From Volume 41, Issue 9, November 2014 | Pages 832-838
Recent changes in healthcare include a shift from mainly restorative or operative-focused healthcare towards more preventive models of patient care. Oral diseases are common and yet largely controllable, thus it is increasingly a priority for dental professionals to support patients in order to promote good health and control disease in an evidence-informed manner.
The publication of the first edition of
In a move to support improvement in oral health rather than merely focus on operativebased services, the Department of Health in England, working with the British Association for the Study of Community Dentistry (BASCD), published a comprehensive evidence-informed Toolkit for dental professionals in 2007.1 The second edition of Delivering Better Oral Health – An Evidence-based Toolkit for Prevention was distributed to all NHS dentists in England in the summer of 2009.2 The third edition has just been published, the development process having been led by Public Health England,3 and with both an executive summary and the main document accessible via their website. There are plans for distribution to the profession but no need to wait – it is online now!
Prior to the Toolkit there was no standardized guideline for prevention and disease control for dental professionals and therefore all were applying their individual knowledge and understanding of what was deemed as clinically appropriate. Much will have depended on when, and where, dental professionals qualified and to what extent they had kept up-to-date.
The Toolkit was produced to support dental professionals, policy-makers and researchers in delivering preventive dentistry and promoting good health (both general and oral) amongst all patients. It also provides specific guidelines for more intensive preventive care on high-risk patients, ie those for whom there is greater concern. This included people considered at higher risk because of active disease or with medical conditions, or with evidence of these, and those for whom the provision of reparative care is problematic.
Delivering Better Oral Health brings together evidence from systematic reviews, research projects and the professional views of experts. The evidence is ranked by level, thus enabling readers to consider the strength of evidence and presenting researchers with clear challenges to contribute to the evidence.1,2,3 The final version was reviewed by the Cochrane Oral Health Group prior to publication. This paper is an account of how earlier editions of the Toolkit have been used by one Senior House Officer/Vocational Dental Practitioner (VDP) (namely EHB) and an academic/honorary consultant in Dental Public Health (JEG).
The Toolkit was introduced through the Dental Public Health course in my final year of dental school (2007/08), shortly after it was first published. Since qualifying, I have gained a more thorough understanding of the Toolkit through tutorials with my assigned consultant trainer (JEG) and this has helped me to gain more confidence in implementing some of the ideas in the current toolkit within primary dental care as well as in hospital and community services. My two-year appointment spanned all three branches of dentistry.
Since beginning my general professional training across hospital and primary dental care, I have been implementing the Toolkit as part of my treatment plans for patients. The Toolkit advises that all patients should receive preventive advice, support and care. Moreover, it is essential to explain the need for change, outline the benefits, agree what may be tackled, and support behaviour change, where appropriate. A summary of the expanded content of version three is provided in Figure 1.
Version 3 of Delivering Better Oral Health has more detailed and expanded information on all the different sections which the dental team will find very useful. As with earlier editions, DBOH3 covers the main oral diseases and key elements of prevention, including both professional advice and action. There is more comprehensive material on pathological toothwear and erosion, periodontal disease and diabetes. The section on periodontal disease discusses management of the disease, including contacting patients' general medical practitioners and the importance of early detection in young patients. There have been more illustrative diagrams to convey the information of the Toolkit to dental professionals. I particularly find information on units of alcohol in different measurements useful, especially in pictorial form, when advising patients about their alcohol intakes, as patients are sometimes not aware of the different units. A new section on behaviour change has been added and highlights the role the dental team plays to support, encourage and motivate patients in terms of their oral hygiene habits.
In this latest version, every section has been presented with references at the end of its individual chapters. It therefore makes it easier to refer to the references relevant to the topics discussed in each section. This is in addition to the supporting references at the end of the Toolkit.
Implementing the Toolkit in practice since qualification has made me (EHB) stop and think about the links we have in the wider healthcare system to support our patients' health and how we run a dental practice to support preventive dentistry and promote health in primary dental care.
As an academic and honorary consultant in Dental Public Health, I welcomed the publication of Delivering Better Oral Health. Introducing it to undergraduate dental students was my first priority. At King's College London, we were privileged to have the Deputy CDO for England, who chaired the working group for this report, come and lecture to the students. We seek to promote better oral health and want all students to leave realizing that they can play an important role on a one-to-one basis with their patients in promoting good health and preventing disease. However, it is also important to recognize the limitations of what is possible, as there also needs to be upstream action according to the principles of the Ottawa Charter.4
The Charter identifies the prerequisites for good health and the methods to achieve better health promotion through advocacy, enabling and mediation. It outlines five key action areas as follows:4
In my role as a consultant in Dental Public Health, advising local Primary Care Trusts, prior to the last National Health Service (NHS) reorganization, I was keen to ensure that, where possible, the NHS provides additional training and support to enable general dental practitioners to embrace the range of actions outlined in Delivering Better Oral Health.2 The benefits of, and need for, prevention become most apparent when you have an established patient base and you see patients returning with ‘preventable disease’. Sometimes this does not become apparent to dentists until later in their professional career. Within local health services, we have provided training for dental practitioners, support for fluoride varnishing and signposting to training courses for extended role dental nurses. In addition, dental practices are regularly provided with information on local tobacco cessation services. These initiatives mark the beginning of a process of change. To support that process, practitioners need to ensure that the environment in which they are working is conducive to a preventive approach. Much can be done through training the dental team,5 and some of the training and research at King's highlights the potential of using extended role dental nurses in delivering fluoride varnish applications.6
In his review of primary dental care, Professor Steele in 2009 suggests that there should be a clear view of the offer made by NHS dentistry.7 In the view of the review team, the NHS dentistry service should be ‘a lifetime-focused, evidence-based oral health service’, which aims to undertake the following:
Historically, payment systems have supported an interventionist reparative approach rather than facilitating prevention across all courses of care. An approach whereby everyone benefits from good home care, healthier lifestyles with regular care should contribute to oral health and support general health.
Figure 2 gives some useful pointers to support implementation of the Toolkit in a general dental practice. This article discusses useful tips as a result of my personal experience with the Toolkit (EHB). It is important to ensure that all necessary resources are available within the practice. This starts with having a copy or copies of Delivering Better Oral Health available for staff, and preferably multiple copies of the quick reference guide in Section 1 (now also available as a separate summary document). Other useful quick reference guides include an alcohol unit calculator, available from Drink-aware at http://www.drinkaware.co.uk/tips-and-tools/drink-diary/ or from NHS Choices http://www.nhs.uk/conditions/smoking-(quitting)/Pages/Introduction.aspx
It is important to consider the advice given to patients in the dental practice and the manner in which it is provided – a useful discussion point for staff meetings! Supporting behaviour change is well covered in the final chapter of the third edition of the DBOH Toolkit as an additional resource.
It is worth taking time to scope what is available in your wider environment. Do you and your team know what local pharmacists are able to provide for your patients, both in terms of high fluoride toothpastes and tobacco cessation products and programmes? Where are your local NHS stop smoking services?
A parallel publication from PHE in 2014 is the second edition of Smokefree and Smiling, which outlines the range of resources available to support tobacco cessation.8 It is worth downloading this publication from the Public Health England website for your surgery.
Remember that smokers attending UK NHS Stop Smoking services are four times more likely to succeed in quitting than those unaided.9 Medication and behavioural support further improve patient outcomes.10 Nicotine replacement therapy approximately doubles the chance of success in stopping smoking; moreover, behavioural support on top of pharmacokinetics further increases the chance of success.11
Many aspects of contemporary preventive care can be delivered by other members of the dental team from dental therapists to extended role dental nurses trained in providing fluoride varnish.12 The skill mix of the team undertaking preventive care may be critical to cost-effective delivery of prevention in future.5 So perhaps it is worth debating who can do what within your dental team and testing out different models of care.
Taking dental caries as an example, most clinicians have been taught that past or current dental caries is a clear indication of risk of future disease. It therefore makes sense for dentists providing care for individual patients to take account of caries risk (as assessed by presentation of active, non-cavitated lesions) when deciding how to allocate the time and effort of themselves and their staff.12 Fluoride is a very effective way of reducing the incidence of caries, and it is recommended that fluoride varnish should be applied to the teeth of all children. There are therefore many arguments for taking a high risk approach for all disease and conditions and The National Institute for Clinical Excellence (NICE) dental recall guideline,13 is one guide to assist with risk assessment of patients.
The Toolkit advocates that all children and adults, including those who are free from dental caries, periodontal diseases and oral cancer, should receive active preventive care.3 Dental professionals may intuitively find it difficult to accept this approach. Many clinicians may view providing prevention therapy to caries-free children as a waste of resources and time; however, this perception is based on the assumption that we can predict who will, and who will not, get caries.
Children, in particular, need our support in facilitating a healthy start in life. And we can provide support through practical interventions, such as applying fluoride varnish. We have no accurate and reliable tools to identify all the children who will develop caries. We know that children with past disease are more likely to develop carious lesions,14,15 but cannot predict who in the supposedly ‘caries-free’ or low caries population will do so. There is evidence from studies that the majority of new carious lesions over time occur in those children classified at lowest caries risk at baseline;14 thus strategies limited merely to individuals deemed ‘at high risk’ would fail to deal with the majority of new lesions and so a population approach is required to ensure that all benefit from prevention.15,16 Once a child contracts caries in the primary dentition, pain and extraction are highly likely,17 and when children develop caries in their permanent teeth they are left with a lifelong legacy of interventions and restorations requiring maintenance.
A similar picture emerges from primary dental care. A recent study of the incidence of dental caries in young children regularly attending dental practices in the north-west of England confirmed this view; as expected, three out of four children who already had caries at their first visit went on to develop further cavities over the three-year period; however, so did one in four children who were cavity-free at their first visit.18 This evidence acts as a stark reminder that, if dentists concentrate active prevention solely on those children with cavities, they will be unable to prevent the majority of new cases of the disease in their practice populations.16,18
It is also in line with the evidence on minimizing inequalities from Marmot which stresses the importance of ‘proportionate universalism’.19 We need a high risk approach which delivers additional support for those groups and individuals most at risk and a population (universal) approach for everyone to improving health19,20 – everyone needs evidence-based preventive care; hence, the importance of Delivering Better Oral Health to all dental practices.3 Over a quarter of a million people attend dental practices each day in England alone, so that provides us with many opportunities to bring about change.21
One exception to this population and high risk approach in the current DBOH guidance relates to toothwear (including erosion), the premise being that pathological toothwear should be picked up by clinicians at an early stage and managed. Thus, only a ‘high risk approach’ is advocated at present in light of the current evidence since, as a nation, we do not eat enough fruit and vegetables.22
Despite the best efforts of many dentists, operative treatment has usually taken priority over the preventive treatment of dental caries.23 Prevention isn't an alternative to high quality dentistry but an important part of the ‘package’ of dentistry for patients in the 21st century. Our national surveys of oral health remind us that many middle-aged and older people require complex interventions and management.24,25 High quality operative treatment is therefore needed and should be delivered by the profession.
It may be that doing things differently involves using other members of the dental team who may be better at delivering prevention than we are. The majority of practitioners will not have had much education in relation to behaviour change. Threlfall and colleagues examined the realities of preventive practice in a qualitative study of some general dental practitioners.26 They looked at the messages conveyed and the factors that influenced preventive care, concluding that there is so much variation in providing information that dentists were inclined to ‘give a short talk’ rather than targeted advice. Furthermore, they were more inclined to give advice to middle class parents as they were perceived as more compliant with following instructions given than those from lower social groups. Compliance, or lack of it, discouraged dentists as patients did not automatically follow advice given. Messages passed on to patients were often based on the subjective view of whoever was educating the patient – we have probably all fallen into this trap at some time. Practitioners will find that the new edition of the Toolkit has a helpful section on ‘behaviour change’ which is a ‘process’, rather than an ‘event’.3 Working with patients to set achievable goals is the way forward.
Finally, and most importantly, let's get the payment system aligned with the guidance, whether NHS or private care. Good prevention takes time. Page et al23 have argued that the practicality of implementing the Toolkit under the Units of Dental Activity-based [UDA] payment system is unattainable, considering the range of tasks that should be undertaken for the value of 1UDA. The 2006 English payment system of UDAs means that dentists continue to be paid largely on the basis of the volume of treatment delivered. In fact, the NHS has, until now, never fully recognized the importance of preventive care in dentistry, nor the value people place on achieving and maintaining good oral health.25 A paradigm shift is occurring across healthcare. It is important to recognize that dentists' remuneration will affect the way in which they deliver clinical care; hence, the benefit of the current pilots,27 which use the evidence-based Toolkit, reward quality care through a Quality and Outcomes Framework (DQOF) and will inform a new payment system.
The new scheme should take into consideration preventive treatment, and reward the dental team, as practices are likely to receive a capitation payment to cover all costs, including preventive, routine and complex work for the type 2 pilots.25,26 Also, let's model promoting preventive care to other healthcare systems.
Additional developments will include an interactive training DVD,28 as before, and a new patient facing edition, which will be important resources in developing our dental teams and serving our patients. There may even be some educational events near you – why not start by downloading the guidance as part of your continuing professional development.
This Toolkit is relevant to all members of the dental team whose scope of practice includes prevention. Practical tips are outlined to support its use in primary dental care and support a high risk and a population approach to care. Educators and policy-makers have a role in supporting its implementation across healthcare.
