Select Committee on Science and Technology Written Evidence

Memorandum by Professor Aubrey Sheiham and Dr Georgios Tsakos

  The questions addressed relate to how Science and Technology can help improve people's prospects of healthy and active life expectancy and whether Government policies are in place to achieve this.


  The evidence we present is on how three aspects of research in technology relating to oral health can help improve people's prospects of healthy and active life expectancy. The first two aspects are related to how the mouth and teeth affect the health and quality of life and diet and nutrition of people in general and older people in particular. The third relates to the methods for assessing needs for dental care and oral health promotion.

1.   How the mouth and teeth affects health and quality of life and diet and nutrition of people in general and older people in particular

  The two main ways that the mouth and teeth affect the health and therefore the ageing process are:

  1.1  The mouth contributes significantly to the quality of life. Quality of life is concerned with "the degree to which a person enjoys the important possibilities of life". A person's oral health status can affect them physically and psychologically and influence how people enjoy life; how they look, speak, chew, taste and enjoy food, socialise, as well as their self-esteem, self image and feelings of social well-being. Successful ageing is related to maintaining quality of life, which in turn is dependent on how well individuals can fulfil these performances. Normal oral functions such as chewing, speaking, laughing and appearance can be impaired by dental pain and discomfort, aesthetically displeasing teeth and loss of natural teeth. Social functions such as communication and aesthetics may be more important than biting and chewing and may be the main determinants in an individuals' subjective need for replacement of missing natural teeth and their feelings about the loss of teeth.

  In a national study of randomly selected free living (753 persons) and institutionalised (202) subjects from the British National Diet and Nutrition Survey (NDNS) aged 65 years and over, the impact of oral status on 10 aspects of daily life was considerable; 17 per cent of free-living edentate older people reported having one or more severe oral related impact in the past six months. Considering that these impacts are "ultimate impacts" and not merely "intermediate impacts", then the effect of dental and oral disorders on quality of life is serious. Oral impacts levels were lowest in dentate subjects with the greatest number of teeth. For the dentate, the most common oral impacts were on eating and speaking. Impacts relating to emotional stability, sleeping, relaxing, carrying out physical activity and social contact were infrequent, but were severe when they did occur. Among those with an impact on eating, 25 per cent said it was severe and 42 per cent had the impact nearly every day or in a spell of three or more months. Oral impacts were more prevalent among the institution sample. The impacts were associated with the inability or difficulty to eat a range of 16 common foods. The impacts had large effects on whether people could not eat or eat with some difficulty a range of common foods such as sliced bread, cheese, roast potatoes, lettuce and apples. A strong significant relationship between having a socio-dental eating impact and perceived difficulty of eating was reported for almost all the 16 foods in dentate and all 16 foods in edentate subjects.

  More edentate than dentate people had an oral impact. This reflects how badly fitting dentures affects oral health related quality of life among people with false teeth. Free-living dentate people with less than 11 natural teeth were more likely to have had an oral impact than those with 11 or more teeth. Eating related oral impacts were the most common impact reported by all groups. Speaking, emotional stability, sleeping, contact with people and smiling were also affected by oral impacts, although less frequently. This indicates that the quality of life of older people was fairly frequently and severely compromised by dental and oral disorders. In particular, the ability to eat several common types of foods was impaired.

  1.2  Dental health status influences diet and nutrition. Oral health status is considered to be particularly important in older people and to influence their nutritional status. Tooth loss has been associated with nutritional deficiency. The presence of dentures and number of natural teeth are associated with masticatory efficiency and ability and being without natural teeth is related to being underweight. One of the most likely mechanisms by which impaired oral health may affect diet is that difficulty chewing causes dietary restrictions. Joshipura et al (1996) found that edentulous health professionals consumed fewer vegetables, less dietary fibre, and carotene and more cholesterol, saturated fats and calories than people with 25 or more teeth. Tooth loss was associated with a lower intake of hard-to-chew foods such as apples and carrots. Ranta et al (1988) found higher proportions of dentate people had eaten vegetables and fruit than their edentate counterparts. Studies which have analysed the effects of dental status on consumption of non-starch polysaccharides (dietary fibre) reported a reduction in intake with tooth loss (Moynihan et al 1994, Joshipura et al 1996). Older people have fewer natural teeth, and are also vulnerable to dietary restrictions for other reasons (disability, medical or social conditions). Tooth loss was associated with changes in foods preference and nutritional deficiency in older people (Chauncey, et al 1984, Brodeur et al 1993, Moynihan et al 1994, Krall 1998). The evidence generally available for elderly populations suggests that tooth loss alters food choice resulting in lower intakes for key nutrients such as iron and fibre. This evidence suggests that eating ability and masticatory efficiency are affected by oral health, and specifically by the number and distribution of natural teeth. Whether or not somebody reported that they had a problem with eating which impacted on their day to day life has been shown to be strongly related to difficulty eating certain foods (Smith and Sheiham 1979, Sheiham et al 1999). In the NDNS study about one in five dentate free-living British people aged 65 and over had difficulty eating raw carrots, apples, well done steak or nuts. More edentate subjects had difficulty eating than dentate. Foods such as nuts, apples and raw carrots could not be eaten easily by over half edentate people in institutions.

  In random national samples of free-living British older subjects who had a dental examination, interview shown to be strongly related to difficulty eating certain foods (Smith and Sheiham 1979, Sheiham et al 1999). (NDNS) aged 65 years and over study, intakes of most nutrients were lower in edentate than dentate. Intake of non-starch polysaccharides, protein, calcium, non-haem iron, niacin, vitamin C were lower in edentate subjects. People with 21 or more teeth consumed more of most nutrients, particularly of non-starch polysaccharide. This relationship in intake was not apparent in the haemotological analysis. Plasma ascorbate and plasma retinol but not a number of key nutrients, were the only analytes associated with dental status.

  An important finding in the NDNS study is that intake of non-starch polysaccharide (dietary fibre) was much higher in people with more teeth and significantly associated with the number of occluding pairs of posterior teeth. Intake of intrinsic and milk sugars, derived from foods such as fresh fruit and its derivatives, was also significantly associated with having more occluding pairs of natural teeth. Dietary fibre are an important component of diet, associated particularly with gastro-intestinal health, so the relationship with oral health in the elderly is of considerable importance, emphasizing the role that maintaining a functional natural dentition may have in improving the general health of the elderly.

The important conclusion from the national survey of older people is that dental status can have an impact on food choice and on the intake of key nutrients, and this can ultimately translate into variation in the blood levels of number of key nutrients, arguably, the most important of which is vitamin C


  1.2.1  More research is needed to explore how the teeth and mouth affect ageing. There is a strong case for dentistry to concentrate more on psychological and social functioning, than on functional restoration, particularly for older people.

  1.2.2  Traditional oral epidemiologic indicators do not tell us much about people's capacity to carry out desired roles and activities and whether people enjoy the important possibilities of life. Moreover, from the point of view of contemporary definitions of health, clinical measures used to define health status and needs in populations are subject to more serious limitations; they tell us nothing about the functioning of the oral cavity or the person as a whole, nor about subjectively perceived symptoms. Socio-dental indicators are measures of oral health-related quality of life and range from survival, through impairment, to function and perceptions. They measure the extent to which dental and oral disorders disrupt normal social-role functioning and bring about major changes in behaviour such as an inability to work, or undertake parental or household duties. They are subjective and their use should be complementary to the clinical measures of oral status and needs.

  Recommendation:  Socio-dental technology for assessing oral health-related quality of life should be developed to assess oral health related subjective impacts on quality of life and the impacts of the mouth on enjoying eating, and on diet and nutrition.

  1.3  Assessing needs for dental care and oral health promotion. The purpose of needs assessment in health care is to assess unmet health and health care needs in a systematic manner and to gather the information required to bring about change beneficial to the health of the population. Health needs assessment is a systematic approach attempting to ensure that the health service uses its resources to improve the health of the population in the most efficient way. The concept of need is at the core of health care planning. Planning health services is, in turn, rooted in the ethical imperative to use resources appropriately. Needs assessment involves setting priorities on the basis of health needs that is taking into account the severity of illness and/or health care needs, which refers primarily to the capacity to benefit. A common assumption in the organisation and provision of health services, including dental health services, which is being challenged, is that the need for health care can be objectively determined by professionals. Now it is known that health care needs may be defined in other ways, because the definition of any given state of ill-health has become open to much wider interpretation than in the past. Health care needs now extend beyond a narrow clinical interpretation to issues like the impact of ill-health on individuals and on society, the degree of disability and dysfunction that ill-health brings, the perceptions and attitudes of patients themselves towards ill-health and the social origins of many common illnesses. These factors influence the utilisation of health services and, ultimately, the effectiveness of treatment. In this sense, they represent key concepts that should be seriously considered in the process of planning health care services so that resources are more rationally distributed by the ability to benefit. Because improving the quality of older people's lives is central to allocation of resources.

  The concern with effectiveness and acceptability is central to any formulation of health care needs. Matthew's definition focuses on the "need for care", which should be distinct from "need for health". Health needs represent the distribution of particular forms of morbidity, as well as the distribution of those environmental, social and economic variables that influence health and illness. Therefore it is important to distinguish between the need for health and the need for health care. Health care is one way of dealing with the need for health. The need for health is perceived as relief from distress, discomfort, disability, handicap and the risk of mortality and morbidity (Acheson, 1978). With the growing demand for treatments based on evidence-based medicine, Matthew's definition has become widely accepted. Bradshaw (1972) constructed a taxonomy of need that incorporates those concepts and forms a sociological background that sets up a useful definitional framework. The main types of need are presented in Box 1 and their interrelation is pictured in Figure 1.


Normative need:Is that which the expert or professional, administrator or social scientist defines as need in any given situation
Perceived (felt) need:This reflects the individual's own assessment of his or her requirement for health care.
Expressed need (demand):This is felt need converted into action by seeking assistance

  The relationship between Normative Need, Perceived (Felt) Need, and Expressed Need (Demand)

  The shortcomings of the normative method of assessing need are:

  (1)  Lack of objectivity and reliability. Professional judgements in normative need are neither value-free nor objective. The so-called objective assessment often depends upon a consensus agreement from a number of subjective approaches. Therefore, objectivity cannot be regarded as a property of measures of normatively assessed health status and needs.

  (2)  Neglect of psychosocial aspects and quality of life concepts. The global definition of health (WHO, 1948) adopts a much wider perspective than that of normative need and incorporates the concepts of functional, psychological and social well-being. Nevertheless, the standard norm of measures of disease accepted by dentists is not always the norm in terms of functional or social requirements of people examined. Oral health problems, but not necessarily the specific pathological conditions, are related to a person's ability to carry out usual daily activities and affect the individual's personal comfort and quality of life. People's dental satisfaction bears little relation to the clinical assessment of oral conditions. The assessment of health by lay persons differs from that of professionals. Furthermore, there are differences in concepts of health and disease among lay people in different cultures. As a result, normative measures fail to assess the level of health-related quality of life.

  (3)  Lack of consideration for health behaviours and patient compliance. Normative criteria are insufficient for deciding treatment needs because they do not take into account the attitudes and behaviours of patients, which in turn have considerable influence on the effectiveness of treatments and improvement of oral health.

  (4)  Neglect of consumer rights. The need justified by purely professional assessment is questioned in terms of human or consumer rights. The clinical definition, based on the disease analogy, rarely coincides with consumer definitions.

  (5)  Unrealistic estimates for treatment planning. This is particularly important because the use of Normative needs, as illustrated in the latest Department of Health Report of the Primary Care Dental Workforce Review, February 2004.

  There are comprehensive measures of dental needs that include the following elements:

  A clinical dimension based upon sound concepts of the life history of the diseases; measures of social dysfunction; the perceived need of the individual; assessment of the propensity of the individual to take preventive action and the perceived barriers to prevention; a prescription of effective and acceptable treatments or cures; assessment of the skills and manpower required (Sheiham and Tsakos 2004). Such measures should be used instead of the inappropriate normative approach.


  Recommendation:  Research on assessing dental needs sociodentally is not used to inform policy. The Department of Health should reconsider the manpower estimates based on normative need. That would encourage a more equitable distribution of care and more rational prioritisation of services.


  Sheiham A, Steele JG, Marcenes W, Tsakos G, Finch S and Walls AWG. The impact of dental and oral disorders on social well-being among older people; a national survey in Great Britain. Community Dentistry and Oral Epidemiology 2001: 29;195-203.

  Sheiham A, Steele JG, Marcenes W, Finch S, Walls AWG. The Impact of Oral Health on Ability to Eat Certain Foods; Findings from the National Diet and Nutrition Survey of older people in Great Britain. Geriodontology 1999: 16; 11-20.

  Sheiham A, Steele JG, Marcenes W, Lowe, C, Finch S, Bates CJ, Prentice A, Walls AWG.) The relationship among dental status, nutrient intake, and nutritional status in older people. Journal of Dental Research 2001: 80 (2); 408-413.

  Sheiham A, Steele J Does the condition of the mouth and teeth affect the ability to eat certain foods, nutrient and dietary intake and nutritional status amongst older people? Public Health Nutrition 2001: 4(3); 797-803.

  Sheiham A, Tsakos G Oral health needs assessment. Chapter in Community Oral Health, edit C Pine. Wright Publishers, Oxford, 2004.

  Smith J M, Sheiham A How dental conditions handicap the elderly. Community Dentistry Oral Epidemioogy, 1979:7; 305-310

  Srilapananan P, Sheiham A Assessing the difference between sociodental and normative approaches to assessing prosthetic dental treatment needs in dentate older people. Geriodontology 2001: 18; 25-34.

October 2004

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