Oral health improvement plan

Focus on Prevention

Moving to a Preventive Based Approach

Dental disease is almost entirely preventable so it makes absolute sense to focus our future policy direction on designing a system that encourages a more preventive approach to oral health care for patients of all ages. As the opportunity to focus on a preventive approach is recognised, the system providing NHS dentistry needs to change to accommodate it.

Water Fluoridation

Although we recognise that water fluoridation could make a positive contribution to improvements in oral health, the practicalities of implementing this means we have taken the view that alternative solutions are more achievable.

Ensuring the Childsmile Programme in All Age Groups

At present the Childsmile programme of toothbrushing and fluoride varnish application at nursery and primary school is a major factor contributing to it’s success. Dental practices can provide preventive care as part of the Childsmile programme for children up to 5 years of age. The programme will continue to be evaluated and amended as required.

For older children, aged 6 to 17 years of age, maintaining good oral health depends on good diet, regular toothbrushing and intervention from the dental practice. The good habits learned through the Childsmile programme need to be maintained in older children. We need to ensure preventive care is available to older children in dental practices. Many dental teams are doing an excellent job but we need to ensure consistency of provision across Scotland.

We intend to change payments to dentists to encourage better compliance with preventive care treatments such as toothbrushing instruction, fluoride varnish application and fissure sealants. The system of capitation payments will be supported by monitoring, meaning that the dentist needs to record the completion of these treatments for future payments to be authorised.

Action 3: The Scottish Government will change payments to dentists and introduce a system of monitoring to ensure that all dental practices provide preventive treatment for children.

New Preventive Care Programme for Adults

We intend to introduce a preventive system of care for adults by phasing in an OHRA. The assessment will include a comprehensive clinical examination and a discussion about lifestyle choices, for example diet, alcohol and smoking, and how these impact on the patient’s oral health. The patient will receive a personalised care plan in relation to oral cancer, gum disease and decay according to their degree of risk. There will be on-going reviews between assessments.

Action 4: The Scottish Government will introduce an Oral Health Risk Assessment.

Basic Check-Ups

At present, patients can receive a basic check-up every six months. However, six-monthly appointments with the dentist for all patients regardless of their state of oral health are not supported by the clinical evidence.

This is reflected in the National Institute for Health and Care Excellence ( NICE) guidelines ‘Dental checks: intervals between oral health reviews’ which states that “Recall intervals for patients who have repeatedly demonstrated that they can maintain oral health and who are not considered to be at risk of or from oral disease may be extended over time up to an interval of 24 months.” ^[8]

Under the new system of preventive care, patients will be seen according to their OHRA. This may mean that many people will no longer have to attend every six months if they have good oral health and a healthy lifestyle. Patients in poorer oral health with higher risk factors are likely to be seen more frequently.

Periodontal Care (Advanced Gum Disease)

Gum disease is caused by the build-up of plaque on the teeth, which if not removed through regular brushing, can cause the gums to become red, swollen and bleed easily when brushing or eating hard foods. Eventually plaque hardens into a substance called calculus which can make brushing less effective, causing more inflammation.

The mainstay of NHS provision has been a simple scaling and polishing which was thought to prevent gum disease. However, the balance of evidence has now thrown significant doubt on the clinical effectiveness of this approach. The most effective option for routine care is adequate oral hygiene by the patient themselves.

The intention is to move to a new system of dental care and treatment that is more clinically appropriate and evidence-based than at present. For patients with periodontal disease or a high risk of developing it, they will receive a clinically proven programme of periodontal care.

As this will be a significant change for patients and dental practices, we envisage that a substantial period of transition will be required to ensure continuity of provision.

Action 5: The Scottish Government will introduce a clinically-proven programme of periodontal care for patients with periodontal disease and those with high risk of developing it.

General Health Checks for Adults

The dentist is the one health care provider in primary care whom adults consult on a regular basis throughout their lives. As at September 2016, 91% of the Scottish adult population were registered with a dentist and almost three quarters attended in the previous two years. ^[9]

It may be of benefit to our general practice medical and nursing colleagues if we could harness this patient cohort for routine general health checks to assist in the early detection of long-term chronic diseases, for example diabetes. It will also allow patients to receive advice and treatment on how to manage their health at the earliest opportunity.

Action 6: The Scottish Government will explore the potential for introducing general health checks for adult patients whilst attending for routine dental checks.