An exemplary model
There is a real opportunity to build a ‘uniquely Scottish bridge over the troubled waters ahead’
I was particularly interested in The Insider’s article – Troubled Waters Ahead – in the last edition of Scottish Dental. The author made some extremely important points. The current situation with NHS dentistry is undoubtedly a threat; but as well as being a threat, and one that we must take very seriously, it is also a massive opportunity for change – and change will undoubtedly be required if NHS dentistry is to survive.
In 2019, a forum called Vision 2030 (V2030) was set up by the FDI World Dental Federation (FDI), and much of what I will say here comes from the consultations within the profession arising from that. The pandemic, of course, has had a serious impact but the FDI V2030 report was not published until 2021 when the effects on the profession were observed and only served to reinforce these concerns that significant changes are required.
The Insider made some very good points about political will being a crucial factor and I particularly liked the comment that ‘workforce planning and training must be the priority’. The situation we find ourselves in here in Scotland, with a changing administration, are ideal for feeding these ideas into the political arena. In fact, on the following page in the same edition, David McColl, Chair of the BDA’s Scottish Dental Practice Committee, is quoted as saying: “NHS dentistry’s survival requires rapid action, with meaningful reform and sustainable funding.”
I was pleased to note the publication of the draft dental practice guidelines for Scotland (Determination 1) and I am keen to provide some feedback. Firstly, I understand that the remuneration structures are still under consideration, and this will be a crucial element of the ultimate uptake and implementation (and that was the main reason for sending the communication).
Remuneration is key; even though the Determination 1 document does not provide the granular detail, the greater emphasis on primary prevention does shine through. Even though not every aspect of primary prevention and minimal invasiveness in clinical practice carries the same level of evidence base, there is no doubt that there is a massive room for improvement in the provision of preventive dentistry and less invasive procedures – and suitable remuneration is needed to influence behaviour and incentivise uptake.
World Health Assembly
I would be keen to feedback on one other aspect that I have taken from my experiences with the WHO’s oral health work and I comment in the capacity of my involvement as a co-author of the V2030 document1 released in January 2021.
This was followed up at the World Health Assembly in May 2021 with the “landmark resolution”, as the WHO’s Director General Dr Tedros Adhanom Ghebreyesus described it, of oral diseases being added to the list of noncommunicable diseases (NCDs)2.
This offers the oral health profession (including, but not confined to, primary care dentists) an unprecedented opportunity to integrate oral care with holistic care/general health and wellbeing; and oral health is now on the elevated platform of the NCD Alliance alongside cardiovascular diseases, diabetes/obesity, cancers and respiratory disorders.
One of the unique aspects of dentistry is the access to healthy people and this in turn offers the potential for dentists to play a much more proactive role in general risk assessment and screening for a range of conditions, such as cardiovascular disease, type 2 diabetes and a whole range of diseases, disorders and health conditions that have oral manifestations.
In addition, there are things that dentists are uniquely qualified to diagnose early such as oral cancers, but dentists could also play a role in the screening for other cancers and a range of other general health conditions. There is also evidence of reciprocation – it is noteworthy that in the United States, the American Medical Association has announced what is hailed to be a landmark gesture towards dental caries prevention – the approval of the application of silver diamine fluoride (SDF) by medical professionals to arrest cavities3.
Undergraduate dental curricula
In the dental profession, in the modern era, Bachelor of Dental Surgery (BDS) curricula are placing more emphasis on the need for primary prevention and new graduates are being trained to appreciate the possibilities for prevention of oral diseases, and the role of oral health in overall health.
The basic principle of the reduction in the inflammatory load in the oral cavity through healthy gingivae and periodontal health having beneficial effects on the cardiovascular and endocrine systems by reducing inflammation in general. There is unprecedented focus on evidence-based dentistry and dental graduates are motivated by their ability to offer real health benefits by their oral interventions.
The role of dental educators
It is well known that entry to undergraduate dental programmes has become highly competitive and as a result dental graduates need to be stimulated to achieve their potential and that self-directed learning prepares them for a more problem-solving approach to their professional practice.
There is undoubtedly a greater emphasis on public health and the primary prevention agenda and the workforce of the future can be well prepared for a new future with new challenges.
If we can motivate these graduate dentists and provide remunerative incentives aligned to prevention and holistic care, with greater integration with medicine, there is a good prospect of ‘building back better’ and restoring a functioning and productive NHS dental service in the UK – and the development of this in Scotland as a pilot for the rest of the UK, and potentially the rest of the world, would be possible.
This programme4 is acknowledged worldwide as an example of an intervention in primary care, and it is highly encouraging to note that it is yielding such tremendous results in reducing the prevalence of dental caries.
This Scottish Government-supported initiative has the amazing bonus of having been tried and tested in Scotland. It is regarded all over the world as a game changer in terms of primary prevention with the impact of supervised toothbrushing being greatest in areas of high socioeconomic deprivation. This reinforces the need for an emphasis on prevention and, provided this is supported by the Scottish Government, it will mean that dentists in primary care in Scotland can lead the rest of the world.
The question is could every dental practice in Scotland be empowered to offer evidence-based preventive treatments using the ChildSmile model of intervention at birth for ensuring optimal dental health? This would be regarded as a very progressive gesture – and the benefits of such a programme go well beyond oral health into general health and wellbeing and levelling-up in terms of the inequalities agenda. This is strongly supported by the NCD Alliance and the World Health Organization (WHO) department of Maternal, Newborn and Child Heath (MNCH).
Evaluation of the role and impact of health educational initiatives over decades has revealed that health education alone remains ineffective, and the prevalence of dental diseases remains largely unaffected.
A new tool is emerging, however, and the evidence for its efficacy is ever increasing – this is called health coaching or motivational interviewing, and a uniquely Scottish model is emerging with the Motivation, Action and Prompts (MAP) initiative implemented by Highland Health Board.
The use of MAP in dealing with a range of NCDs is potentially a powerful and extremely cost-effective tool in actioning the common risk factor (CRF) approach whereby the risk factors for a range of NCDs can be simultaneously addressed. In dentistry, we already do some of this very well – the prime example being the smoking cessation programmes that are undertaken in primary and secondary dental care settings, but so much more could be achieved in terms of cardiovascular disease (CVD) and diabetes or obesity.
The other aspect of health and prevention that utilises the dental skillset in a really special way is vaccination programmes; dentists rose to the challenge of being vaccinators throughout the COVID pandemic and they were involved in the actioning of a preventative agenda in the interests of the overall health of the population. Other dental healthcare professionals such as nurses, therapists and technicians were also deployed to play roles in the health of the nation and were motivated and incentivised by their roles and teamwork.
A final point relates to the need for closer working relationships between a range of stakeholders, firstly within dentistry – between NHS primary care and secondary care – universities and NHS Education Scotland (NES). But I also believe this would be an ideal opportunity to take a meaningful step towards integration with medicine and a range of other health professionals, with social care and all this in a way that utilises the skills of dental professionals fully.
I am involved in these discussions at WHO, FDI and IADR levels, and I am always impressed around the world how much countries are aware of Scotland, through initiatives such as ChildSmile, SDCEP and their global guidelines during the pandemic, and the sensible approaches that we adopt. My offer would be – work with the Scottish Government and others to bring those issues pertaining to Scotland (and building back NHS dentistry) to bear on the ongoing discussions.
Could Scotland provide one, perhaps exemplary, model for the delivery of dentistry – a model that others might adopt or adapt to their own circumstances? It could also be applicable to low resource settings – in the spirit of universal health coverage (UHC). This is already happening in Malawi with the Jeremy Bagg and Lorna Macpherson interventions.
I am therefore suggesting that perhaps there is a real opportunity to build a uniquely Scottish bridge over the troubled waters that you may anticipate ahead. Please contact me if you would like further dialogue or discussion (email@example.com).
Peter Mossey is Professor of Craniofacial Development and Associate Dean for Internationalisation at the Dundee Dental Hospital & Research School.