Is Scotland’s oral health record something to smile about?
Scotland’s Minister for Public Health, Michael Matheson is full of cheer about the “great progress” that is being made on oral health across Scotland. In the not too recent past Scotland’s oral health record was, by the then Scottish Executive’s own admission, “very poor”, and our children had some of the worst teeth in Europe. According to its 2005 dental action plan, which set out steps to improve oral health and modernise NHS dental services, progress for children’s oral health had been “relatively static”, with 55 per cent of Scottish 5-year-olds showing some signs of decay.
But now, Matheson is pleased to report that children’s dental health is “better than ever before.” “Over 86 per cent of all children in Scotland are registered with a dentist. For 6 to 12 year olds this figure stands at almost 98 per cent, which is a tremendous achievement,” he says.
“…We have exceeded our targets for Primary 1 and 7 children, and Primary 7s have the best dental health since records began. For the first time, all 14 NHS boards have exceeded the target of 60 per cent of Primary 7s with no obvious signs of tooth decay. Now 69.4 per cent have no obvious signs of decay, compared to just 52.9 per cent in 2005.” The statistics are a sign that Scotland is “reaping the reward” of investments in children’s dentistry such as the £15m Childsmile programme, which offers every child who attends nursery in Scotland free, daily, supervised toothbrushing.
“All dental practices can now offer the Childsmile programme, including fluoride varnish application and oral health advice.
Childsmile also delivers preventative care interventions – including fluoride varnish – to children in nursery and Primaries 1 to 4 in the most deprived communities,” Matheson explains.
Additionally, all families with newborn babies across Scotland are now offered information on Childsmile by their health visitor, with parents made aware of the importance of establishing a healthy diet from the earliest stage and offered help to register with a dentist.
Childsmile is a “really good initiative”, agrees Dr Andrew Lamb, national director, BDA Scotland.
“The Childsmile programme as a whole is one that is looked upon very admiringly from other countries, not just in the UK but throughout the world, Lamb says, adding that he thinks the Scottish Government should be “commended” for the work it has done with children.
However, while he says we have seen “big improvements”, he cautions that there is still a long way to go, particularly with children from more deprived areas.
“Whilst the children from the more affluent families have actually now got virtually no tooth decay there is still quite substantial tooth decay amongst those children from the less well-off families. So, oral health in children is very much related to social deprivation, unfortunately.” While the Childsmile programme has had success amongst the young population, Lamb feels there is also a need for a greater focus on the oral healthcare of older people.
“The knock-on effect of fluoride toothpaste over now 40-odd years and the benefits of Childsmile as the child gets older is that the majority of people now have very little experience of tooth decay when they become adults,” he explains.
In contrast, those who are currently over the age of 50 who did not grow up with these same protections may have experienced a lot of tooth decay and now have teeth that have been heavily restored, such as with fillings, crowns and dentures, and this so-called ‘heavy metal generation’ may have significant restorative needs in later life.
“When they are healthy they can look after these things and keep them clean so they don’t get problems. But as their general health deteriorates then those heavily restored dentitians are going to be the ones who are the big challenge for dentists to look after,” says Lamb.
In 2010 the Scottish Government launched ‘Caring for Smiles’, a programme that provides guidance for oral health professionals to deliver training to staff in care homes so they can provide a high standard of oral healthcare for dependent older people.
“That is quite a challenge, actually, because it is always a surprise when you go into a care home how carers are prepared to do virtually everything for a patient – clean the beds, clean the patient, etc. – but they don’t seem to like, or want to brush their teeth,” says Lamb.
However, he warns that if oral health is poor then the patient’s general health can also suffer, with tooth decay and gum disease potentially leading to malnutrition and dehydration.
Further, an older person with a condition such as dementia may also be unable to communicate that they are in pain, and so Lamb says it is important that older people in residential care are given a proper assessment on a regular basis and carers are equipped with the information they need to look after the oral hygiene and dietary needs of those patients.
Scotland’s ageing population raises questions about the demand for and supply of dental services in the future. A strategic review of the dental workforce in Scotland that was published by the Scottish Government last year noted that we now have more dentists in Scotland’s NHS than every before, but also recognised that challenges remain.
Lamb admits it is difficult to answer whether we have got the numbers right.
“If you asked me that question about five or six years ago, I would have said, ‘We don’t have enough dentists in Scotland.’ We are probably still not training enough dentists for the needs of Scotland, but there is quite a lot of movement from dentists from the EU into the UK as a whole and into Scotland.” While he says the balance is “getting there”, he argues it would be unwise for Scotland to rely too heavily on migration of dentists from the EU for making up numbers of dentists in Scotland.
“There is no problem about EU dentists coming into Scotland – they are dentists in their own right – but I think it would be unfortunate if the Scottish health service was dependent on the flow of dentists from the EU into Scotland.
We should be training enough dentists for our own needs.” What should we be hoping for from the next generation of Scottish dentists? In addition to being able to cope with a wide range of clinical situations and people in a competent and professional manner, Professor Mark Hector, Dean of Dentistry at the University of Dundee, says he is “very keen” that when the students leave the university they are “socially aware” so that they understand the environments they will be working in and the various factors that influence oral health.
“That is what we are looking for. It is an understanding that just because you are poor it doesn’t mean you have to have bad oral health… If we can get that understanding into the students then I think we will have gone an awful long way towards producing very good young dentists.” Having spent the largest part of his career working in England, Hector says he has been impressed since his arrival in Scotland last year by investments in Scottish dentistry and the extent of collaborative working.
“I think what I’ve been impressed by up here is things seem very joined-up. It seems to be easier.
It is a smaller environment. England is very big with a large population and you are dealing with such huge variation within that population.
So I was based in the east end of London and what happened there was often very different from what happened elsewhere in the country.
Whereas Scotland is almost a single organism where you can have one organisation responsible for the training of newly qualified dentists and the dental schools work very closely with each other. We meet on a regular basis, we agree a common line on things, and we have common or complementary research agendas. We try and share teaching amongst the schools where we have a sparsity of certain types of teaching, for example, between ourselves and Aberdeen school we’ve just made an appointment of a senior consultant that is shared between the two schools to allow there to be much better teaching. That seems to be possible here. I couldn’t imagine working easily in London, there was too much historical rivalry between the schools.” The Dental Health Services Research Unit at Dundee University is “leading the way”, not only in primary research into oral health but also in finding ways to assimilate the data in a systematic way and to translate best practice into oral health, Hector says. However, he adds they are not working alone. Last year the Scottish Funding Council (SFC) awarded the Universities of Glasgow and Dundee £132,000 to strengthen their collaboration on dental and oral health research and facilitate a greater level of effective collaboration on issues such as inequalities in dental health, access to dental services, oral cancer, and craniofacial birth defects such as cleft lip and cleft palate, which Hector said he hopes will accelerate progress towards finding solutions and implementing them.
The universities are also working together on analysis of data from the Childsmile programme.
“That is relatively early days with Childsmile but the early indications are that it is having a huge impact on the oral health of young children,” he says, adding that he would now like to see a greater focus on reaching children at a younger age, pointing out that for those growing up in a susceptible environment tooth decay could already have taken hold by the age of 3, “so by 5 it is too late.” However, while Lamb readily recognises the successful role Childsmile has had in making inroads in children’s oral health, he argues that communities who choose to do so could benefit further still from fluoridation of water supplies.
It is, he acknowledges, a “highly politically sensitive area,” and so emphasises that it is important that communities are allowed to make those decisions for themselves. However, the Scottish Government can play a role in supporting them.
“The role that the Scottish Government can play is to make sure that the legislation is there to allow water to be fluoridated if the communities choose to do it, and in fact the legislation is there to allow that,” he explains.
“The problem is it is a great challenge to the communities to actually grasp the nettle and take it forward. It is a very emotive issue and you are going to get a substantial amount of publicity around it, probably from a relatively small number of people. But the communities that take on that challenge are going to find it extremely difficult and many of them say it is just not worth the hassle, unfortunately.” And yet adjusting the level of fluoride in the water to an appropriate level to reduce tooth decay has been found to be “very, very effective”, he says, adding that he will continue to take opportunities to impress upon politicians the benefits water fluoridation could bring.
However, until then, he agrees with Matheson that Childsmile is making “a substantial difference.” And while Scotland’s oral health record has not always been a source of pride, Lamb says we can be proud of these significant improvements in the oral health of children.