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Within: Oral Health

Related to: Oral Health of Children, Deprivation and Oral Health, Ill Health and Disability, Diet and Malnutrition, NHS Health Checks, Patient Experience, Older People, Child Health and Wellbeing Survey , Inequalities

Key Facts:

  • Adults who do not attend a dentist regularly have fewer teeth and more decay. 
  • An estimated 36% of adults have an average of 3-4 decayed teeth each.
  • An estimated 60% of adults have gum disease with around 9% experiencing severe disease.
  • Tooth decay varies by age and prevalence is highest in adults aged 25-34 and 75 years and over.  

Certain groups of adults are at greater risk of oral diseases.


Figure 1: Groups of adults at higher risk of oral diseases

What does the data say?

Information on the oral health of adults in Bath and North East Somerset is not is routinely collected. Local oral health needs must therefore be estimated using South West England estimates from the decennial national surveys known as the Adult Dental Health Survey (ADHS).  These surveys collect data on clinically defined (‘normative’) and patient defined (‘perceived’ or ‘felt’) oral health needs. It is an accepted convention to use data from the old Strategic Health Authority as a proxy for local data with the caveat that it will only be an estimate and will not take account of local variations. 

It is important to bear in mind that survey data is always an underestimation of the true level of disease.  1

Tooth decay

The overall prevalence of tooth decay in adults in England fell from 46% in 1998 to 30% in 2009.  In South West England 36% of adults have at least one decayed tooth (Figure 2). 2

It is important to note however, that prevalence of tooth decay is likely to be underestimated due to limitations of the survey methods used.

Traditionally, it has been assumed that more tooth decay occurs in children than in adults when the opposite is true.3  4 Tooth decay is a cumulative and chronic disease which can progress in adulthood.  There is evidence to suggest considerable development of tooth decay between 12 and 35–44 years of age and suggests that decay is occurring later than in previous decades. 5  6

The recent ADHS shows the highest proportion of adults with decay in the 25-34 age band with (a minimum of) 35% experiencing tooth decay. A substantial proportion of the 75 years and over age band also have tooth decay.  7

Figure 2:  Proportion of adults in England with tooth decay (%) by age band in 2009 8

As well as variation in experience of tooth decay between age bands, there is geographical variation: this ranges from an average of 39% in West Midlands to 21% on the South East Coast. Prevalence of tooth decay in adults the South West is above the English average at 36% (Figure 3).

Figure 3: Proportion of adults with any decayed teeth (%) by Strategic Health Authority, 20099

While the prevalence of decay has fallen over time, the severity is essentially unchanged.  In England adults with obvious decay had an average of 2.7 teeth affected. 10 In South West England, an average of 3.2 teeth are affected in each person with decay. 11

Adults who never go to the dentist, or who only attend when they have trouble, are more likely to experience tooth decay, multiple decayed teeth and to have fewer teeth (fgure3).

Figure 4: Proportion of adults with primary tooth decay (%) by pattern of dental attendance, 200912


Oral health in older people

Improvements in oral health over the last 50 years have changed the mouths, and needs, of older people at a population level.  Over the past 50 years, we have seen a shift from most older people having no teeth to only 6% of adults aged 65 or over having no teeth. 13

Keeping natural teeth as we age is good news however; many of the natural teeth that remain in old age will have received dental treatment. Many older people who have natural teeth will have an abundance of fillings, crowns and bridges (known as the “heavy metal generation”)14 which can lead to substantial, and often complex, oral health needs.  These treated teeth are more vulnerable to tooth decay and gum disease than sound, natural teeth.  Heavily restored teeth are also more difficult to maintain.

Vulnerable older people with poor oral health can experience, for example:

  • Pain and discomfort, which can lead to mood and behaviour changes, particularly in people who cannot communicate their experience
  • Altered facial appearance, which in turn affects self confidence
  • Speech problems that make communication challenging leading to psychosocial problems like stress
  • Problems chewing and swallowing which limits their ability to eat nutritious foods like fibrous fruit and vegetables.  This can lead to dehydration and general health problems like frailty and anaemia
  • Systemic diseases, such as pneumonia, diabetes and heart disease, which are associated with poor oral health
  • Poor quality of life
  • Depression and social exclusion

It is widely accepted that in order to eat a wide range of foods, without the need for a denture, a person requires a minimum of 21 natural teeth. Yet the number of natural teeth in a person’s mouth reduces with age. In adults aged over 85 years, only 26% had 21 or more natural teeth compared to 86% of all adults.  These older dentate adults with enough natural teeth remaining to enable functional dentition represent only 14%of all adults aged 85 and over.

Preventing oral diseases is increasingly important as we age.  The risk of oral diseases however, increases as people experience phases of dependency or frailty and self-care becomes more challenging.  A survey carried out with residents of care homes found that 40% of the residents reported that poor oral health affected their daily life.15

Older people are also more prone to oral cancers, with the peak of incidence occurring in males aged 60 to 64 (figure 5).  16

Figure 5: Average number of new oral cancer cases per year in 2009-2011 in the UK(age-specific incidence rates)


Oral health behaviours

Certain behaviours will increase risk of oral diseases alongside other common chronic diseases; particularly poor dietary choices, using tobacco and alcohol, poor oral hygiene  and irregular use of dental services (table 1). 18 There is also evidence to suggest that unsafe sexual practices may increase the risk of oral cancers due to the association with Human Papilloma Virus (HPV).  These behaviours tend to cluster together in the same individuals and are more prevalent in men, lower social class households, singles, and people who are economically inactive. 19

Risk factors

Oral diseases associated with risk factor



Frequent consumption of sugary drinks or foods causes tooth decay.


Poor diet increases the risk of oral cancer


Alcohol consumption above recommended levels increases the risk of oral cancer


Smoking and drinking alcohol multiplies the risk of oral cancer

Tobacco use

Smoking or chewing tobacco increases the risk of oral cancer and periodontal (gum) disease


Smoking and drinking alcohol multiplies the risk of oral cancer

Drug misuse

People who have a history of drug use tend to have poor oral health, particularly tooth decay and gum disease.


Poor oral hygiene

Poor mouth cleanliness increases the risk of gum disease and tooth decay


Unprotected sexual health practices

Contracting Human Papilloma Virus (HPV) through unprotected sexual activities increases the risk of oral cancer

 Table 1: Risk factors associated with poor oral health and oral diseases  

These damaging behaviours should not be seen in isolation from the circumstances in which people live and work.  Health related choices are made in response to complex social and environmental conditions and so are only partially controlled by personal choice.  Social, economic and environmental factors have a profound effect on oral health and wellbeing.

Figure 6: The underlying causes of poor oral health 20

What does the community say?

2016 Oral Health Promotion Strategy Public Consultation21

Following the development of the draft Oral Health Promotion Strategy in 2016, Bath and North East Somerset Council, in partnership with Bristol, South Gloucestershire and North Somerset, ran a public consultation. Key findings of this consultation are: 

  • The vast majority (97%) of respondents agreed with the strategic vision of improving oral health of all people.
  • Of the five strategic priorities, promoting healthier food and drink choices that are lower in sugar received the strongest support (96% strongly agreed) whilst the strategic priority on supervised tooth brushing and free tooth brushes received the lowest support – though still very supportive – with 91% of the respondents strongly agreeing to the priority. 

Of the comments received, key themes raised by people include:

  • Access to NHS dentists and the cost of dental treatment • Provision of dental care for those with disability
  • Questions about fluoridation of water (this is not within the remit of this strategy)
  • Quality of oral health care provision Supportive suggestions were made about • Including oral health promotion within primary care contacts , such as GPs, Midwives, health visitors and family support workers
  • Working with dentists and dental practitioners to raise awareness on oral health promotion • Teaching of oral health promotion to people working in the wider community and voluntary sector; care, social and education staff, in particular for young children, people dependent on care and carers.

UK 2009 national adult dental health survey 22

Adult experience of their oral health according to the UK 2009 national adult dental health survey:

  • The general perception of adults about their dental health was quite positive, with 71% saying that it was good, or very good. But in the South West, the equivalent value was slightly lower at 68%.
  • The most commonly reported problems nationally were physical pain (30%) and psychological discomfort (19 %)
  • 34% of dentate adults in the South West reported that they had experienced pain in their mouths occasionally/ fairly or very often, in the previous 12 months, above the national average of 30%
  • 33% of adults nationally described difficulties linked to their oral health, 21% with eating, 15% with smiling, 13% when cleaning teeth, and 10% when relaxing.

What can we realistically change? 

2016 Oral health Promotion Strategy 23

We have worked to develop an Oral health Promotion Strategy in partnership with the local authorities of, Bristol, South Gloucestershire and North Somerset. This strategy aims to improve oral health and reduce inequalities by endorsing five strategic priorities:

  • Promote oral health through healthier food and drink choices

  • Promote oral health by improving levels of oral hygiene

  • Improve population exposure to fluoride

  • Improve early detection, and treatment, of oral diseases

  • Reduce inequalities in oral health