primary care.Methods Data on urgent and emergency dental care attendances in primary dental care in the North East and Cumbria were analysed from 2013-2019. Variables included: patient sex; ten-year age band; lower super output area; and Index of Multiple Deprivation. Period prevalence was calculated and data were considered year by year to identify trends in attendances. Analysis was with descriptive statistics and predictors of repeat attendance were identified using logistic regression modelling.Results Over the six-year period, there were 601,432 attendances for urgent primary dental care, equating to a period prevalence of 2.76% for the geographic population studied. In total, 16.15% of attendances were repeat attendances (period prevalence 0.45%) and predictors included being a woman and residence in deprived and rural areas. All urgent care attendances decreased over the six-year period, with one-off attendances beginning to increase again in 2019, while repeat attendances stabilised.Conclusion Interventions to encourage regular dental attendances should be targeted at patients from the most deprived and rural areas of the North East and Cumbria; however, a decrease in repeat attendance was noted in these areas.

NHS dental activity: a population marker for the effectiveness of community water fluoridation in children in England.

Aim To understand the possible beneficiary effects of artificial and naturally occurring water fluoridation on dental health of children, using routinely collected NHS Dental Statistics.Method A secondary analysis of the NHS Dental Statistics for England 2018-2019 dataset. The proportion of Band 1 courses of treatments are compared with Band 2, Band 3 and urgent treatments collectively, for children attending dental practices in naturally and artificially fluoridated local authorities compared with non-fluoridated authorities who are their statistical peers. Proportions of dental treatments are described by the levels of Index of Multiple Deprivation for the area in which the practice is located.Results The dataset had, 2,001,921 banded paediatric courses of treatment; 1,227,282 provided by dental practices in fluoridated local authorities and 774,639 in non-fluoridated local authorities. Water fluoridation was associated with a significant reduction in dental interventions in the most deprived populations. The proportions of active interventional treatments in the 10% most deprived decile (decile 1) are 0.243 (Cl 0.239-0.247) and 0.188 (Cl 0.184-0.191), in non-fluoridated and fluoridated local authorities, respectively.Conclusion Analysis of routinely collected NHS dental statistics shows potential utility as a tool for demonstrating the effects of community water fluoridation schemes in reducing oral health inequalities among the most deprived socioeconomic populations. The pattern of dental need and intervention is not as expected and therefore, further research is required to control for systematic confounding factors.

Investigating the Effectiveness and Acceptability of Oral Health and Related Health Behaviour Interventions in Adults with Severe and Multiple Disadvantage: Protocol for a Mixed-Methods Systematic Review.

Increasing numbers of people in England experience homelessness, substance use, and repeated offending (known as 'severe and multiple disadvantage'; SMD). Populations experiencing SMD often have extremely poor oral health, which is closely inter-linked with high levels of substance use, smoking, and poor diet. This study aims to undertake an evidence synthesis to identify the effectiveness, resource requirements, and factors influencing the implementation and acceptability of oral health and related health behaviour interventions in adults experiencing SMD. Two systematic reviews will be conducted using mixed-methods. Review 1 will investigate the effectiveness and resource implications of oral health and related health behaviours (substance use, smoking, diet) interventions; Review 2 will investigate factors influencing the implementation of such interventions. The population includes adults (≥18 years) experiencing SMD. Standard review methods in terms of searches, screening, data extraction, and quality appraisal will be conducted. Narrative syntheses will be conducted. If feasible, a meta-analysis will be conducted for Review 1 and a thematic synthesis for Review 2. Evidence from the two reviews will then be synthesised together. Input from people with experience of SMD will be sought throughout to inform the reviews. An initial logic model will be iteratively refined during the review.

Exploring Interventions to Improve the Oral Health and Related Health Behaviours of Adults Experiencing Severe and Multiple Disadvantage: Protocol for a Qualitative Study with Stakeholders.

The number of individuals in England experiencing homelessness, substance use, and involvement with the criminal justice system is increasing. These issues, referred to as severe and multiple disadvantage (SMD), are often interlinked and co-occur. Health inequalities, particularly poor oral health, persist for those facing these inter-related issues and are closely linked with high levels of substance use, smoking, and poor diet. However, evidence for interventions that can improve these health outcomes for those experiencing these issues is limited. This paper outlines the design of a qualitative study which aims to explore the perspectives of stakeholders to understand what interventions can help to support SMD groups with their oral health and related health behaviours (i.e., substance use, smoking, diet). Interviews and focus groups will be undertaken with stakeholders comprising two groups: (1) individuals with experience of SMD, and (2) service providers (staff and volunteers), policy makers, and commissioners who support such individuals. Public involvement and engagement is central to the project. For example, stakeholders and research partners in policy and practice and people with lived experience of SMD will provide input at all stages of this study. Findings from the study will inform an 'evidence for practice' briefing outlining recommendations for policy. Dissemination will occur through presentations to a range of practice, policy and academic beneficiaries, and through peer-reviewed publications.

Evaluation of NHS dental uptake by nursing mothers for local authorities throughout England in 2016-2018.

Introduction NHS dental treatment for pregnant and nursing mothers with children aged less than 1 year is free for the patient. The rationale being women during this time are more susceptible to dental disease. By providing this free service it is hoped that access rates will increase by removing barriers in inequality and therefore reducing dental disease prevalence.Aim Identify variations in the uptake of free NHS dental treatment by nursing mothers during pregnancy across different local authorities in England and investigate possible factors linked to this variation.Methodology Public Health NHS Business Services Authority (BSA) data on mothers' exemption forms was compared to a three-year average from Office for National Statistics (ONS) birth data in 2016, 2017 and 2018; the percentage uptake of free dental care for nursing mothers was derived for lower tier local authorities (LTLAs) in England. Using Local Health (Public Health England) mapping data, this was compared to markers of deprivation and other indices to illustrate poor areas of uptake.Results The proportion of mothers accessing dental care ranged from 28-61%. Correlations between access and socioeconomic and ethnic backgrounds within local authorities are illustrated.Conclusion The general low uptake of free dental services among nursing mothers shows more can be done to improve access for this vulnerable group.

A comparison of the sedation provision of NHS dental services 2014-2016 for local authorities throughout England.

Background Conscious dental sedation is commissioned by NHS England for patients who are unable to accept dental treatment under local anaesthetic and behavioural techniques alone. Dental sedation provided by NHS England is carried out on a referral basis but this can be carried out in a primary or secondary care setting. This paper reports a study carried out to improve NHS dental services by supporting the work of multiple NHS England area teams in reviews of sedation services.Aim The aim of this paper is to identify variations in the provision of sedation services by NHS providers across England and explore possible factors affecting this variation.Method The project makes use of the recently developed NHS Business Services Authority (BSA) national public health data set, which Public Health England has developed in association with the BSA.Results Variations in population experience of sedation in England have been graphically demonstrated using a comprehensive BSA data set which captures all general dental service and public dental service (GDS/PDS) activity for a two-year period. There are wide and significant variations in population experience of sedation across England.Conclusion The variations in population experience of sedation across England are difficult to explain on purely clinical grounds.

The equity of access to orthodontic dental care for children in the North East of England.

OBJECTIVES: To assess the equity of access to primary care orthodontic treatment in relation to deprivation in the County Durham and Tees Valley Strategic Health Authority area. STUDY DESIGN: An observational study based on Dental Practice Board data for the County Durham and Tees Valley Strategic Health Authority area with a population of 1.13 million. METHODS: The postcode of all orthodontic claims made by National Health Service dentists across the area in the financial years 2002/2003 and 2003/2004 were obtained and the claim rate per 1000 at risk population calculated for each ward. These ward rates were then compared to both the level of deprivation measured by the Index of Multiple Deprivation 2000 and the children's dental registration rate of the area. RESULTS: Inequity in access to orthodontic care was observed. There was a moderate negative correlation r = -0.40 suggesting wards with the lowest claim rates had the greatest deprivation. In addition, the wards with the lowest child dental registration rates also had the lowest claim rates for orthodontic treatment. CONCLUSIONS: Currently, there is inequity of access to orthodontic treatment for children in County Durham and Tees Valley. The move towards local commissioning for dental services within the NHS will provide an opportunity to reduce inequalities in access.