Important and achievable
Good oral health will require commitment from professionals – and the political will to make it happen
As the division between the dental profession and the Irish Government over the state’s new oral health policy deepened last month, their counterparts in Northern Ireland gathered at Stormont to find common ground.
At an event organized by the British Dental Association (BDA), more than 80 stakeholders, including dentists, public health representatives, health spokespersons from the main political parties, policymakers, and representatives of charities, heard from BDA Northern Ireland representatives, the Chief Dental Officer, the Head of Dental Services at the Health and Social Care Board (HSCB), and experts involved in delivering care to vulnerable children and the elderly.
Tristen Kelso, BDA Northern Ireland’s National Director, commented: “Ultimately our aim for today is that it marks the start of a fresh, ambitious and renewed vision that reconnects oral health to general health, that achieves better outcomes for our population, that is based in collaboration within the profession and beyond. He added: “It would be remiss not to acknowledge the dedication and commitment of local dentists to provide the best care possible to their patients – often in spite of difficult working conditions, including growing workforce pressures in the community dental service and what has become a very challenging financial context for GDPs to provide health service dentistry. A strategic approach towards addressing these workforce realities will have to be factored into any new oral health policy process for it to succeed.”
The Oral Health Matters summit in Belfast came in the wake of a statement by the Faculty of Dentistry in Dublin that the Irish Government’s Smile agus Sláinte policy, published last April, was “fundamentally flawed”. Dr John Marley, faculty dean at the Royal College of Surgeons Ireland, wrote to Simon Harris, Ireland’s Minister for Health, reiterating its concerns about the policy. Dr Marley said it should be changed to provide for a mandatory system of continuing professional development for dentists, as well as introducing further specialist lists beyond the existing ones in orthodontics and oral surgery.”
Dr Marley said the Department could not “simply race ahead” with the policy without putting in place the foundations needed to make it a success. “Enacting the legislative changes now to ensure that our dentists are sufficiently trained and educated must be the immediate priority for the Department. Unfortunately, we see no evidence of this promised legislative change being actioned.”
At Stormont, however, there was an air of consensus. Not on everything – including whether, fundamentally, there was a need for a new oral health strategy in Northern Ireland – but certainly on where new effort should be focussed; that is, on young people and the elderly. Simon Reid, the Chief Dental Officer (CDO), was nonetheless pressed by a delegate on the strategy. It had been raised earlier by one of Reid’s fellow speakers; the fact that it dates from 2007. In response, the CDO questioned whether spending two years on writing a new strategy was a good use of scarce resources when there was already broad agreement on current priorities.
It had been a “significant piece of work,” he said. However, the key principles – prevention, complimentary health promotion programmes, partnerships, and reducing inequalities – hadn’t changed. The recommendations were still valid, and targets originally set had been met, said Reid. He did say that, regarding partnerships, there should be more “embedding” of oral health in wider public health. In addition, he recommended consideration of new targets. The outcome of this thinking, as Reid revealed at the summit, is the establishment of two ‘oral health options’ groups, focussing on the oral health of children and the elderly in Northern Ireland. Caroline Lappin, chair of BDA Northern Ireland’s Council, said the announcement was “welcome news”.
She added: “The pressing needs of the local dental workforce will have to be factored in if this work is to ultimately succeed. Our Community Dental Service is already unable to meet the existing demand for oral health care – while General Dental Practitioners are increasingly struggling to make health service dentistry a financially viable proposition. Whatever options are generated, additional investment to bolster oral health in Northern Ireland will be necessary. Going forward, improving oral health must be viewed as integral to embedding the prevention agenda, and delivering wider public health benefits to the population.”
Oral health in Northern Ireland has, for many years, been considered the worst in the whole of the UK. Despite recognised progress, considerable challenges continue to be faced in 2019, not least affecting the youngest and oldest cohorts of the population. According to the latest Child Dental Health Survey, published in 2015, just 19% of 15-year-olds here were considered to have ‘good oral health’. In 2017/18 almost 5,000 (4,724) children faced tooth extraction under general anaesthetic in Northern Ireland (pro-rata, three times more than in England). BDA Northern Ireland has also highlighted the mounting pressures on dentists to meet the increased challenges from a growing ageing population that is increasingly retaining some natural teeth into old age.
In their presentations at the summit, Caroline Lappin and Dr Gerry McKenna, Specialist in Restorative Dentistry and Prosthodontics at Belfast HSC Trust, outlined the detail of the scale of the problem facing Northern Ireland’s young and elderly populations. McKenna outlined the demographic trends leading to more people living to old age and their increasing life expectancy at that stage in life.
This age group is also keeping more of their teeth. But, he said, managing natural teeth in older people is challenging, with increased incidences of chronic dental disease. A 2019 Care Quality Commission report found the majority of care homes had no policy to promote and protect people’s oral health, almost half of homes did not provide staff training to support people’s daily oral healthcare, and 73% of residents’ care plans covered oral health partially or not at all.
McKenna outlined the National Institute for Health and Care Excellence guideline for improving the oral health of adults in care homes, a National Institute for Health Research-funded study designed to test the guideline, and the development of a ‘core outcome set’ specifically for older patients, supported by the BDA, in partnership with the Patient and Client Council, Age Sector Platform, Public Health England, and the Regulation and Quality Improvement Authority.
Caroline Lappin noted that she had been fortunate to study as a post-graduate under Aubrey Sheiham, Professor of Dental Public Health at University College London Medical School. “He was a man ahead of his time,” she said. In 2005, Professor Sheiham wrote: “The compartmentalisation involved in viewing the mouth separately from the rest of the body must cease.” She also highlighted the Faculty of Dental Surgery’s position statement, published this year, on how dentists could play a broader role in supporting their patients’ general health to deliver a “more holistic model of care”.
Lappin said there had been improvements in children’s oral health in recent years but, “sadly there is still a huge level of dental disease amongst children in Northern Ireland; the most recent survey, in 2013, revealing that obvious dental decay experience was present in the primary teeth of 40% of five-year-olds, rising to more than 70% by the age of 15. The Global Burden of Disease study from 2010 found that most disabilities amongst five to nine-year-olds in the UK was caused by poor oral health and that it was the most common reason for a child to be admitted to hospital. “This situation is almost entirely preventable,” added Lappin.
In the year 2017-18, 23,035 teeth were removed under general anaesthesia – of which 20,566 were baby teeth.
“My day job is working in the community dental service in the South Eastern Health and Social Care Trust. So, less than a mile down the road in the Ulster Hospital, you will find me on a Monday morning doing just this,” said Lappin, pointing to a photograph of a child under general anaesthetic surrounded by clinicians. “However, more worrying is the weekly occurrence for me and my colleagues in trusts across Northern Ireland who carry out these roles, that we are taking 12, 14 teeth out of one child on the list due to dental decay, which is an almost an entirely preventable disease.”
Lappin acknowledged the efforts of colleagues in the Department of Health and the Health and Social Care Board to reduce dental disease, through the ‘Happy Smiles’ programme for children and the fluoride varnish programme for children and the elderly. “Those projects ran extremely well last year,” she said, “unfortunately, in this financial year, the money was not available to continue the fluoride programme.” Lappin said there was a “clear need” to link oral health policy to over-arching health policy. She urged everyone in the room to confront this. “The case for change is clear, but we need support from each of you to bring it forward. We in the BDA are asking for a new vision for oral health care in Northern Ireland. Training more dentists, building more clinics is not realistic; it is also not the way forward. We in the BDA, along with colleagues in the Department of Health, the Board, the Public Health Agency, the regulators, our charity and third sectors, and our population; we need to work together to make change happen.
“Twenty years ago, the mantra was very much ‘prevention, prevention, prevention’. It’s still true today and even more relevant. Other regions have demonstrated that cost-effective and evidence-based programmes do work. However, we need a commitment from professionals and the political will to make this happen.” Quoting from a 2019 Lancet report, Lappin concluded: “Preventing oral disease is important and achievable. Good oral health should be everybody’s business.”