4. Oral Health Improvement
The fundamental objectives of a dental service for the 21st century in Scotland were set out in the 2005 Dental Action Plan: to improve oral health and provide accessible prevention services and high-quality, effective treatment. SDCEP's recently published Oral Health Assessment and Review (OHAR) guidance document (www.sdcep.org.uk/index.aspx?0=2336) further supports this philosophy and aims to "facilitate the move from a restorative approach to patient care towards a preventive and long-term approach that is risk-based and meets the specific needs of individual patients". It also acknowledges the fact that patients need to be encouraged to manage their own oral health.
It is important to recognise that for the majority of the population individuals themselves make the biggest contribution to better oral health.
Despite improvements in recent years, Scotland's oral health remains worse than that of some other Western European countries, and there continues to be a wide disparity between those with the best oral health and those carrying the burden of the disease. However, national approaches to improving oral health and reducing inequalities have been developed for both children and priority adult groups.
4.2 Children's Oral Health Improvement
The Scottish Government has invested significantly in "early years" health improvement and firmly believes that putting resources into initiatives in the early stages of children's development has many short-, medium- and long-term benefits.
Many of the national policy documents relating to oral health published at the turn of the millennium had a particular focus on improving children's oral health, through a combination of health promotion and the early identification and management of oral disease.
The Action Plan for improving oral health and modernising NHS dental services in Scotland (2005) (http://scotland.gov.uk/Publications/2005/03/20871/54817) was partly based on the combined responses to two consultation documents, Towards Better Oral Health in Children (2002) (www.scotland.gov.uk/Publications/2002/09/15477/11087) and Modernising NHS Dental Services in Scotland (2003) (www.scotland.gov.uk/Publications/2003/11/18542/29107).
One of the proposed outcomes of the 2005 Dental Action Plan was the development of Childsmile (www.child-smile.org.uk), the national programme designed to improve the oral health of Scotland's children and reduce inequalities in oral health and in access to dental services.
The programme promotes wider partnership working among healthcare professionals and agencies to deliver primary care prevention programmes, anticipatory care and the appropriate management of caries within NHS services and in other settings. The Scottish Government continues to fund and invest in the programme, which now has four main components which have been rolled out across all 14 NHS board areas.
The universal programme aims to give every child a dental pack to support toothbrushing at home, free daily supervised toothbrushing in nursery and a tailored programme of care within Primary Care Dental Services. Meanwhile, the targeted programme provides additional help, including:
- Home support and community interventions.
- An enhanced programme of care within Primary Care Dental Services to children and families requiring additional support.
- Clinical prevention programmes in priority nursery and primary schools.
- Daily supervised toothbrushing programmes in priority primary schools.
- Facilitated access to appropriate dental services.
Childsmile is delivered using a broad skill mix, including dental health support workers (DHSWs) trained in oral health promotion, to support families in need of help to attend a dental practice. DHSWs also provide a crucial link between families, health visitors and dental teams. Health visitors and public health nurses introduce families to Childsmile and reinforce the key oral health messages and promote dental registration from birth. In 2012, Childsmile was embedded into the pre-5-year-old National Child Health Programme and is included in the 6-8 week assessment made by health visiting teams.
Appropriately trained extended duty dental nurses (EDDNs) also deliver preventive oral care and caries management based on the individual needs of the child. EDDNs operate in general dental practice and are also employed by salaried dental services to target nurseries and schools in more deprived areas with children at increased risk of caries and apply fluoride varnish.
From October 2011, Childsmile became part of "mainstream" NHS general dental services and was incorporated into the Statement of Dental Remuneration (SDR) to shift the balance of care towards prevention rather than treatment of established disease. All practices delivering NHS care to children must deliver Childsmile interventions, including preventive dental care and caries management tailored to the individual child's needs.
In April 2010, the Scottish Government set a Health Improvement, Efficiency, Access and Treatment (HEAT) target for oral health, as part of a range of NHS performance indicators, that all NHS boards are monitored on. The target supports improving the oral health of children and states:
"At least 60% of 3- and 4-year-old children, in each SIMD quintile, to receive at least two applications of fluoride varnish per year by March 2014."
There is extensive variation in these reported quintile scores between NHS boards, but generally children in more deprived SIMD quintiles are achieving better results than those in more affluent quintiles. This may be partly due to the Childsmile programme's targeting of schools and nurseries attended by children from more deprived backgrounds.
Further information is provided at: http://www.isdscotland.org/Health-Topics/Dental-Care/Publications/2012-11-27/Fluoride_Varnish_Statistics_Boards.xls
Since October 2011, additional funding has been provided to dentists for Childsmile activities, including the application of fluoride varnish.
Meanwhile, the focus of Childsmile research is on whether the programme can improve oral health and reduce health-related inequalities; it also considers which components of the interventions are responsible for the greatest impacts on health improvement.
4.3 Priority Groups
4.3.1 National Oral Health Improvement Strategy for Priority Groups
The National Oral Health Improvement Strategy for Priority Groups www.scotland.gov.uk/Publications/2012/05/7031/0 was published in May 2012. It focuses on the oral healthcare of frail older people, adults with additional needs and homeless people and makes a number of recommendations on improving their oral health. It is recognised that such vulnerable people often experience increased incidence of oral disease, and it is critical that the dental team support the needs of both patients and their carers. Progress made against the strategy's recommendations will be closely monitored.
4.3.2 Homeless people
Prior to the strategy being launched, research informed action in a number of key priority group areas including the oral health of homeless people in Scotland. A survey was conducted during 2008-2009 and the Smile4Life Report: the oral health of homeless people across Scotland was published in 2011 to provide insight into the views and health of those experiencing homelessness, in order to better support them to maintain and improve their oral health (www.dundee.ac.uk/dhsru/docs/smile4life_report2011.pdf).
4.3.3 Older people
The focus of this section is on the oral care of dependent older people and the work already done with partners service-wide to achieve oral health improvement. The multi-faceted approach taken has included the need to ensure equity of access through the promotion of dental registration, as registration rates among older people are significantly lower.
People in Scotland are generally living longer lives, and it is projected that the population aged 75 years and over will increase by 82% between 2010 and 2035 (http://www.gro-scotland.gov.uk/files2/stats/population-projections/scottish-areas-2010-based/10pop-proj-scottishareas-alltables.xls) (See Figure 2.1). Although tooth loss is reducing, the dental aspirations of the population are such that people wish to retain their teeth but thereby need more complex restorative care. The retention of natural teeth may bring its own problems, such as decay in the roots of teeth as gums recede and excessive tooth wear.
Longer lives also bring medical and poly-pharmacy complications for the dental team to manage successfully. Personal care may need to be carried out by carers, which brings further training and support needs.
Increasing numbers of frail elderly people requires wider consideration of the role of domiciliary dental care. The 2010 SDNAP report into Domiciliary Dental Care (www.scottishdental.org/index.aspx?o=3064) made detailed recommendations on service provision, including the need for enhanced training for staff, particularly care home staff, and the promotion of oral disease prevention in older adults.
NHS Health Scotland, in partnership with the National Older People's Oral Health Improvement Group, published The Caring for Smiles: Guide for Trainers in May 2010 (www.healthscotland.com/documents/4169.aspx), a comprehensive training package for oral health professionals to deliver training to staff in care establishments. Work is ongoing with key stakeholders including Healthcare Improvement Scotland (www.healthcareimprovementscotland.org) Scottish Care (www.scottishcare.org) and corporate care providers to ensure successful roll-out across Scotland.
The National Older People's Oral Health Improvement Group has raised the profile of oral health as part of the overall routine care of dependent older people. It is fundamental to establish and sustain effective relationships with care establishments and individual carers to provide oral health improvement and address health inequalities.
Email: Elizabeth McLear