The Newcastle BSPD conference through the lens of a recent graduate.
By Bethany Allan, BDS, Newcastle University Graduate 2023
I attended the BSPD conference in September this year as a recent graduate of the Bachelor of Dental Surgery degree. Paediatric Dentistry is something which I have grown to enjoy throughout dental school and certainly within the few months of starting my foundation year. My experience so far treating paediatric patients has made me appreciate the difficulty in providing high quality dental treatment. Alongside the complexity of the treatment itself, there are additional requirements such as ensuring that the parent is engaged and educated, behaviour management and verbal and non-verbal communication styles - to name a few. Therefore, I attended the BSPD conference to gain further insight on how to manage this patient group and explore the potential career options available within this field of dentistry.
On arrival, we were greeted by a busy trade fair full of enthusiastic company reps and even more enthusiastic paediatric dentists! I was immediately struck by the lively atmosphere, made clear by the swirling noise of old colleagues conversing and new colleagues connecting. We started the morning session in the lecture theatre where we were treated to a series of presentations looking at caries and how we combat health inequalities. The first presentation was delivered by Prof. Yasmi Crystal followed by Dr Sarah Sowden and Dr Sameena Hassan who delivered the second talk. I thoroughly enjoyed the first two presentations of the morning session, I thought the speakers were extremely knowledgeable in their field of dentistry and very informative, providing me with ideas which I could adopt within my own practice.
Prof. Yasmi Crystal
Lunchtime came, which provided a useful opportunity to explore further all that the trade fair had to offer. It was beneficial to gain further insight into the most recent products, materials, and technology used within dentistry. It is clear to see these companies are fully embracing preventative dentistry in Paediatrics. It was useful to take samples away which I have then been able to use with my own patients. The lunch break also provided an opportunity to catch up with my former university supervisors. As a recent Newcastle University graduate, it was great to see members of staff present at the conference who I had the privilege of being taught by throughout dental school. Being in the presence of such individuals, who are highly regarded in this field of dentistry, made me appreciate the level of experience, education and knowledge that was provided to me throughout my university years.
Following lunch, the afternoon session comprised a series of presentations from core trainees and registrars within Paediatric Dentistry. There was a mix of clinical cases and clinical governance-based discussions where the presenters gave insight into the projects that are happening within the different dental hospitals and their departments. Despite these presentations being very informative, some of the ideas discussed were more specialised than I would be able to utilise in my own clinical practice as a general dentist, as they were better applied to a hospital setting.
Prof. Hal Duncan delivered the last presentation about deep caries management and vital pulp therapies. I thoroughly enjoyed this presentation, there was lots of interesting and very useful content delivered in a relaxed and engaging style. Vital pulp therapy in paediatric dentistry was something I was not very knowledgeable and confident in, so this was one of the most useful aspects of the conference for me.
Generally, the day was very well organised with the social media presence helping to inform me of the proceedings throughout the day. I thought the venue was appropriate for the type of conference, however, a lecture theatre which was entered from the rear would have been less distracting as those entering the lecture theatre would not have to cross in front of the presenter.
This BSPD conference has not only been beneficial in terms of gaining better insight into the field of Paediatric Dentistry but also for networking with an array of different individuals who are also inspired and motivated to provide high quality care to this patient group. I found it very inspiring to hear of the hard work and determination of each speaker, which has ultimately led to the improvement of services provided to paediatric patients. As a dental student, I found Paediatric Dentistry particularly challenging, but the hints and tips I gained from the conference speakers has changed my opinion significantly. I have now applied multiple aspects into my current practice, and I would recommend this conference to any new graduate colleagues.
Why targeted supervised toothbrushing is the smart, yet simple approach for equitable children’s oral health.
By Professor Paula Waterhouse
Consultant in Paediatric Dentistry, Claire Stevens holding jar of teeth extracted in one day at University Dental Hospital of Manchester . 13.09.17
Last week colleagues at the British Society of Paediatric Dentistry and I sighed with collective relief when, after over ten years of calling for supervised toothbrushing in England, the Labour Party announced a scheme to target three to five year olds in the twenty percent most deprived areas in England (based on the CORE20 part of the CORE20PLUS5 CYP1 initiative.
There is evidence, from Scotland that reaching children as early as possible with supervised toothbrushing schemes gives them a better oral health start to life and is more cost effective in the long term for the NHS.
Our Society’s team of spokespeople had a busy day once the announcement broke on Friday allowing us to explain to broadcasters and the press how this simple intervention, that is already happening in Scotland and Wales need only take a few minutes out of a school day. The debates ran all day with lively challenges from some who rightly aired concerns about teachers’ precious time being stretched – yet again. But the reality is, which we heard from a headteacher at a school in Bolton on Nicky Campbell’s BBC Radio 5 Live phone in, that it takes a sum total of 7 minutes after their lunchbreak to get all the 3-5 year olds brushing enthusiastically together – overseen by a teacher or assistant. The reality is that in this cost of living and NHS dentistry crisis, children’s oral health is everyone’s business.
This costed and funded proposal would see children attending schools and nurseries in areas of socioeconomic deprivation who receive supervised toothbrushing, also getting a supply of toothbrushes and toothpaste to take home. Additional investment has also been announced, increasing the number of children who should be able to see an NHS dentist. This is a serious plan to grip both the immediate crisis and set NHS dentistry on the path to recovery in the long-term. In an ideal world, BSPD believes that every child should have a ‘dental home’ – an ongoing and preventively-focused relationship with an NHS dentist. However, in the meantime we must recognise that, through no fault of their own, some children need greater help to get the oral health start in life that every child deserves.
We have heard of five year olds who have never seen a toothbrush before. We know of teenagers who have never been to the dentist. This is not OK. We want to put an end to stories like these. Some children, through no fault of their own, are not getting the oral health start that would set them up for life. This targeted approach will make a big difference and because the children get to take their toothbrushes and toothpaste home, this is about partnering with parents to ensure every child has a smile for life.
We therefore welcome these measures as we know we need urgent action to address the persistent and immoral inequalities we see in children’s oral health. Intervening with a targeted supervised toothbrushing scheme is proven to deliver beneficial oral health outcomes that also pay for themselves severalfold in the future.
Children and young people from lower socioeconomic groups are more likely to experience dental decay and more likely to report that their poor oral health impacts on their daily lives. These children can suffer pain, lose sleep and miss days at school. Dental disease is almost always preventable. This approach, that is based on targeting the most deprived 20% of children, is a step towards an oral health approach that is equitable – not just equal.
FDS RCS England Guideline for the Extraction of First Permanent Molars in Children
By Dr. Greig D. Taylor and Prof. Paul Ashley
Care for children and young people presenting with compromised first permanent molars (cFPM) of uncertain prognosis, where either restoration or extraction are valid treatment approaches, can be difficult to plan. In these cases where cFPM are of uncertain prognosis, consideration and inclusion of other patient and tooth-related factors are needed to support the decision-making process (Ashley and Noar, 2019, Somani et al., 2021). We would like to promote that children and young people are an integral part in a shared decision-making process. Until recently, it was common these views were either not obtained, or valued by clinicians, when healthcare decisions were made. Personally, we feel this contradicts children and young people’s rights. They should have the right to assert their autonomy and their views, and as clinicians we should be prepared to listen to them.
In March 2023, the Royal College of Surgeons of England published an update to their 2014 ‘Guideline for the Extraction of First Permanent Molars in Children’ to help support these management decisions (Noar et al., 2023). Several changes have been made to this updated version, mainly to reflect the current available evidence, but also to highlight the importance of shared decision-making with the child, parents/guardians, and dental professionals (Ashley and Noar, 2019, Taylor et al., 2019, Somani et al., 2021, Noar et al., 2023).
Previous versions of the guideline have focused on removal of the cFPM at the time when the bifurcation of the second permanent molar was calcifying as this was believed to be the main predictor of successful closure, particularly in the lower arch. Identifying this feature remains in the updated guideline; however, it is not relied upon as the sole predictor as several others have since been identified. Factors such as presence/absence of third permanent molar and angulation of the second permanent molar are now important to ascertain when determining the likelihood of successful closure. Indeed, the presence of a third permanent molar and a mesially angulated second permanent molar, combined, are high positive indicators of successful closure (Patel et al., 2017). This highlights the need for a full radiographic assessment to observe such features and then rely on this information during the decision-making process.
The new guidance also supports the need to consider orthodontic implications upon enforced or planned removal of cFPM. It could be argued that the previous guidance was quite prescriptive on when to extract cFPM in terms of their potential orthodontic implications. The updated version takes an approach that promotes multidisciplinary working, and provides more overall guiding principles that should be considered. This multidisciplinary approach is reinforced by encouraging referrals for such patients to centres where combined orthodontic and paediatric services are available, as the gold standard, to allow comprehensive treatment planning to be undertaken. In cases where this is not practical, or feasible, if clinicians work in an area without ready access to a combined service, it is recommended that sharing clinical images and radiographs would be appropriate. Utilising the expertise of colleagues within managed clinical networks is one approach that can overcome these challenges.
An interesting section of the guidance relates to whether balancing and compensating extractions should be provided. The recommendation remains the same in this updated version – that is a cFPM should not be balanced. However, potentially more controversial, is the change in the guidance that states when a lower molar is extracted, then it should not be routine practice to compensate an opposing sound upper molar. The caveat to this being if the upper molar will be unopposed for a ‘significant’ period of time. Despite limited evidence, the change was directed by expert opinion of the authorship as in their clinical experiences, over-eruption of a molar that has not been compensated is rarely observed. We feel this is a positive change to the guidance with unnecessary removal of sound opposing teeth not being completed merely as a matter of course. Of course, this guidance change is likely to require some re-thinking of clinicians who are programmed to always compensate, but it also provides an opportunity for future research to generate sufficient evidence to inform future guidance updates.
Of course, this guideline is only useful when trying to optimise successful spontaneous closure following removal. However, caution should be maintained as successful closure, even in optimal circumstances, is not guaranteed (Eichenberger et al., 2015, Noar et al., 2023). Similarly, in cases where there is acute pathology and the child is in pain or the second permanent molar has erupted, then removal of the cFPM should be completed at any time and the guidance on obtaining spontaneous closure should be disregarded.
In summary, the updated RCS extraction guidelines have been written in a much more pragmatic manner, supporting treatment planning for cFPM that have been decided to be extracted. Reassuringly, rather than focusing purely on removal, the updated guidance reflects current reality and recognises that not all cFPM in children should be removed. To us, this is one of the most positive changes to the guidance, as acknowledging that for some children and young people, restoration should be considered, or preferred, to enforced removal. A paradigm shift is required, and hopefully there is a move towards a balanced shared decision rather than confining any cFPM to the bin.
Ashley, P. & Noar, J. (2019) ‘Interceptive extractions for first permanent molars: a clinical protocol’, British Dental Journal, 227(3), pp. 192–195.
Eichenberger, M., Erb, J., Zwahlen, M. & Schätzle, M. (2015) ‘The timing of extraction of non-restorable first permanent molars: a systematic review’, European Journal of Paediatric Dentistry, 16(4), pp. 272–278.
Noar, J., Taylor, G.D., Williams, A., Ashley, P.F., Harrison, M. & Cobourne, M.T. (2023) A Guideline for the Extraction of First Permanent Molars in Children. [Online] [online]. Available from: https://www.rcseng.ac.uk/dental-faculties/fds/publications-guidelines/clinical-guidelines/ (Accessed 29 March 2023).
Patel, S., Ashley, P. & Noar, J. (2017) ‘Radiographic prognostic factors determining spontaneous space closure after loss of the permanent first molar’, American Journal of Orthodontics and Dentofacial Orthopedics, 151(1), pp. 718–726.
Somani, C., Taylor, G.D., Garot, E., Rouas, P., Lygidakis, N.A. & Wong, F.S.L. (2022) ‘An update of treatment modalities in children and adolescents with teeth affected by molar incisor hypomineralisation (MIH): a systematic review’, European Archives of Paediatric Dentistry, 23(1), pp. 39–64.
Taylor, G.D., Pearce, K.F. & Vernazza, C.R. (2019) ‘Management of compromised first permanent molars in children: Cross-Sectional analysis of attitudes of UK general dental practitioners and specialists in paediatric dentistry’, International Journal of Paediatric Dentistry, 29(3), pp. 267–280.
How accurate activity coding of hospital paediatric dentistry can improve patient care
By Professor Sondos Albadri
The Getting It Right First Time (GIRFT) Hospital Dentistry National Report was released in September 2021, providing an in-depth review of hospital dental services in England.
The report, led by Liz Jones OBE Consultant Orthodontics and GIRFT national Lead for hospital dentistry, identified the inaccuracy of coding as a common issue across all dental specialties, limiting our understanding of patient needs and ability to inform workforce planning. The report recommended a review of main specialty codes, treatment function codes and procedure codes to improve consistency and clarity.
The report also called for the recording of primary and secondary diagnoses, the type of anaesthetic used and the identification of the clinician responsible for care - and the clinician who delivered the care. This is especially important for us in Paediatric Dentistry, as improved coding would allow us to identify the number of children having treatment under different pain control modalities and the workforce skill mix to enhance service design and future delivery.
During my presidency at BSPD I worked closely with the GIRFT team to lead a small working group aiming to address the recommendations, specifically to review the OPCS-4 procedure codes.
OPCS-4 stands for "Office of Population Censuses and Surveys Classification of Interventions and Procedures Version 4". It is a classification system used in the United Kingdom to code medical and surgical procedures. OPCS-4 is used by healthcare professionals to record the procedures and interventions that are performed on patients during hospital admissions or outpatient visits.
Phase 1 was to review the current codes rapidly in order to understand the gaps in being able to reflect all clinical activities within Paediatric Dentistry. The group successfully requested new codes for procedures such as silver diamine fluoride application, apexification, and inhalation sedation. This was followed by phase two which included defining the main procedures used by Paediatric Dentistry and obtaining agreement with other specialities on shared procedures. This is an important step for us as a speciality allowing us to be recognised and have our stand-alone activity coding booklet which will be released in 2023 to support the national implementation for OPCP-4 version 10 (OPCS-4.10).
One of the significant changes resulting from our work is the ability to record the type of anaesthetic and specific code for inhalation sedation. This step is very important as it will have direct impact on the accuracy of Hospital Episodes Statistics (HES) data. The HES data is used to inform service planning, resource allocation, and policy within the NHS. Accurate HES data defining the type of anaesthetic allows NHS managers and policymakers to understand the true demand for hospital delivered paediatric dentistry better and the resources required to meet that demand.
Although recording of the anaesthetic codes is advisable, it is not mandated and therefore chairs and members of Manged Clinical Networks (MCNs) are asked to support and advocate for the implementation of this recommendation. This can help to ensure that resources are allocated appropriately, and that services are delivered efficiently and effectively.
We had requested the inclusion of additional procedures such as Hall technique preformed metal crown placement as a distinct procedure from crown placement, acclimatisation, and differentiation between primary and permanent teeth codes to enhance our comprehension of the procedures being conducted on children. Regrettably, these codes were not sanctioned and will not be accessible this year. However, there is currently a wider national revision of OPCS-4 codes, and we are optimistic that those requests will be acknowledged and accepted as they are vital for our speciality.
We acknowledge that the current coding work only captures hospital-based activity, excluding the community dental services where a significant amount of paediatric dentistry procedures is carried out. However, GIRFT has now recognised this and has developed a work stream into the community dental services.
The effort to improve coding in dentistry is the beginning of a process to reduce variation in recording the delivery of clinical care to patients. Communication between clinicians and coders to improve the accuracy of data capture, providing better evidence for discussions within trusts and with commissioners is vital to ensure implementation of this work.
Overall, the GIRFT report and the subsequent work to improve coding in dentistry demonstrate the commitment to providing the best quality care to patients and reducing unwarranted variations.
Good OR bad news for children’s oral health?
The latest admissions stats debate!
By Urshla Devalia, BSPD Spokesperson
The latest official statistics on hospital admissions were published on 23rd February 2023 amid predictably alarmist headlines and questionable analysis. So, what does this mean and how should we interpret this latest data. Is it good OR bad news for children’s oral health…?
This annual report details trends in hospital admissions – the number of episodes (not the number of children) who have been admitted to hospital for dental extractions. It can include both children who were treated under sedation as well as those who required an anaesthetic.
It comes as no surprise that removal of decayed teeth remains the most common reason for a 6-10 year old child to be admitted to hospital in England. In 2021-2022 there were 42, 180 episodes of tooth extractions in 0-19 year olds, an increase of 83% in caries-related extractions on the previous year. Some organisations were quick to jump on this statistic as a negative, with some even going as far to say it was a “lack of dentists leading kids’ teeth to rot”. If we pause for one moment, we will realise that this increase could actually be welcomed as a good piece of news – rather than bad. In 2020-2021 we saw a significant reduction in elective activity as a result of the COVID-19 pandemic. Therefore, this 83% does not represent a dramatic increase in the prevalence of dental disease, more likely a partial recovery of elective care post-pandemic. We should actually welcome the increase as a sign that children and young people are now increasingly able to access the care that they need.
To understand the data better, it is more helpful to look at trends over the last few years which are best shown in this figure from the report:
Viewed through an optimistic lens, it might appear that there has actually been a small decrease in the number of episodes of extractions over the last 5 years. However, ultimately, we should be aiming to see a dramatic decrease in the number of episodes as evidence-based interventions are implemented. The findings of Childsmile suggest this might be 3 to 5 years down the line.
The biggest story of the data is actually the persistent and immoral inequalities we see in children’s oral health with children in lower socioeconomic groups experiencing 3.5 times the extraction rate of those in the most affluent areas. This adds further support for a targeted approach to health improvement and for those of us in clinical leadership roles we need to consistently advocate for the adoption of evidence-based interventions to improve oral health. CORE20PLUS5 CYP gives specific mention of supervised toothbrushing and there has been some progress in this area, with a number of regions going out to tender for schemes focused on their most deprived populations.
BSPD would like to see supervised toothbrushing schemes in early years settings for the most deprived 20% of our population as a minimum. Supervised toothbrushing is an intervention with known return on investment. These green shoots of progress should be welcomed but there needs to be more action, and now - if we are serious about preventing dental decay.
What is CORE20PLUS5 and what on earth has it got to do with children’s oral health?
By Dr Urshla Devalia, Spokesperson, BSPD
NHS England has last month announced its approach to tackling health inequalities in Children and Young People (CYP) with the launch of CORE20PLUS5 - CYP. But what is CORE20PLUS5, how did we get here and what does it mean for children’s oral health?
CORE 20 An approach to target the most deprived 20% of the population
PLUS A focus on locally-determined groups such as autistic children and young people, those with learning disabilities, looked after children or children from asylum-seeking families
5 Five clinical areas requiring accelerated improvement
The CYP version follows CORE20PLUS5, launched in November 2021. Whilst there was wide support for the chosen clinical areas and the approach to target resource to those most in need, there were many who felt that the clinical areas were too adult-centric and that the voice of the child had not been heard.
BSPD responded strongly to the CORE20PLUS5 consultation exercise, advocating for inclusion of CYP and oral health in the approach. BSPD members know only too well the persistent and immoral inequalities we face in children’s oral health. Children from lower socioeconomic groups have poorer oral health and are more likely to report that this impacts on their daily lives.
Fast-forward to December 2022, and we now have the launch of CORE20PLUS5 CYP with oral health named as one of the five clinical areas requiring accelerated improvement. This is a huge win for Paediatric Dentistry. Suddenly the newly formed Integrated Care Boards (ICBs) will be asking about children’s oral health. CORE20PLUS5 doesn’t come with ring-fenced funding, but it will shape how decision makers chose to spend their budget. We need to be ready to step up and provide local clinical leadership.
CORE20PLUS5 CYP has a strong focus on the backlog of children waiting for dental extractions, using this as its key metric. This is understandable given that Paediatric Dentistry has been the most severely affected Paediatric surgical specialty, and slowest to recover from the COVID 19 pandemic. Between March and April 2020 there was an 85% reduction in elective activity, and as many BSPD members know, work continues to recover services. It is important to note that the wording is to “address” the backlog recognising that there may initially be an increase in the number of CYP requiring hospital admission for dental extractions (as systems work to reduce their waiting lists). The hope is that the numbers will then fall as systems develop and implement evidence-based preventive interventions, such as supervised toothbrushing.
The choice to use Hospital Episode Statistics (HES) data as a key metric is an interesting one, but not surprising given the focus on elective activity and the need to choose a data source that is frequently updated so that progress can be measured. There is widespread acknowledgement that this data set is far from perfect – it under reports activity, doesn’t distinguish between sedation and general anaesthetic and represents the number of times a child needs a procedure, rather than the number of children requiring a procedure. But interestingly, this time the data is being used as a proxy measure for the recovery of services, rather than a proxy measure for oral health. It’s not perfect, but it can be improved and most importantly it is a “foot in the door” for oral health – bringing us into discussions and plans, from which we would have been historically excluded.
Mention is also given to establishing pathways for Looked After Children (LAC). The ask is not prescriptive – local teams can determine their own solutions, and there are already areas of good practice. The important thing is that pathways are in place, these are known and understood throughout the system and that vulnerable children can access care. The Mini Mouth Care Matters team are again ahead of the game, designing e-learning resources to support the care of LAC. These will shortly be available on e-LFH MMCM.
CORE20PLUS5 will undoubtedly lead to an increased focus on children’s oral health but it is up to us to make the most of this opportunity. Now is the time for us to step up and ensure that the most vulnerable children we care for, can access the care that they deserve.
Click here to download/view CORE20PLUS5 infographic.
What are your views on CORE20PLUS5? We’d love to hear your feedback, so please email us at: email@example.com
BSPD Blog 6 December 2022: Deep caries management in primary teeth: What’s new?
By Alaa Bani Hani
Over the last 10 years, considerable research on the management of carious primary teeth has been published. This has led to a paradigm shift in managing deep dentinal caries towards maintaining pulp vitality and tooth structure through minimal intervention dentistry (MID).
Previously, British Society of Paediatric Dentistry guidelines (Rodd et al., 2006), recommended indirect pulp capping in vital primary teeth with deep carious lesions and favoured pulpotomy over direct pulp capping where pulp exposure was encountered. These techniques are carried out using local anaesthesia, rubber dam isolation and teeth drilling hence requiring patient cooperation. Whilst these are still valid approaches to manage primary teeth with pulpal involvement, and continue to be recommended (eg American Academy of Pediatric Dentistry, 2021) there is an increasing emphasis on Minimal Intervention approaches to avoid pulpal involvement wherever possible.
The European Academy of Paediatric Dentistry (EAPD) has recently undertaken systematic and umbrella reviews to provide clinicians with the best evidence-based recommendations for treating deep carious lesions in primary teeth and to identify gaps in knowledge with a view to guiding future research on the topic. One of the important outcomes of these reviews by BaniHani et al. (2021) was that MID is effective in managing deep dental caries in primary teeth and that increased use of MID will minimise or even eliminate the risk of pulp exposure through techniques such as no carious tissue removal (38% silver diamine fluoride), sealing dental caries (Hall Technique) and selective caries removal. The latter has a similar concept to indirect pulp capping but it is carried out without local anaesthetic or rubber dam isolation.
The EAPD is updating its policy on deep caries management in children and based on the recommendations made in the 12th EAPD virtual interim meeting in Oslo in April 2021, different MID techniques will be included in their updated policy recommendation.
With the introduction of these conservative techniques, we are hoping to increase children access to dental care, decrease prevalence of untreated dental caries and number of children requiring dental treatment under general anaesthesia worldwide including its substantial cost to families and governments.
American Academy of Pediatric Dentistry. Pulp therapy for primary and immature permanent teeth. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2021:399-407.
Bani Hani A, Santamaría RM, Hu S, Maden M, Albadri S. Minimal intervention dentistry for
managing carious lesions into dentine in primary teeth: an umbrella review. Eur Arch Paediatr Dent. 2021 Nov 16. doi: 10.1007/s40368-021-00675-6
Rodd HD, Waterhouse PJ, Fuks AB, Fayle SA, Moffat MA. Pulp therapy for primary molars. Int J Paed Dent. 2006;116(Suppl. 1):15–23. doi: 10.1111/j.1365-263X.2006.00774.x
Introducing the New BSPD Blog Column
Dr Jenny Harris President, BSPD
I am delighted to launch this, our new BSPD Blog page, on our website.
Our aim is to provide a forum to share interesting news and opinion pieces from our members and the broader dental community. We will be publishing new blogs every one-to-two months.
This new website section will allow those interested in paediatric dentistry to share points of view and developments in areas of interest. I hope you enjoy reading our first blog from Alaa BaniHani on pulp treatments.
If you have any thoughts on a blog you would like to be considered for publication on our website, please send your ideas to our PR consultant, Kate Clark at firstname.lastname@example.org.
With best wishes