How teamwork pays off
Shetland is among the UK’s top performing areas for oral health in children. Scottish Dental spoke to some of those involved in the programmes achieving results
The National Dental Inspection Programme (NDIP) looks at the teeth of two school year groups – P1 as children enter local authority schools and P7 before they move to secondary education. In 2019-20 the teeth of more than 3,000 children – 22.5 per cent of the estimated P1 population – were examined across Scotland.
While the inspections in school are not necessarily as rigorous as those conducted in a dental surgery, they do record decay where disease has penetrated below the white enamel layer. The latest findings, published by Public Health Scotland (PHS) last October, showed that nearly 74 per cent of children in P1 had no obvious decay in their baby teeth – a three percentage point improvement on the previous year.
When the programme began in 2002-3, only 45 per cent of P1 children were without evidence of tooth decay. The figures also showed the average number of decayed, missing or filled teeth per child had reduced from 2.76 in 2002-03 to 1.04 in 2019-20.
Despite improvements, PHS highlighted the link between deprivation and poor dental health. Almost 42 per cent of P1 children in the most deprived areas had obvious dental decay, compared with just over 13 per cent in more affluent parts of Scotland. P1 children in the most deprived communities experience more than four times the level of tooth decay – an average of 1.78 decayed, missing or filled teeth per child compared to 0.40 in the least deprived areas. The report said the gap had narrowed in recent years, but the British Dental Association warned decades of improvement could be at risk as a result of the pandemic.
The top performing areas in Scotland were Orkney (84.02 per cent of P1 children had no experience of dental decay) and Shetland (84 per cent). Antony Visocchi, director of dentistry for NHS Shetland, said: “Our NDIP figures have been maintained at a very high level for some years and I am glad to say we are still there after the results were recently published. We are aware the lack of access to dental services and the long lockdown could have had a detrimental effect on the dental health of all vulnerable groups across the island.”
His comments coincided with the launch by the NHS oral health improvement team in Shetland of a Facebook page and, during Mouth Cancer Action Month in November, an initiative which saw Lerwick Town Hall illuminated in blue, the health campaign’s signature colour. “The team is so enthusiastic and knowledgeable, getting the message across effectively and with fun,” he added.
Last month, Scottish Dental caught up with some of the team on Shetland.
Morag Mouat, oral health improvement team leader, is responsible for the Childsmile, Caring for Smiles, Open Wide and Smile4Life programmes. A dental hygienist, she works in clinic two days a week. “I travel to satellite clinics, both require a ferry crossing,” she said. “There are some interesting trips in winter!” Because of the pandemic, Morag has not been in clinic since March last year. It was “all hands-on-deck”, supporting staff and devising ways to continue their work.
Morag did her dental nurse training in Edinburgh before coming home to work for the then community dental team. “I was fortunate to be involved in the fluoride research project in the isles in the 1980s. Professor Ken Stephens, from Glasgow Dental Hospital, was the lead and through this my interest in prevention grew.”
She completed a hygiene course at Glasgow before returning to Shetland to launch a preventative programme. She worked in practice and joined the Public Dental Service, assuming her current role in 2016.
“I have seen how oral health has improved since my first days of dental nursing,” she said. “I’m aware that projects we start may not see the benefits until many years in the future. Oral health was always a poor relation of medical health and I hope that during my time in this job I have worked hard in making sure it is included in all aspects of care.
“During the pandemic I’ve tried to do the best I could in the ever-changing situation; supporting staff and encouraging them to think outside the box on how we can deliver oral health messages with new barriers in place. For the Childsmile team, who are used to daily interaction with children, this was a massive change. Once we settled down and Teams came into the equation, they started to brainstorm on how they could reach children and particularly vulnerable families.”
Morag added: “Some staff enjoyed working at home, others not so! Once we get back to normal we will look at how we can make this work. We have all become more au fait with technology. We looked at setting up a Facebook page for a few years, but this time has allowed the team to set it up and keep it updated. The team, from being nervous about appearing in front of a camera, have embraced it. I’m really proud of them.”
Her aims for 2021? “To make sure staff are well and feel supported. I fear coming out of this pandemic may be more difficult than going into it – a bit like staggering towards your holidays and then ending up with a heavy cold. Getting back into schools will be a major part of our year for the Childsmile team. I know they can’t wait to be able to engage with the children again. Personally, this is a time to look at how we engage with vulnerable, non-engaging families. This has always been a challenge and although Near Me has been a success we have to understand digital poverty and not everyone has, or wants, the ability to connect to us.”
Michelle Sinclair is a senior dental nurse tutor and oral health educator. During the pandemic, she participated in webinars provided by allied health professionals and the Near Me video consultation team to explore the use of online appointments for Childsmile Community and (dental) Practice (CSC&P) appointments. Michelle hosted weekly appointments, mainly for children from six months to two and a half years.
“This is the age group who have had the least oral health input as they have not started nursery or school,” she said. Older siblings can take part and, said Michelle, they have “engaged with the Near Me process, being honest about their oral health regimes”.
The frustrations of IT and lack of in-person contact aside, there are benefits to online appointments, she said. They are less prone to cancellation if a child is unwell, or the weather is bad, and even if the child becomes distracted, parents remain engaged and welcome the opportunity to discuss their child’s health.
Michelle said she found online appointments less bureaucratic, allowing more time for rapport-building, discussion and advice. “Usually, by the time the paperwork is complete in a normal clinic setting, children have lost patience,” she said. “Online, we are able to get on with the appointment immediately.”
She is collaborating with researchers from Dundee University’s School of Dentistry on using observational analysis to evaluate Near Me appointments for potential permanent incorporation, into the standard Childsmile, Community and Practice appointment system, already well established in Shetland.
Angela Hopwood is an oral health improvement nurse who works on all aspects of Childsmile, as well as liaising with other health professionals and working with vulnerable groups. “A small, but important, part of my role is in the delivery of local interventions for the national oral health and homelessness project, Smile4Life,” said Angela. Shetland does not have a rough sleeping population per se, but there are people not in settled accommodation.
“Routine dental care is an important part of building self-esteem and improving mental health, and supporting a return to education and employment, which are important parts of the route back into safe and settled accommodation,” said Angela.
With the help of specialist colleagues, Angela has developed an autism and learning disability Patient Communication Passport for Shetland’s dental service. It allows clinical teams to be briefed on a patient’s needs before they attend, improving compliance in treatment and reducing missed or delayed appointments. She has also developed sensory aid boxes for dental settings, for patents with autism or learning disabilities and people with dental anxieties.
“Raising awareness around mouth cancers has been a huge driver for me,” said Angela. “We have always held campaigns in Shetland to raise awareness. We include mouth cancer awareness in lessons with secondary school pupils and more people are aware of mouth cancers, not just locally but across the country, thanks to the Oral Health Foundation’s campaign.”
She added: “The plan for 2021 is how we deliver programmes under restrictions. We have concerns when schools are closed in regard to the content of snacks at home and the potential for children to graze rather than have break times. This could impact on oral health. Near Me appointments will go a long way to reach families and encourage positive behaviours, but we are mindful that it is going to be motivated families engaging with us so finding new ways to target hard-to-reach groups is to me paramount.”
Team views
CLARE BALFOUR is an oral health support worker and extended duties dental nurse who, in normal times, visits and supports nurseries and schools with the Childsmile programme and fluoride varnish visits.
“From working many years ago as a dental nurse and seeing the poor state of children’s teeth, it made me want to help make a difference. Due to hard work by staff – both dental and in educational establishments, as well as by parents – NDIP results have shown the children here now consistently have among the best teeth in Scotland,” she said.
“I would like to keep that trend continuing and keeping parents engaged and appreciating how important good oral health is for all and why.” Clare has begun training in Near Me consultations and is looking forward to holding Childsmile appointments online.
“The consensus so far is that parents have been finding the appointments very useful, so we hope to build on that,” she said.
Elizabeth White is also an oral health support worker who, pre-pandemic like Clare, visited nurseries and schools across Shetland. “Childsmile has greatly improved the oral health of children in Shetland over the past 10 or more years – we have been successful in getting to see every nursery-aged child in Shetland for toothbrushing and oral health education – and the aim is to ensure this continues. Hopefully we will be able to get back into nurseries and schools in the not-too-distant future.”
Colleagues Niki Madai and Zdenka Mlynarikova both highlighted the benefits of thinking differently about how to engage people. Niki commented: “While the pandemic meant face-to-face appointments and visits couldn’t go ahead, it’s pushed me to be more creative. Being able to reach people through Facebook has been a huge success. We aim to keep enrolling children, even if we can’t visit them, and to find new ways of encouraging people to pay attention to their oral health.”
Zdenka, who is also studying music, agreed: “Creativity seemed to be a way forward in everything we have done, using our spare time effectively to learn new skills, such as video editing or social media insights.
“The Facebook page has been quite a success so far, and our two-minute tooth brushing song and video was shared by many health-related organisations within the isles and sent out to schools and nurseries, which we believe had positive impact on children’s oral health.”
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