dental health in lothian

Despite an overall improvement in dental health over the past 30 years, tooth decay remains a significant public health problem as it affects the majority of the population. There were big improvements in the dental health of Scottish children in the 1980s which most dentists agree was due to the introduction of fluoride toothpaste. However, the trend has levelled off and there has been no sustained improvement for over 20 years (see figure 1).

Improving oral health in children is particularly important as it is during childhood that many lifestyle behaviour patterns are established. By comparison with other western European countries and especially Nordic countries, the oral health of children in Scotland is poor.

As with most human disease, dental decay disproportionately affects the poor and is strongly linked to poverty. These oral health inequalities mean that children living in the poorest, non-fluoridated communities continue to suffer unacceptably high levels of tooth decay and the pain, costs, embarrassment and disfigurement it causes. However, more than two thirds of the children living in the most affluent parts of Scotland are free from obvious tooth decay experience. Their dental health is so good that as a group they have already achieved the Scottish Executive Health Department target of 60% disease free by 2010. In contrast, over three-quarters of primary school starters in the most deprived areas of the country (DepCat 7) experience tooth decay. The 2006 study of five year olds shows that the situation in Lothian is improving, that Lothian is ahead of the national figure and that East Lothian has achieved the child dental health target for decay free teeth (see figure 2). This confirms the need for both efficient and effective general dental services to be provided across Lothian.

The Action Plan to Improving Oral Health and Modernise NHS Dentistry

The Scottish Executive Health Department consultation 'Improving Oral Health and Modernising NHS Dentistry' was published in April 2004 and contained several workstreams related to improving oral health. The subsequent publication in April 2005 of the Scottish Dental Action Plan for Improving Oral Health and Modernising NHS Dental Services will start to drive improvements in Scotland's oral health. Lothian is currently committed to working within the national programme.

Core Programme

Every child in Scotland will have free fluoride toothpaste and toothbrushes provided on at least 6 occasions in their first five years of life. (Children who are at greater risk of dental decay are given additional supplies of free toothpaste and toothbrushes, usually via their health visitor or other health workers). In addition, every child who attends a nursery (whether private or local authority) should be offered free daily supervised toothbrushing from age 3 upwards. National Standards for toothbrushing programmes in nurseries and primary schools have been agreed and disseminated widely. The Core Programme will also have a public health focus in that children who attend nurseries, childminders, afterschool clubs and other similar care settings should be offered healthy snacks and drinks as part of national initiatives to improve dental health and reduce childhood obesity.

Oral Health Demonstration Programme (Childsmile)

The programme's aim is set out in the Dental Action Plan as follows:

CHILDSMILE is targeted at children in nursery or primary school who would benefit from additional preventive dental care and who are not already regular attenders at a dental practice. Entry into the nursery element of the programme will be targeted on those nurseries in areas with the highest levels of deprivation. Entry into the school based element of the programme will normally follow a visit by the national dental inspection programme team who will inspect and assess every child at Primary 1 level. In the first instance, this additional preventive care will take the form of twice yearly fluoride coatings applied to their teeth by CHILDSMILE Dental Care Teams, in the nursery or school. These teams are composed of new extended duties Dental Nurses who have been specially recruited and trained to provide this type of care.

As children progress through primary school there will be further opportunities for preventive care to be provided through CHILDSMILE including fissure sealants. At all stages in the programme, children who require further assessment and possible dental care will be identified and referred to a dentist.

Box 1 shows progress of the CHILDSMILE programme in Lothian up to March 2006.

Acess to NHS Dental Care

Current levels of NHS dental registration.

General Dental Practitioners (GDPs) provide 93% of all NHS dental treatment undertaken in Lothian. 49.1% of the adult population is registered with a high street dentist and 71% of children, both figures above the national averages (47% and 67%). Currently there are 356 GDPs working in 130 practices across Lothian. There has been a move away from NHS dental practice by many practitioners in the past 5-8 years although the registration figures for children are stable and the total cost of NHS dental care has not declined. The ratio of dentists to the population in Lothian is close to 1:1750 which is the national target. This is one of the best ratios for Health Boards in Scotland.

Salaried Primary Care Dental Service

Currently there are 15 clinics throughout Lothian with 41 dentists plus supporting staff. Historically this service provided secondary care services for children, adults with physical and mental disabilities, phobic patients as well as screening for caries through schools for 5 and 11-year-old age groups. Recent expansion of the service across Scotland has seen the introduction of Salaried General Dental Practitioners (SGDS) providing GDS treatment under salaried contracts.

Recently emphasis has been on access to emergency dental care and the Chalmers Street Dental Centre (and the proposed Bonnyrigg dental centre which will come on stream in Autumn 2007) saw over 17,000 patients in 2005/06. This confirms the need to maintain and expand this walk-in service.

Hospital Service

The Edinburgh Dental Institute (EDI) based in the Lauriston Building provides most secondary dental care in the form of specialist departments covering Restorative, Oral Medicine, Paediatrics, Oral Surgery and Radiology. There is also the Maxillofacial Unit based at St John's Hospital, Livingston.

This is the variation we would expect given the average levels of social deprivation across the Local Authorities in Lothian. However, even in the best area (East Lothian) more than 1 in 3 children have experience of tooth decay. So to reduce the pain, misery, disruption, disfigurement and embarrassment caused by rotten teeth we need to have a population based approach working across all of Lothian to make a genuine difference.

Steps Taken to Improve Acess

1. Opening of access centres to treat nonregistered patients with a dental emergency.

Opening of access centres to treat non-registered patients with a dental emergency. Chalmers Street Dental Centre (opened April 2005, Bonnyrigg Dental Centre (due to open in Autumn 2007).

2. Access grants

Access grants up to 100,000 are available to practitioners opening new surgeries guaranteeing NHS care delivery for 7 years. Recent approval has been granted for one in Midlothian and two in Edinburgh. A practitioner in West Lothian also recently extended his practice under the scheme. Early discussions are underway on the development of a large vocational training dental practice in Prestonpans (East Lothian).

3. Back to work incentives of 10,000 over 2 years for dentists returning to work after a break of more than 5 years and guaranteeing NHS care delivery for 5 years.

4.Increase in dental graduates from Scottish universities from 120 per year currently to 142 per year by 2010.

5. "Golden Hello" payments to encourage Scottish dental graduates to stay in Scotland.

6. New grants and funding for High Street dentists complying with commitment criteria.

Of the 142 practices in Lothian, a total of 86 (61%) qualified as NHS committed in February 2006 compared with the national figure of 69%.

7. Provision of Salaried Dentists

In October 2005, 8 new full-time salaried dentist posts were approved. Currently 4 posts have been filled. However, employing salaried dentists to replace independent GDPs may not be cost effective as an NHS Education for Scotland report showed that salaried dentists produce, on average, only 40% of the NHS output of an independent GDP (NES 2004).

8. Increase in the number of dental care professionals including new therapists capable of carrying out many routine procedures.

9. Overseas Dentists

The Scottish Executive Health Department centrally recruits overseas dentists and NHS Lothian has accepted two dentists from Poland. Further expansion of the salaried service now relies on the provision of suitable clinical facilities.

10.New Dental Premises for Salaried Dentists

Other proposed new dental premises under development: Liberton Bank development - two dental surgeries; Liberton Hospital - two dental surgeries; Musselburgh Treatment Centre - two dental surgeries; and Midlothian Community Hospital - one surgery. Early discussions are under way regarding the inclusion of dental surgeries in the new GMP development in Morningside.

11. Emergency Dental Care

Emergency dental care is available across Lothian to ensure freedom from pain and to ensure that out of hours emergency services (medical and dental) are not saturated by patients who should be managed during normal office hours. Dentists provide emergency dental care to their own patients during daytime hours. An out-of- hours service has been established to ensure access for all Lothian residents. This is based at Chalmers Street Dental Centre. In addition, children with a dental emergency can attend the paediatric dentistry department of the Edinburgh Dental Institute during daytime hours as well as the Chalmers Street Centre out-of-hours in the evening and at weekends.