1

Oral Health Education:

What lessons have we
learned?
Despite hundreds of studies involving thousands of
individuals, we know remarkably little about how best
to promote oral health. (Kay and Locker, 1997)
1
Catherine Stillman-Lowe*
Key Points
Primary care dentists and their teams have a pivotal
role to play in providing health education to patients
in the surgery setting
Guidance on the scientifc content of the advice to be
given is widely available
However, much more support could be provided for
dental care professionals on the most effective ways
to provide advice to patients
Introduction
The dental team has long been encouraged by the UK
Government to educate their patients in the surgery setting
in order to promote good oral health, and prevent dental
disease. This article defnes oral health education, and
reviews comments that have been made about its practice
by dental care professionals (DCPs). The policy framework
for oral health education is examined, and national
guidance, current initiatives and suggestions for the way
forward are discussed. The emphasis throughout is on
the advice available to the dental team on how to support
patients to change their behaviour, rather than on shifts in
the scientifc basis of the content of that advice.
Major improvements in the oral health of adults and
children have been achieved over the past 50 years, and the
role that DCPs have played in this must be acknowledged.
*Catherine Stillman-Lowe is an independent oral health
promotion adviser, having worked for 16 years for the Health
Education Council, Health Education Authority and Health
Development Agency. Co-author of The Scientic Basis of Oral
Health Education published by BDJ Books, she is also Patron
of the National Oral Health Promotion Group. On a voluntary
basis, she contributes to the work of the charity Action for
ME by writing for their magazine; she has also participated in
the development of the clinical guideline on Chronic Fatigue
Syndrome/ME being prepared by the National Institute for
Health and Clinical Excellence.
However, this article is necessarily focused on what more
needs to be done, and how dental teams can be better
supported in their key role in patient education.
Oral health education
Health education has been defned as any learning activity
which aims to improve individuals knowledge, attitudes
and skills relevant to their oral health. Oral health
promotion by contrast has been described as any process
which enables individuals or communities to increase
control over the determinants of their oral health
1
. It
should be noted that the phrase dental health education
was commonly used during the early 1990s; later the term
oral health education was widely adopted, refecting a
greater emphasis on the health of the whole mouth. This
gradual shift in terminology is refected in the article.
Criticisms of dental and oral health education
Reviewing the history of dental health education in 1993,
Towner
2
observed some improvements in the way it was
delivered:
Table 1
Changes in dental health education
There has been a move away from propaganda
and a reliance on didactic teaching methods,
towards education which stresses involvement and
participation in learning experiences.
Over the last 20 years dental health education
has increasingly sought inputs from the felds of
education, sociology and psychology.
Dental health education has moved away from
supplying information and towards seeking to modify
attitudes and change behaviour.
Dental health education has become more specifc,
and has increased the number of target groups to
which it is directed.
A major change has been that of accountability, the
need to evaluate what is done at every stage.
2
Discussing the limitations of dental health education,
Croucher
3
suggested that the dominant approach has been
expert led, and individually orientated, featuring persuasive,
behaviour changing communication, based around the KAB
(knowledge, attitudes and behaviour) concept. There have
been many criticisms of this:
Its prescriptive and expert-led nature is victim-blaming
It can cause ill health by making people feel guilty
It is elitist, as being expert-led it assumes that the
individual has a limited amount of knowledge
It operates separately from the people it serves, with
little if any attempt to fnd out what they need.
Following the critiques of Towner and Croucher, two
reports examined the research evidence, and some of their
conclusions are shown below:
Table 2
Reviews of research evidence
1996 Health Promotion Wales (HPW) review
4

Some studies show that health education which
targets whole populations may increase inequalities in
health.
Changing personal health behaviour appears to be
more diffcult for some groups than others; this
may result in blaming the victim for not making the
appropriate behaviour changes.
1997 Health Education Authority (HEA) review
1
There is no evidence of effectiveness of educative
programmes aimed at caries reduction, unless fuoride
agents are being used.
The evidence suggests that oral health promotion is
effective in increasing knowledge levels, but there is
no evidence that changes in knowledge are causally
related to changes in behaviour.
Attempts to control individuals consumption of
sweet foods and drinks are generally not satisfactorily
evaluated. However, when such interventions are
directed at individuals, they appear to be of limited
value.
The HEA report raised some serious issues: was oral health
education worth investing in if increases in knowledge did
not necessarily lead to changes in behaviour? Should more
emphasis be placed in the future on the use of fuoride in
reducing caries, and less on dietary counselling?
Blinkhorn certainly left no room for complacency,
examining the reasons for the apparent failings of dental
health education
5
. His analysis pointed to a failure to
evaluate these activities, and anecdotal evidence suggested
that initial enthusiasm for a preventive approach in the
surgery faded quite quickly, with dentists tending to be
disease centred rather than patient centred. Further, many
dentists did not offer specifc advice which patients could
understand, and unrealistic goals were set for patients to
achieve. Sheiham and Watt
6
expanded on these concerns,
stating that a simplistic and outdated approach had
dominated dental health education for many years, failing
to acknowledge the complexities of human behaviour and
the broader social, economic and environmental factors
determining behaviour change.
Prevention in practice
The realities of adopting a preventive approach were
examined by Threlfall and colleagues, who revealed
troubling shortcomings in relation to both the content
and delivery of advice to patients by General Dental
Practitioners (GDPs). Looking frst at the messages that
were conveyed
7
, the authors concluded that it was worrying
to fnd so much variation in approach to the essential
activity of preventing caries in young children. They
secondly examined the factors that infuenced the provision
of preventive care
8
. Generally, dentists were more inclined
to give advice and spend more time advising middle class
parents, whom they perceived as being more motivated
than parents from a lower social class. Dentists reported
that they became disillusioned when people did not listen
or obviously had not acted upon their advice. Almost all
believed that the key to preventing caries in young children
was education and the majority provided preventive advice
verbally, in the form of a mini lecture. There was a lack
of imagination in the delivery of preventive advice and a
lack of additional materials for parents to take home. Most
GDPs seemed to limit their role to being prescriptive, many
seeming to model themselves on a teacher in a classroom
with parents and patients as their pupils, some of whom
were good, and listened attentively, and others of whom
were bad and did not listen. There was little evidence of
refection about the way the GDPs delivered preventive
advice.
The authors concluded that the arrival of the new dental
contract provided an opportunity for change by placing
prevention at the heart of dental care, but that this would
be squandered unless efforts were made to improve both
the content and the delivery of preventive advice. Training
could be provided, both as part of the undergraduate
curriculum and as part of continuing professional
development, to promote a better understanding of
counseling skills and educative techniques. In addition,
individual GDPs needed to refect on their own delivery
of preventive care to identify ways in which it might be
improved.
Commenting on the authors papers, Hancocks noted
that a picture emerges of somewhat haphazard content
and delivery of messages in many ways skewed by the
subjective views of the individuals doing the educating
9
.
Hancocks suggests that some consistent guidelines, as
well as effective teaching methods, should be developed.
However, the question remains as to whether the dentist or
other members of the dental team, with different skills, are
best placed to fulfll the patient education role
10
.
3
The policy framework: national guidance
The National Institute for Clinical Excellence (NICE) dental
recall guideline
11
put preventive advice at the heart of the
oral health review, with the effects of oral hygiene, diet,
fuoride use, tobacco and alcohol on oral health, being
discussed where appropriate. However, a recommendation
was made that research was therefore needed on the long-
term clinical and cost effectiveness of one-to-one oral
health advice and whether this might depend on:
the frequency with which it is delivered,
the physical or oral health of the patient,
other characteristics of the patient (for example, age,
sex, social class, occupation),
the medium used to deliver the advice,
who delivers the advice.
Four years later, this gap in the evidence base appears still
to need flling - a serious omission.
In 2007, NICE issued guidance on changing health-related
behaviours
12
. The principles most relevant to one-to-one
health education are summarised below.
Table 3
Changing health-related behaviours
Practitioners whose work impacts on, or who wish
to change peoples health-related behaviour should
prioritise interventions and programmes that:
Are based on the best available evidence of effcacy
and cost effectiveness
Can be tailored to tackle the individual beliefs,
attitudes, intentions, skills and knowledge associated
with the target behaviours
Are developed in collaboration with the target
population, community or group and take account
of lay wisdom about barriers and change (where
possible)
Are consistent with other local or national
interventions and programmes (where they are based
on the best available evidence)
Use key life stages or times when people are more
likely to be open to change (such as pregnancy,
starting or leaving school and entering or leaving the
workforce)
Include provision for evaluation.
Practitioners working with individuals should select
interventions that motivate and support people to:
Understand the short, medium and longer-term
consequences of their health-related behaviours, for
themselves and others
Feel positive about the benefts of health-enhancing
behaviours and changing their behaviour
Plan their changes in terms of easy steps over time
Recognise how their social contexts and relationships
may affect their behaviour, and identify and plan for
situations that might undermine the changes they are
trying to make
Plan explicit ifthen coping strategies to prevent
relapse
Make a personal commitment to adopt health-
enhancing behaviours by setting (and recording) goals
to undertake clearly defned behaviours, in particular
contexts, over a specifed time
Share their behaviour change goals with others.
Whilst this guidance on generic principles is welcome, it
does not spell out in concrete terms how to translate these
principles into practice in specifc areas such as oral health.
Expecting each DCP or even each dental team to do this
individually without support would seem unrealistic.
Current initiatives
Delivering Better Oral Health: An evidence-based toolkit
for prevention
13
, produced by the British Association for
the Study of Community Dentistry and the Department
of Health, could help meet the need for more consistent
evidence based advice to be offered by dentists to their
patients. The resource emphasises the simplicity of the
messages because too often in the past, there has been
confusion and a lack of consistency in the preventive
information offered to patients. It goes on to advocate a
two tier approach:
All patients should be given the beneft of advice
regarding their general and dental health, not just those
thought to be at risk.
For those patients about whom there is greater concern
(eg those with medical conditions, those with evidence
of active disease and those for whom the provision of
reparative care is problematic) more intensive actions are
required.
However the pack does not address in any depth the issue of
how advice should be best delivered, if it is to be effective.
This signifcant gap in the professional education market
apparently remains to be flled, though DCPs can refer back
to Blinkhorns 1997 guidance
14
below.
4
Table 4
Practical advice on oral health education
The dental team needs to form a partnership with
patients, working together to solve a health problem.
Many dentists complain that, despite their best efforts,
patients do not change their behaviour and the whole
health education exercise is ultimately futile. Two
factors must be considered:
Patients bring with them the oral health values
current in their own community dental care may
be given a low priority.
The dental team may over-estimate the time
and effort given to educating patients. Verbal
interaction is often minimal and dentists talk
speedily at rather than slowly to their patients.
To be successful:
Information for patients needs to be: understandable,
relevant, non-authoritarian, and given with conviction.
Try to make a specifc preventive diagnosis, in the
same way that you would make a clinical diagnosis,
and offer only advice which is aimed at solving the
dental problem under discussion.
Avoid generalist throw-away lines such as brush
your teeth better. Specifc advice, with an evaluation
component to assess patient progress is a more
sensible approach. Offer positive reinforcement when
some success is achieved by the patient.
Be realistic about the amount of advice which can
be given within a certain time. Aim to build up
knowledge gradually.
Practical demonstrations involving the patient
themselves will make education more interesting.
The way forward
Munday
15
has stated that the NICE guideline on behaviour
change is perspicuous and encouragingly realistic. However,
with no strategic approach, and no co-ordination on
behaviour change within the NHS itself or with other
sectors, their application may have a limited effect. It is
encouraging that NICE recommends training and support
for those involved in changing peoples behaviour, in turn
developing competencies for which national organisations
should develop standards and skills. Advancing the skills
and competencies of practitioners would augment the
viability of these guidelines.
Looking slightly more broadly at oral health promotion
(OHP), Richards
16
further commented that the following
points should be considered in any OHP activity.
OHP as it has been practiced has increased social
inequalities in oral health. It is necessary to be mindful
that primary prevention is required for all social groups
not only those with high need (predominantly the
socially deprived).
We need consistent, up-to-date and correct messages,
cultural sensitivity and understanding and consistent
evaluation of OHP activities. We must be wary of
inadvertent non-verbal communication.
Application of the NICE guideline should emphasise
education and training, especially to Provide training
and support for those individuals involved in changing
peoples health-related behaviour so that they can
develop the full range of competencies required.
Conclusion
DCPs are still awaiting detailed evidence-based guidelines
on the delivery (in addition to the content) of oral
health education in the surgery setting. Surprisingly
little guidance emerges from the published literature;
for example, Watt and Marinhos
17
review of oral health
promotions potential to improve oral hygiene and gingival
health concluded that although all the studies evaluated
educational interventions, there was no clear indication that
any particular type or style of educational approach was
more effective than any other.
The NICE guidance
12
provides a valuable framework for
planning and delivering behaviour change interventions,
but does not go into the fner detail. However, in the
guidance on brief interventions and referral for smoking
cessation in primary care
18
, NICE comments that:
Brief interventions involve opportunistic advice,
discussion, negotiation or encouragement. They are
commonly used in many areas of health promotion and
are delivered by a range of primary and community care
professionals.
For smoking cessation, brief interventions typically take
between 5 and 10 minutes and may include one or more
of the following:
simple opportunistic advice to stop
an assessment of the patients commitment to quit
an offer of pharmacotherapy and/or behavioural
support
provision of self-help material and referral to more
intensive support such as the NHS Stop Smoking
Services.
NICE recommends that everyone who smokes should be
advised to quit, unless there are exceptional circumstances.
This brief intervention acts as a gateway to more intensive
support for those who want it, so that there is a two-tier
approach available to practitioners and smokers. This is
consistent with the two-stage team approach to dental
health education recommended by Daly, Watt, Batchelor
and Treasure
19
, when they state that dentists should be
involved in assessing their clients health education needs,
and where appropriate, providing opportunistic advice and
support. When more intensive health education support is
required, dentists should be able to refer these individuals
to other members of the team who have the time, resources
and skills required. The production of national occupational
standards for oral health promotion
20
may help with the
5
development of such skills. However, the requirement for
further research as originally stated in 2004 in the NICE
guideline on dental recall
11
remains.
DCPs could draw encouragement from the statement of the
Chief Dental Offcer (England)
13
that the resource Delivering
Better Oral Health: An evidence-based toolkit for prevention
should be seen as the frst version of an evolving series
designed to support evidence-based preventive dental care.
However the passive dissemination of guidelines should
never be regarded as suffcient in itself to secure changes in
professional practice, as Newton has suggested
21
. There is a
wealth of knowledge on how to promote change, whether in
terms of the overall strategy to be adopted
22
or the specifc
wording of guidelines to help them effectively alter clinical
behaviour
23
. In particular, Newton has suggested that the
techniques of social marketing could be used, as set out by
Evans
24
, and illustrated below:
Figure 1 Social marketing wheel.
To sum up, the Department of Health rightly recognises
that oral health should be considered as part of general
health, and that health education helps, but is not enough
to make a real difference by itself hence the importance
of working across agencies and sectors to develop a range
of complementary approaches
25
. However, it needs to work
in partnership with other professional bodies to ensure that
the way health education is delivered in the dental surgery
setting reaches a consistent standard and that it is within
the capability of individual primary care dentists to fully
ensure that their teams have the skills and knowledge to
promote oral health effectively to patients.
Supporting GDPs and their teams to help patients who
may be irregular attenders, have the poorest oral health,
and come from lower socio-economic groups, will need
particular emphasis; GDPs have been the powerhouse
of patient education but their approach has not been
structured and may have disregarded health literacy
26
.
The importance of reducing both the prevalence of oral
disease and oral health inequalities across all age groups has
already been recognised
25
.
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Acknowledgements: the generous assistance of Professor Anthony Blinkhorn, Dr
Sue Gregory, Ms Polly Munday, Professor Tim Newton, Mr Jerry Read, and Professor
Wayne Richards with the preparation of this article is gratefully acknowledged.
* Independent oral health promotion adviser, and co-author, The Scientic Basis of
Oral Health Education.