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R. S. Mann, W. Marcenes and D. G. Gillam British Dental Journal 2015; 218: E10

Editor's summary

How can we tackle the inequalities in oral health which are still so prevalent despite the great strides made by dentists, fluoride and oral health education over the past fifty years? What makes it all the more frustrating is that the vast majority of oral disease is completely preventable. We hear this over and over again in dentistry. Eventually a sense of hopelessness starts to kick in. We get used to it. Indeed, it is in danger of becoming the accepted status quo. However, imagine for a minute if colds were entirely preventable. How ashamed would we be to live in a society where the vast majority of people and children in lower socioeconomic groups suffered from colds but those who were more well off didn't. That would seem bizarre and grossly unfair.

The problem is that no matter how much we may desire to do so, it is difficult and sometimes almost well-nigh impossible to change behaviours – particularly to do with oral hygiene and diet. It's not as if we don't try. But what we are trying is not working as quickly as we need it too. As I hear dentists so often say 'once we have them in the chair we can help them'. But the majority of the people who need the most help are not getting next or near the chair. We must try some different ways of reaching these people.

If you type 'pharmacists under...' into Google the top suggested search terms are: 'pharmacists underutilised'; 'underappreciated'; 'underpaid'; 'undervalued'. We hear all the time that pharmacists could be the answer to many of the NHS' problems. This might be a slight overstatement but what this research paper demonstrates is that pharmacists are a willing, valuable and largely untapped resource for oral health education. Training, contract incentives and support for pharmacists are required to enable this but it could result in a great pay off for the nation's oral health. The authors of the paper point to some simple things which could have an impact, such as ensuring that pharmacists have a list of local GDPs so that they can refer patients appropriately. Perhaps this is something dentists could do – make sure their local pharmacies have this info.

Some people say that dentists need to be encouraged to get out in their local communities and find the people most in need of help. Practically, this is very difficult. The vast majority of dental teams are already swamped; coping with busy patient lists, reams of regulatory paperwork, management, keeping up to date with new materials, research and CPD... the list is endless. In the case of pharmacists, this key group of patients is often already coming to them – they don't need to 'go out' anywhere.

Ten years ago, in this Journal, we published another paper examining the role of pharmacists in the provision of oral healthcare advice.1 Funnily enough that paper also suggested that through pharmacy contracts and education, pharmacists could perform an increased role in oral healthcare provision. Ten years on we come to the same conclusion here. So let's do it this time! We need all the help we can get to tackle the persistent inequalities in oral health.

The full paper can be accessed from the BDJ website ( www.bdj.co.uk ), under 'Research' in the table of contents for Volume 218 issue 5.

Ruth Doherty

Managing Editor

Author questions and answers

1. Why did you undertake this research?

Oral conditions are a common cause of discomfort and have a great impact on the patient's quality of life. Restorative measures for oral diseases are usually expensive; therefore, the prevention of oral disease through oral health promotion is a cost effective strategy. Recently, there is an increased interest in widening the role of community pharmacists in public health.

The community pharmacist can be an important contributor in oral health promotion as the pharmacist is usually the first point contact with respect to providing healthcare services. Individuals from the lower socioeconomic strata can easily access the pharmacies which in turn may help reduce health inequalities. Therefore the community pharmacist would appear to be the ideal channel for the distribution of credible and relevant information to a larger proportion of the population due to their accessibility, availability, and the frequency of contact with the public. However, currently there appears to be limited evidence available that would support a role for them in oral health promotion.

2. What would you like to do next in this area to follow on from this work?

Future research should be conducted in order to recognise the barriers pharmacists may perceive to be preventing them from delivering oral health education within the community. Subsequent qualitative research may be conducted with pharmacists (as a focus group). A cross-sectional study comparing the advice provided by the pharmacist on oral conditions before and after training on oral conditions may also be considered.

Commentary

Oral diseases are largely preventable and the availability of fluoride has seen active disease in the adult population reduce decade on decade. Despite this, there remains substantive oral health inequalities in the adult population, intransigent disease in the very young and a predicted increase in the number of older people, who have already experienced a high restorative burden. Prevention could not be more important, particularly as those with the most risk factors and highest disease have the lowest health literacy and are the least likely to attend general dental services regularly.

This interesting paper explores whether pharmacists could have a role in the promotion of oral health advice within the community. Despite the moderate response rate for a descriptive study, 99.4% of the pharmacies recognised that there was a role for pharmacists in oral health promotion. The vast majority of pharmacies also reported a fairly high level of knowledge for most of the common oral conditions.

As oral diseases share common determinants with other chronic conditions such as heart disease, cancers, and diabetes, the use of pharmacists in the management of unhealthy diets, poor oral hygiene, smoking and excess alcohol is warranted. As Gillam highlights, pharmacists could be 'ideal for this type of extended role on the basis that pharmacies have extended opening hours, easier accessibility, geographic location and frequency of visit within the centre of the local community'.

The only caveat is that changing behaviour is not without its difficulty. Lifestyle attention is grinding and foregoing immediate gratification can be difficult. Equally, good oral health can be an ephemeral concept for many, particularly those from deprived backgrounds with poor health literacy. However, community-based programmes that have supported an evidence-based oral health promotion message with the provision of fluoride toothpastes and toothbrushes have shown promise.

Equally, pharmacists could play a key role during life's transitions: the pregnant mother who is about to start a family or the older person who is now committed to taking multiple forms of medication and receives a regular drug review. Evidence suggests that behavior change is best initiated at times of change, so opportunities like these and others, could be better used to deliver oral health promotion and the means of improving the uptake of fluoride.

The consistency of the message and the need for appropriate sign-posting are key, so training remains paramount. With a public-facing section, the latest version of Delivering Better Oral Health should form the foundation moving forward, such that all advice provided is grounded in the evidence base.