Reflections on the future of dentistry in Scotland
The SDR continues to have fundamental flaws and a paradigm shift to address primary prevention, as described in the WHO Global Oral Health Action Plan, is required
I had the privilege of being asked to speak at the Scottish Dental Show 2024 – and, thereafter, the great pleasure of attending the presentation by Tom Ferris, the Chief Dental Officer, and Elaine Hutchison, DCP Advisor.
I am full of admiration for what they have both achieved in recent times – and Determination 1 (the revised dental contract) has undoubtedly made an impact. When Tom reported that his inbox has been much more manageable since 1 November 2023, that shows how well received it has been as this was not an easy task. However, I suspect this might also be a reflection of the reduced number of dentists still practising NHS dentistry, and the most disgruntled are now in private practice.
The commentary I provided dealt with both the global and local pictures of oral health provision. Dental and oral diseases are the most prevalent of all human diseases and the most deprived bear the greatest burden and endure the greatest suffering; yet the model we have adopted in dentistry allows disease to happen and the spiralling costs of treatment make dental interventions increasingly unaffordable. The global expenditure on oral and dental disease was reported as being 550 billion dollars in 20151, and this despite the fact that these diseases are eminently preventable. I argued that by failing to grasp the prevention aspect, expenditure on treatment is becoming overwhelming and introducing serious inequalities in access.
Dentistry remains firmly stuck in its own silo, with no mention of the holistic benefit of good oral health
My presentation was primarily concerned with solutions however, and the following highlights the differences and synergies between the current situation as described by the CDO and the projected future.
Future workforce
The workforce initiatives that Elaine mentioned are absolutely essential for the future – with DCPs, such as hygienists and therapists, being able to undertake an increasing amount of preventive-oriented healthcare – and it would be incredibly important that their value is recognised and enhanced with whatever that takes. The World Dental Federation (FDI) Vision 2030 document2 highlights how the revision of our ideas on an expanded workforce within (via DCPs) and beyond the dental profession provides the solution worldwide.
Yet dentistry remains firmly stuck in its own silo, with no mention of the holistic benefit of good oral health despite the common risk factors and increasing evidence of the value of oral health to overall health and wellbeing. Acknowledgement and understanding of the consequences of tooth decay, tooth loss and of gingivitis and periodontal inflammation to systemic inflammation and overall health is essential to developing appropriate prevention strategies.
Integration and holistic care
The notion of integration of oral health with our colleagues in medicine, pharmacy, physio, mental health and so on is now being driven globally by the World Health Organization (WHO), FDI, the International Association for Dental Research (IADR) and the Non-Communicable Disease Alliance (NCDA). Thanks to the adoption of the so-called ‘landmark resolution’ on oral health at the May 2021 World Health Assembly, an unprecedented opportunity presents for oral health to make a meaningful contribution to overall health.
The resolution on oral health provides an unprecedented opportunity for oral health to make a meaningful contribution to overall health.
The opportunity for the dental profession to drive this broader agenda of integration is now a major global priority and encompassed by WHO in the May 2024 Global Oral Health Action Plan (GOHAP)3, yet it is not even mentioned in Determination 1. Furthermore, integration of health and social care did not receive attention or consideration despite the fact that this is now a Scottish Government priority. If we aspire to address the root causes of non-communicable diseases (NCDs) the social and commercial (e.g. sugars) determinants of health need to be incorporated, and dentistry is well placed to make a meaningful contribution to disease prevention and overall health and wellbeing.
The recall interval dilemma
The message that the lengthening of the recall interval has sent to the dental profession and to the general public is fundamentally flawed, as is the evidence it is based upon, and the reason for this is that to define oral health risk through a measure of gingivitis is a misrepresentation. Oral health is no longer confined to the oral cavity and cannot be defined by this single metric, as the future of oral health lies in holistic care and thinking of the oral cavity as a window on the rest of the body.
Prolonging the recall interval has had a profoundly negative effect on the perception of the importance of oral health and has ignored one of the fundamental values of recall as a screening tool (direct observation and biomarkers) for a range of diseases, and this includes oral cancer detection for which the evidence for dental recalls being life-saving4 is overwhelming. As well as increasing risk of disease it also has negative effects on the dentist/patient relationship, it has failed to acknowledge the importance of the public voice and the wishes of both patients and primary care dentists, is not a practice builder and it is contrary to attempts to project the dental profession as a caring profession playing a role in holistic care. For some combination of these reasons, many NHS dentists realised that their pastoral, professional and business interests were being undermined by this and regrettably were forced to leave NHS Dentistry.
In the INTERVAL trial it was acknowledged that patients were overwhelmingly in favour of retaining the six-monthly recall interval, yet the new Determination 1 ignores this.
A fundamentally important issue in the vision for the future of the dental profession and dentists as oral health professionals is behaviour change and the empowerment of patients to take ownership of, and responsibility for, their own health and wellbeing using motivational interviewing or health coaching. An important aspect of the “motivation / action/ prompt” (MAP)5 behaviour change approach for holistic care is longitudinal monitoring and continuous motivation. This health coaching model is evidence-based, requires regular contact and, importantly, can be facilitated by mobile technology so the recall would not necessarily be always an in-person visit.
In the INTERVAL trial6 it was acknowledged that patients were overwhelmingly in favour of retaining the six-monthly recall interval, yet the new Determination 1 recall guideline ignores this, has recommended a longer recall interval for the vast majority of patients and states “a practice may wish to offer a private examination and hygiene visit for any patient who would desire a more extensive or frequent input”. The fact is that while such desire for regular recall is unlikely to vary with socio-economic status, it is only more wealthy patients who would be able to afford this, and the most vulnerable in society are being effectively denied access to care – making this a breach of the principle of equality of access to care and a derogation of our duty of care for a procedure (oral screening) that we know saves lives.
Scottish Government support
I applaud the fact the Scottish Government is so supportive of dentistry – as the packages for streamlined interventions outlined in Determination 1 are needed and are not cheap, and the roll out of the preventive ChildSmile programme7, in particular, is to be warmly welcomed. I believe it is the first and best example in the world to date of a government supported public health initiative which promises to deliver very significant health and economic benefits in the future.
A recent health economics evaluation has put the implementation costs of Childsmile at around £4m, while the direct cost savings at this early stage are estimated to be around £8m. It has the other incredibly important feature of being built on the platform of ‘proportionate universalism’, the provision of a greater level of care to those in greatest need and therefore it has the potential
to address health inequalities.
A white paper published by the World Economic Forum in May 20248 focused on global oral health and concluded that better oral health lowers overall health costs and that current systems that fail to integrate oral health as part of primary care are fundamentally flawed in terms of both a) health and well-being, and b) health economics. Unfortunately, the beneficial effects of Childsmile are being countered by the detrimental effect of introducing a longer recall interval, as less frequent recall will inevitably increase subsequent treatment costs. The cost to the NHS of one delayed oral cancer diagnosis would pay for many thousands of recalls, not to mention the human costs in terms of morbidity, distress and suffering.
The solution
My final slides highlighted the upstream work of WHO, FDI and IADR; there is evidence that the tide is turning, with recent literature reflecting changes in attitudes in the profession towards involvement in the provision of holistic care in primary dental care settings with unique access to the general population9; and research is producing evidence of the impact of dental and oral health in prevention of other NCDs10 and the cost-effectiveness of such a model8.
All of this should be reinforced by educational institutions being proactive in the revision of their curricula, and the changes made recently by the GDC in launching the ‘safe practitioner framework’ are helpful towards achieving this objective. Interactions with colleagues in medicine are critical and the undergraduate medical curriculum could be enhanced by ensuring future doctors can work alongside their dental colleagues. Adopting this would be the first step towards a National Health Service to replace the disease-oriented and unaffordable National Sickness Service we currently have.
SUMMARY
The crisis underlying oral health globally is a result of dentistry’s inappropriate model for the delivery of dental care. Determination 1 in Scotland continues to have fundamental flaws and will widen the inequalities gap.
A paradigm shift is required that begins to address primary prevention as described in the WHO Global Oral Health Action Plan (GOHAP) released in May 2024 in response to the World Health Assembly Resolution in May 2021.
Scotland, by introducing an Oral Health Improvement Plan (OHIP) for marginalised groups and Childsmile for mothers and infants, is uniquely well positioned to adopt the preventive paradigm. Both are government-supported initiatives underpinned by proportionate universalism to address oral health inequalities.
The integration of health and social care in Scotland, introduced in 2016 and more recently a behaviour change model (MAP) are other progressive initiatives for primary prevention and both at an advanced stage of preparation.
A new model for appropriate remuneration of the workforce in primary dental care that rewards the integrated and prevention-oriented agenda that the Scottish Government already aspires to would transform the health service, improve population health and wellbeing and ensure long-term sustainability.
Scotland is also leading the world in public health research and a recently UKRI-funded project entitled REALITIES11 aims to improve the evidence base for social prescribing and community assets contributing to sustainable health improvement and reducing inequalities.
References
1 Listl S, Galloway J, Mossey PA, and Marcenes W. Global Economic Impact of Dental Diseases. J. Dent Res, 2015, Vol. 94(10) 1355–1361
2 FDI World Dental Federation. Vision 2030: Delivering Optimal Oral Health for All. 2021. Available at www.fdiworlddental.org/vision2030 (accessed July 2024).
3 World Health Organisation. Global Oral Health Action Plan (2023–2030).
May 2024. Available at GOHAP: iris.who.int/bitstream/handle/10665/376623/9789240090538-eng.pdf?sequence=1
4 Weaver M. Rise in mouth cancer deaths linked to NHS dentist shortages, say campaigners. The Guardian (London) 8 November 2023.
5 NHS Education for Scotland (NES): Behaviour change for Health. www.nes.scot.nhs.uk/our-work/behaviour-change-for-health/
6 Clarkson J E, Pitts N B, Fee P A et al. Examining the effectiveness of different dental recall strategies on maintenance of optimum oral health: the INTERVAL dental recalls randomised controlled trial. Br Dent J 2021; 230: 236–243.
7 Childsmile. Homepage. Available at www.childsmile.nhs.scot/ (accessed July 2024).
8 World Economic Forum (WEF)_White paper (accessed July 2024). www3.weforum.org/docs/WEF_The_Economic_Rationale_for_a_Global_Commitment_to_Invest_in_Oral_Health_2024.pdf
9 Doughty J, Gallier S M, Paisi M, Witton R, Daley A J. Opportunistic health screening for cardiovascular and diabetes risk factors in primary care dental practices. Br Dent J 2023; 235: 727–733.
10 Herrera D, Sanz M, Shapira L et al. Association between periodontal diseases and cardiovascular diseases, diabetes and respiratory diseases: Consensus report of the Joint Workshop by the European Federation of Periodontology (EFP) and European arm of the World Organisation of Family Doctors (WONCA Europe). J Clin Periodontol 2023; 50: 819–841.
11 REALITIES in Health Disparities: Researching Evidence-based Alternatives in Living, Imaginative, Traumatised, Integrated, Embodied Systems. Lead Research Organisation: University of Edinburgh. gtr.ukri.org/projects?ref=AH%2FX006131%2F1