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An ounce of prevention is worth a pound of cure in the struggling dental market

Professor Liz Kay MBE
December 23, 2020

The coronavirus pandemic has had huge impacts on the UK's dental care system, with services still at 50% of their capacity. The government must prioritise the Green Paper proposals, writes Professor Liz Kay. 

Recent media stories about patients resorting to DIY dentistry have grabbed the headlines. As gruesome as these stories are, I am happy to confirm they are a rarity rather than the norm. But, while media talk of a 'crisis in oral health' may be exaggerated, a combination of missed appointments and lifestyle changes as a result of COVID-19 is undoubtedly posing a threat to the nation's teeth.

As in virtually every other area of public life, the impacts of COVID-19 on our dental system will necessitate a rethink of our current arrangements, and rightly so. We need a wholesale shift of emphasis from costly ex post facto remedial work to repair damaged teeth, to a prioritisation of better dental practices that prevent problems occurring in the first place.

The problems with our primary and secondary dental care systems are well documented. Senior dentists have been calling for reform of the NHS dental contracting framework since well before the pandemic.

Instead of the current contract, which is focussed on units of dental activity, we need a new arrangement which focuses on prevention and improved access to check-ups. A Government that prioritises 'levelling up' needs to recognise that dental problems are far from 'equal opportunity': it is the poorest and most vulnerable amongst us who suffer the most from tooth decay and restricted access to dental care.

Happily, calls for reform are being taken up in Parliament. The All Party Parliamentary Group on Dentistry is pushing for reform of the contract, Without it, according to Vice-Chair Judith Cummins MP, "Dental practices across England – and with them the very fabric of dental care for millions of people – are facing an existential threat."

Unsurprisingly, given current conditions, access to dental care is the most pressing problem. According to the British Dental Association, 19 million fewer dental appointments were taken up this year. There were 40 million in the whole of 2019 but only 21 million in 2020. During the first lockdown, NHS dental services were running at only 25% of capacity. The situation has improved since, but service levels are still below 50% and expected to stay that low into 2021.

There are also pressures on secondary care. Hospital waiting times for dental procedures are much longer. Thousands of children and vulnerable adults requiring dental treatment under general anaesthetic are waiting in pain for treatment.

Most worrying is the potential cost in human lives. As Natalie Bradley, a special-care dentistry registrar at Guy's Hospital in London, recently told The Times newspaper, "the 19 million missed appointments are also 19 million missed cancer screening appointments". The risk is not more cancer cases necessarily, just later diagnosis and poorer outcomes as a result.

Lifestyle factors related to the pandemic are compounding the problems. And small behavioural changes to address these should be important components of a prevention strategy.

The 'COVID 15-30' is a recognised phenomenon in western countries. In other words the number of extra pounds typical adults have put on during two lockdowns. Britons are snacking more on sugary foods, with consequences for their teeth.

Again, young people are worst affected. Children's protective enamel is thinner and the pulp (nerve tissue) proportionately larger, so problems occur and progress quicker in children.

In tandem, home care (brushing and flossing) has got worse during COVID. Rather than using the additional time for better home care regimes, surveys show people are brushing and cleaning less.

Less intuitively, the pandemic has also led to a sharp drop in the use of chewing gum. Sales of sugar-free gum have fallen owing to vastly reduced footfall at supermarket tills, where the majority of gum purchases are made.

Research by the Faculty of Dentistry at King's College London with the support of the Wrigley Oral Health Programme in 2019, found that people who regularly chew develop 28% fewer cavities than those who do not. The equivalent percentage for using fluoride toothpastes and supplements was 24%.The stimulation of saliva neutralises plaque acids and acts as a natural barrier to protect teeth. The mechanical act of chewing clears food debris from the mouth and contributes to the prevention of dental caries.

As the lead author of the King's research, Professor Avijit Banerjee, said: "The results should serve as an important reminder to dental professionals and policy makers of the important role sugar-free gum can play in reducing the economic, societal and health burden of poor oral health."

I wholeheartedly agree. And, encouragingly, most of these preventative measures are included in the Government's 2019 Green Paper on public and dental health.

The effects of COVID-19 have heaped unprecedented pressures on our dental care system. Dental professionals and support staff have worked minor miracles to maintain access to services in the circumstances. But the pandemic has also revealed the acute need for a system shift towards preventative measures. The Government needs to follow through on its Green Paper proposals as a priority.

Professor Liz Kay MBE is President Elect of the British Dental Association, a Trustee and Fellow of the College of General Dentistry, Past President of the Oral Health Foundation and Founder of the Peninsula Dental School.
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