Health June 21, 2019
Prevention: It’s like pulling teeth

By Daniel Male - Accountable Care Journal

In response to the emphasis on prevention in the NHS Long Term Plan (LTP), Dan Male spoke to Professor Michael Escudier, Dean of the Faculty of Dental Surgery at the Royal College of Surgeons, about delivering prevention schemes, workforce training and the role of digital in oral health care.

Children’s teeth emerge before 18 months and their oral health is already at risk by this stage. With NHS dental care free of charge until the age of 18, there is no socioeconomic reason why individuals are not able to attend the dentist. However, this does not translate into attendance rates. As a result, caries is the most common cause of admission to hospital for those aged five to nine. “If you can really get the good habits in terms of oral hygiene and dietary advice in the early years, they are habits that will hopefully stay with you for a lifetime and reduce your need for treatment at a later date,” says Professor Escudier.


Engraining positive practice in old and young

Nearly six in ten children aged between one and four did not visit the dentist last year according to NHS Digital data analysed by the Faculty of Dental Surgery at the Royal College of Surgeons. To address low rates of attendance, the British Society of Paediatric Dentistry launched a campaign, ‘Check Before One,’ to address the trend of parents not taking their children to the dentist before they have teeth.

The Faculty of Dental Surgery, under the Deanship of Professor Escudier, recommends that parents and carers register their children with a dentist before the age of one and visit at least once every 12 months to prevent increased risk of tooth decay and extensive dental damage in later life. One solution seeking to generate positive behaviours is supervised brushing in nursery and pre-schools, turning oral hygiene into a “social exercise”.

In the acute sector, the Mouth Care Matters initiative, developed by Health Education England and spearheaded by Mili Doshi at Surrey and Sussex Healthcare NHS Trust is one of the best examples of successful intervention. The scheme targets frail and vulnerable individuals at risk of developing oral health issues while admitted to hospital, as well as training healthcare professionals to identify issues and provide basic oral hygiene. Aside from boosting the health of patients and avoiding hospital-acquired pneumonia, the Mouth Care Matters scheme has made evidential savings of £2.66 for every £1 invested. This was achieved through fewer bed days and reduced numbers of prescriptions and GP visits.

Considering the impact of the programme, Professor Escudier is examining the prospect that it could be rolled out more broadly across the NHS, as part of the prevention agenda outlined in the LTP to “enhance oral health throughout life. ”


Integration 

One of the most notable elements of the NHS LTP for Professor Escudier was that “dentistry was not separate,” supporting the idea that oral health has a core place in the prevention agenda, providing “added value” to the care of vulnerable patients. Public Health England has devolved responsibility for regions to collaborate between national government, local government and NHS providers.

“There is a political awareness and a will to pursue integrated working in terms of oral health,” says Professor Escudier, referring to recent debates in the House of Commons and House of Lords, as well as meetings between the Royal Colleges and Baroness Dido Harding, Chair of NHS Improvement, on the subject. This will was also demonstrated by Sara Hurley, Chief Dental Officer for NHS England, who has written in the latest issue of Hospital Times, as she placed emphasis on prevention to reduce admissions for NHS trusts and ensure positive oral health care for patients when they are admitted.


Workforce

Considering “oral health” as opposed to just “dental health” is advantageous from a workforce perspective, suggests Professor Escudier. A key element of progress for primary care, as well as the acute sector, is educating healthcare staff more broadly about the importance of oral health. This includes clinicians, health visitors and community teams.

“The amount of training I had 20 to 30 years ago in terms of oral health as an undergraduate medic was very limited,” says Professor Escudier. “I think that has moved forward and I think there is a greater emphasis on oral health now. ”

Advancing Dental Care, a project run by Health Education England, is examining workstreams in oral health and the broader healthcare needs across the practice. The outcome of this will shape multi-disciplinary teams of dentists, hygienists and therapists who will have greater awareness of oral
health issues.

A paper published by the Faculty of Dental Surgery in 2017 entitled 'Older people’s oral health' examined the social care sector, looking at the considerations that care homes were taking to manage the oral health care of their residents. As a result of this, the Care Quality Commission now considers oral health when assessing care provision. Addressing this is thought to have a positive impact in reducing the involvement of the acute sector.


Digital opportunities

There are a spectrum of applications for digital innovations in the dentistry sector, from 3D printers that can produce dentures and crowns, to digital radiographs producing high-quality imaging which can be stored and transmitted securely. However, recent digital innovations are spreading beyond clinicians and having an impact on prevention, with apps that can be taken into bathrooms to spread awareness of positive dental hygiene. Some apps are even using “nudge” technology to prompt individuals towards certain positive behaviours.

Good data falls at the heart of all prevention strategies. The crucial point for Professor Escudier is ensuring “the outcome you need to measure, not the one you can measure” and that “just because you can measure it, doesn’t mean it’s the right outcome”.


Future work

For Professor Escudier, further identification of the links between oral and systemic health and wider conditions is required; such as diabetes, CVD and even dementia. These form part of a “package” of conditions that can then be addressed with a broader preventative approach to boost overall health outcomes of vulnerable individuals.

Work is currently underway by the Department of Health and Social Care to review and reform the dental contract which Professor Escudier hopes will follow suit and place greater emphasis on incentivising prevention. While the UK has some positive examples of best practice, the message is clear; we must use evidence-based, data-driven strategies to boost oral health throughout life. In doing this, pulling out rotten teeth could become a thing of the past.


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