With the publication of the Five Year Forward View, the arguments for what Simon Stevens called ‘mission critical’ change through new models of care were made. Various priorities were noted including conditions such as diabetes and obesity and a considerable emphasis on primary care within the redesign services.
Conspicuous by its absence was any specific mention of dentistry. This lack of a mention of dental elements in any ‘change’ in health services is not new. Over the years it would appear that as a policy is completed someone then asks ‘’Eeerh, what about dentistry?’ Subsequent policy decisions have tended to continue to be dental specific as opposed to looking at how better integration might evolve, truly placing the individual user at the centre of the whole system. Indeed, a recent example was the fanfare surrounding entrants to residential care homes being given a ‘health’ assessment. No thought appears to have been given to including a dental element, even simply to ask “Have you any problems or would you like to see a dentist?”
Why this happens could be for a number of reasons. The NHS dental system is different to general NHS medical services. There is no registration. Once a course of treatment is finished, the patient can go wherever they wish. An individual can choose to see any dentist who has an NHS contract irrespective of where they live – unlike General Practice where until the recent boundary changes, patient choice of their doctor was limited to a geographical area.
There has never been an attempt to distribute practitioner numbers across NHS planning units except on a very small scale, unlike medicine with open and closed areas. And then there are patient charges. Despite the rhetoric of many politicians that the NHS is free at the point of delivery, since 1952 dental charges have existed. Except for children and those individuals who meet any exemption criteria, dental care including the initial assessment has a co-payment. Indeed, the cost of a set of dentures on the NHS exceeds that of the current winter fuel payment. The co-payment issue perhaps helps to explain the considerable variation in usage of NHS dental services by age band.
But the position described above masks some important evolving changes in the epidemiology of oral diseases over a very short period of time. For example, since 1968, the proportion of all adults with some teeth has increased from 37 to 94%. Indeed, the latest national survey of England and Wales highlighted that 53% of those aged 85 or over had some teeth. The improvements have also occurred at the other end of life: the percentage of children with no obvious dental decay has changed from 69.1% in 2008, 72.1% in 2012 to 75.2% in 2015; a change of six percentage points and an improvement of 8.8% since 2008.
However, for the older age groups, the improvements in oral health create a more complex set of issues. Now, instead of losing their teeth and having dentures or, implants, it is the management of them that is becoming an issue. All teeth restored or otherwise, are at risk of future disease. With co-morbidities, such as various forms of dementia and even arthritis, an individual’s ability to clean their mouths becomes more difficult. Numerous of the drug regimens that people are on impact on saliva flow and increase the risk of tooth decay and the gum diseases. So where then does dentistry fit into these new models of care or indeed should it?
It certainly adds ‘value’ to the patient experience but it can also have a positive effect on clinical outcomes. Poor oral health may be linked to other diseases, probably more through association than causation, but care can reduce the risks of other problems. Evidence showing a reduction in aspiration pneumonia reductions in hospitals through improved oral hygiene practices and fewer falls in the elderly (and potentially A&E admissions) through improved nutritional intake are two examples of where dental care can offer benefits.
The main determinants of oral disease are ‘diet’ and ‘dirt’. It is the management of these two items that will help. Helping support self-care where possible; and when not, ensuring that all care staff have an understanding of how best to make a contribution is central. Policies aimed at ensuring that sound nutritional polices are followed, not least ones that are low in sugar; and advice and support on oral hygiene practices are key. The promotion of health supporting activities by all care staff who have contact with various groups; the incorporation of an oral healthcare element within health assessment arrangements; and the adoption of sound oral health practices, will all help.
As the rapid changes in the epidemiology of oral diseases filter through the population, their management will be the critical factor. Enabling someone to socialise, be free of pain, to eat and enjoy their food are factors that add value to an individual’s wellbeing as well as their health. Collaboration between health and social care professionals and dental care providers can add value. This is where dentistry can and should be included. Indeed, the benefits to be gained from this approach are surely a central pillar for the justification of the new models of care?
Dr Paul Batchelor is the Vice-Dean of the Faculty of General Dental Practice UK and an Advisor in Dental Public Health