As someone who has recently started to work with Community Dental Services (CDS) at a clinical and strategic level, I have come to understand firsthand how vital these services are for some of the most vulnerable members of our society. I was invited to be a member of the working group for the Getting It Right First Time (GIRFT) Community Dental Services Report and feel this to be a landmark moment—an opportunity to address long-standing disparities and finally raise the profile of CDS. But let’s be honest: making these recommendations work “in the real world” won’t happen without effort, collaboration, strong leadership and, in some areas, a fundamental shift in how we think about service delivery.

A System in Need of Change

Why is this report so significant? For years, the CDS has been the safety net for patients who fall through the cracks of mainstream dental care—children requiring general anaesthesia for tooth extractions caused by preventable decay, adults with complex special needs, and those who face social or economic barriers to care. Yet the system that underpins these services has been fragmented, under-resourced, under-funded and inconsistently managed. The GIRFT report doesn’t just identify the problems; it offers a workable pathway to a more consistent, efficient, and equitable future for CDS.

Key Wins: Where the Opportunities Lie

The report highlights several areas that, if addressed properly, could be game changers for CDS. 

1. Standardised Data Collection: For too long, locally held waiting lists have been invisible at a national level, leaving commissioners in the dark about the true scale of the problem. Establishing consistent national datasets is a no-brainer—it will bring transparency, enable benchmarking, and ensure resources go where they are needed the most.

2. Governance and Accountability: The call for formal Service Level Agreements (SLAs) between CDS and acute trusts will be critical. These agreements will create clearer lines of accountability, particularly for general anaesthetic services which are regularly cancelled as felt a low priority, in exchange for what are deemed to be “more important” services. This report will help ensure that standards of service delivery are consistent across the board.

3. Training and Workforce Development: CDS has untapped potential as a training ground for dental professionals. Investing in training posts will not only help to address workforce shortages, especially in rural and coastal areas, but also make CDS an attractive, sustainable career choice. This is a long-overdue step that could transform the workforce landscape.

4. Collaboration Through Shared Care Models: The push for stronger collaboration with Managed Clinical Networks (MCNs), Integrated Care Boards (ICBs), and primary care providers is another highlight. A shared care approach ensures that patients receive the right care, in the right place, at the right time—avoiding duplication and reducing pressure on secondary care services. 

5. Focus on Prevention: Prevention has always been the holy grail of healthcare. By integrating health promotion into core CDS services, we can hope to reduce reliance on general anaesthesia and tackle dental disease at its root cause. This isn’t just good for patients—it’s cost-effective and aligned with the broader NHS strategy.

A Realistic Reflection: Where the Challenges Lie

While the recommendations are strong, implementing them won’t be easy. Establishing consistent national datasets may appear straightforward on paper, but this requires robust systems, training, and buy-in from all stakeholders. Without clear definitions and processes, we risk creating another layer of bureaucracy without improving outcomes. Similarly, while investing in training is critical, it will take time to see the benefits. In the short term, workforce shortages will remain a challenge, and services will need support to manage increased demand. 

Additionally, many CDS services already operate on underfunded budgets, so whilst the reports’ recommendations are sensible, they require investment, and we need to ensure funding is available to implement these changes without compromising existing services. Finally, while preventative care is noted as a key-win in the report, embedding it into the core of CDS service delivery demands both cultural and operational shift as prevention often takes a backseat to immediate clinical priorities. Addressing these challenges thoughtfully will be key to the report's success and real-world applicability.

Looking Ahead

The GIRFT report represents a golden opportunity to transform CDS—but success depends on all of us. Commissioners, clinicians, policymakers, local leadership and service users must come together to make this vision a reality. There will be challenges, but the potential rewards—healthier communities, better patient experiences, and more sustainable services—are well worth the effort.

To formally explore the CDS GIRFT recommendations, I encourage you to join the upcoming webinar:
Community Dental Services – Reducing Variation to Improve Dental Care for the Most Vulnerable

📅 Date: 29 January 2025
🕒 Time: 12:30pm – 1:30pm
🔗 Register Here

This is our moment to get it right for CDS, even if it’s not the first time!

MY THOUGHTS ON ATTENDING THE 3rd IAPD GLOBAL SUMMIT

DR SHANNU BHATIA, PRESIDENT, BSPD
January 2025

I was delighted to represent BSPD at the 3rd IAPD (International Association of Paediatric Dentistry) Global Summit: Pulp Therapy Rooted in Evidence which was held between November 8-10, 2024 in the beautiful city of Porto in Portugal. 
 
The summit saw leading clinician scientists from across the globe gather to explore and share the latest developments in pulp therapies for children and young people. Expertise from across the world shared advancements in our understanding of pulp biology, the inflammatory response to dental caries and trauma, as well as innovations in diagnosis and pulp treatment. I fully appreciated the value of what a unique opportunity it was to connect with professionals at the very forefront of paediatric dentistry research and development – which allows me to bring back knowledge that can benefit practice. Renowned experts Yasmi Crystal, James Coll, Anne O’Connell, Nicola Innes and Jonas Rodrigues shared cutting-edge research on effective pulp management of primary and permanent teeth affected by deep caries or trauma.
 
During the three day conference, I was invited to attend the Association Leadership workshop led by John S Rutkauskas which was particularly stand-out in terms of the insights and practical take-away messages. We learnt about value-based leadership, with its emphasis on core values like reflection, balance, humility, accountability, clarity, and empowerment. These are excellent approaches for organisations focused on healthcare, where the ultimate goal is to make a difference in patient outcomes. By aligning leadership practices with these principles, paediatric dentistry can foster stronger teams, more transparent decision-making, and long-term ensure a more collaborative and sustainable impact.
 
The topic of good management and ultimately the wellbeing of the dental workforce are subjects of particular interest to me, since I have focused much of my research time recently - back at the School of Dentistry at Cardiff University, where I am the lead for Paediatric Dentistry - on this important subject. What my own investigations have shown me is that whilst appropriate patient care is of course fundamental, this must be considered alongside ensuring the mental and physical well-being of trainees and staff who are tomorrow’s dentists. So, I was heartened to see a focus in a global forum on the importance of the working environment for the dental team. 
 
Further discussions provided valuable strategies for managing the challenges specific to paediatric dentistry, particularly as it relates to improving the oral health of children on a broader scale, with the importance on the most vulnerable paediatric patients being a focus.  This an area of particular importance for us in the UK, so again it was interesting to see this engagement on a wider level.
 
Overall, the conference felt well-rounded with its focus on up-to-date research on managing carious teeth in young people. Having international speakers share insights on current evidence-based practices undoubtedly enriched the experience, giving attendees practical knowledge to enhance care within their own communities. 
 
I was able to meet with Paediatric Dentists from a myriad of other organisations, including Dr Figen Seymen, the current President and Dr. Soni Stephen, the President-Elect of IAPD, to discuss the common values we all share.
 
International conferences to share global insights and experience provide a valuable exercise in sharing best practice and the latest learnings, so it was heartening to see the engagement from the large number of attendees in Portugal this year.

ATTENDING THE CHIEF DENTAL OFFICER’S ROUND TABLE: INSIGHTS ON THE FUTURE OF DENTISTRY

DR SHANNU BHATIA, PRESIDENT, BSPD
SEPTEMBER 2024

Recently, I had the opportunity to attend the Office of the Chief Dental Officer’s (OCDO) Round Table event, as BSPD President where I engaged with leaders from various specialties and key stakeholders in the dental field. The event provided a unique platform for updates, policy discussions, and collaboration on the pressing issues facing dentistry in the UK.

The CDO, along with other policy makers, delivered insightful updates that sparked engaging discussions. Notably, Navina Evans, Chief  Workforce training & education officer for NHSE, shared updates on workforce development. Dominic Robson, Senior Policy Manager, Dentistry, and Jane Luker, Postgraduate Dental Dean and Chair of the English Dental Deans, also contributed with thought-provoking presentations on policy and training pathways.

Round table discussions centred on critical topics like dental disease prevention, workforce retention, and supporting trainees in the field. I know from my own experience and research just how important focusing on the wellbeing of the dental workforce is in terms of helping with retention and shoring-up the dentistry workforce for the future. BSPD’s ‘Right Care at the Right Time’ theme at our recent conference expounded on this understanding – ie: that caring for the patients is of course our focus, but to do that we must support the dental teams to deliver the best care.

Paediatric dentistry also took a spotlight moment at the round-table, with a strong emphasis on the importance of prevention for the youngest in our society. Public health campaigns promoting preventive care, along with initiatives like community water fluoridation (CWF), were suggested as essential steps forward. We also know the positive impact to patients’ oral health - and the NHS purse – initiatives such as targeted supervised toothbrushing can have. These campaigns are working effectively in the devolved nations (Scotland – and back in my home nation, Wales), as well as being carried out with good results in some areas in England. Rolling targeted supervised toothbrushing out in England should be a priority and we need to hold the new government to account on this, since it was one of their manifesto pledges pre-election.

This OCDO round-table meeting highlighted the importance of collaboration across specialties and the need for proactive public health measures to improve oral health outcomes for the future. I look forward to seeing the actions discussed implemented, and meeting again with the group at the next round-table in the near future.

With dentistry currently in crisis, only continued collaboration, vision and on-going pressure can bring the much needed changes so badly needed.

The Looked After Children Oral Health Toolkit – a vital resource to help identify and support the oral health needs of children who often experience greater dental care needs

By Julia Hurry, Academic Clinical Fellow (ST1) in Paediatric Dentistry at Queen Mary University of London and Barts Health NHS Trust & General Dental Practitioner at 2 Green Dental

June 2024

Last month the “Looked After Children (LAC) Oral Health Toolkit” was published on the British Society of Paediatric Dentistry (BSPD) website. It is now available as a helpful resource to support those working with LAC including Integrated Care Boards (ICBs), Integrated Care Systems (ICSs) and dental care professionals. This guidance document was written by a group of dedicated experts in the field who shared the joint aim of broadening awareness of the specific oral health needs and challenges facing LAC in the UK.

The number of LAC in England rose to 83,840 in 2023 - an increase of 2% - continuing the rise seen in recent years both in England and the rest of the UK. This is a rate of 71 LAC per 10,000 children with regional variation across England. Most LAC are in foster placements (68%), where an approved carer looks after the child. LAC can experience high instability of placement with one in ten having 3 or more placements within 1 year. This high frequency of placement movement can make the continuity of dental care exceptionally challenging.

Local authorities have a statutory duty to arrange an initial health assessment, including a dental check, for LAC within 20 working days of a child being taken into care. Review health assessments occur every 6-months (for children <5 years) or 12-months (for children >5-years). Dental check-ups are monitored by local authorities; however, they are only reported for children who have been in care for at least 12-months and do not specify that young children must have their teeth checked by a dentist. This makes it more challenging to understand the true oral health needs of LAC.

There is little known about the oral health needs of LAC. A recent scoping review found that LAC had poor oral health outcomes and unmet needs including tooth decay, dental trauma, gum disease, pain and crooked teeth. These were thought to be possible consequences of entering care with untreated dental disease and/or lacking established oral health routines including low sugar diet and toothbrushing. However, as most of the data was accrued from LAC already accessing care, this is likely to only be the tip of the iceberg.

Four existing dental care pathways were identified within England for LAC by the scoping review, and it recognised the need for better integrated working between professionals involved in the care of LAC.

The Looked After Children Oral Health Toolkit aims to support ICBs, ICSs and key stakeholders in LAC oral health to identify their oral health needs and to help plan and deliver dental services for LAC. It is an easy-to-use guidance document which provides six key questions that ICBs can use to plan their dental services.

The Toolkit also provides examples of key organisations and partners as well as the roles that each of these bodies may take on to support the oral health of LAC and care leavers. The Toolkit has embedded personal reflections and case studies from real-life examples of current activities and programmes in use across the UK, making the document feel relevant and achievable. The reflections and case studies provide further details of where these activities are taking place to encourage collaboration with the shared aim of improving the oral health of LAC. Support and resources available for professionals, foster carers and LAC themselves as well as a summary table of policy drivers and NHS initiatives can be found towards the end of the document.

The Looked After Children Oral Health Toolkit is a helpful guidance document for all those engaged in caring for LAC as well as LAC and care leavers themselves. It helps clarify the roles of key organisations and stakeholders, summarise policy drivers and NHS initiatives, collate useful resources, and provide real-life examples of current activities and programmes in the UK.

The authors hope this supportive document can be used to identify the oral health needs for LAC in their area and allow key organisations to plan and deliver dental services for an increasing cohort of children and young people who are known to face additional barriers in accessing dental care and have greater dental care needs. I hope that the Toolkit will help to make a real difference in the quality of life of a particularly vulnerable group of children, and will provide clear guidance to identify, address and monitor the oral health needs of LAC so that we can start to see an improvement in their oral health outcomes.

References:
Children looked after in England including adoptions. 2023. GOV.UK. Available at: https://explore-education-statistics.service.gov.uk/find-statistics/children-looked-after-in-england-including-adoptions (accessed 17/05/2024).

Hurry KJ, Ridsdale L, Davies J, Muirhead VE. The Dental Health of Looked After Children in the UK and Dental Care Pathways: A Scoping Review. Community Dent Health. 2023 Aug 31;40(3):154-161. doi: 10.1922/ CDH_00252Hurry08. PMID: 37162290.

 

Putting the fluoridation ball in the net…

By Simon Hearnshaw
Coordinator National Community Fluoridation network

April 2024

BSPD is a founder member of our community water fluoridation (CWF) network. Set up in 2016 working closely with the British Fluoridation Society, the network’s role is to raise the profile of fluoridation and work with a range of organisations with similar views on the importance of prevention and the effectiveness of the public health measure. BSPD has been key to the work that the network does because of the improved child oral health and reductions in exposure to GA extractions that fluoridation can bring. BSPD members have been instrumental in working locally and across organisational boundaries with groups like RCPCH. Elizabeth O’Sullivan has worked closely with the network in Hull and helped us get consideration of fluoridation included in the Starting Well Programme way back in 2017, and BSPD was amongst the first to publish a Position Statement (updated in October 2021) on CWF. There have been a lot of small steps along the fluoridation road, and now we are approaching the leap forward that we all want to see in the interests of the communities we work within.

Health & Care Act 2022 – taking fluoridation out of the ‘too hard box’

For many years it has felt like CWF has been put in the ‘too hard box’. Certainly, that’s what it felt like in the early days of the network. The Health and Care Act 2022 changes this, giving the Secretary of State the power to directly introduce, vary or terminate water fluoridation schemes. This removes the burden from local authorities effectively taking politics out of decision making and making this all about health and health equity. Now we have arrived at the first public consultation on CWF since 2008 with it the possibility of the first wholly new scheme since 1985. I qualified in December 1984, so this is quite literally a generational opportunity to make a difference.

Supporting the Public Consultation.

The Government is consulting on plans to expand community water fluoridation schemes across the north east of England. This area was chosen because of the poor oral health and inequalities in the region, and because the Local Authorities have all worked together over many years to achieve this goal for the communities they serve.

The consultation must take into consideration the extent of support for the proposal, the cogency of the statements made and the areas that are being represented in the responses.

Everyone can submit a response and all MCNs, LDCs should be encouraged to do this. However, submissions from the North East will be weighted. So, whilst it is important that we all get involved, it is critical that BSPD members in the North East do so.

Cogency is around the strength of the arguments put forward so these need to be based around the evidence base and professional lived experience.

The Evidence Base is extensive, but the key messages are:

CWF is effective.

CWF is safe.

CWF reduces inequalities.

CWF is cost effective.

CWF is sustainable.

The North East Water Fluoridation briefing has been produced by Kamini Shah and BSPD’s very own Chris Vernazza to support consultation responses. It contains a summary of the evidence base including cost effectiveness and local epidemiology data describing the local oral health need and impact of CWF.

More information can be found on the consultation site, in the recent dental update series on fluoridation, and the webinar from 2022.

Professional experience

International reviews and papers clearly contribute to the strong evidence base around CWF described in the position statement by the four UK CMOs. However, our professional lived experience is also convincing. Describing seeing the benefits of fluoridation, the impact of poor oral health, having to extract children’s teeth on a daily basis and admit children to hospital for a GA exodontia are powerful statements that add to the argument that communities need fluoridation as the only universal prevention intervention that requires no behaviour change and helps those that need help the most.

Please find the consultation here and take care to respond by the deadline of June 17th. Between us all we can ensure it is our generation of clinicians who put the evidence–based fluoridation ball in the net for the communities and in particular the children we serve.

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

October 2023

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

July 2023

 

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.

References

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

June 2023

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

March 2023

 

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.

1 https://www.gov.uk/government/statistics/hospital-tooth-extractions-in-0-to-19-year-olds-2022
2 https://www.child-smile.org.uk/professionals/research-and-evaluation/evaluation-reports.aspx
3 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/321503/CBOHMaindocumentJUNE2014.pdf
4 https://www.england.nhs.uk/about/equality/equality-hub/national-healthcare-inequalities-improvement-programme/core20plus5/core20plus5-cyp/
5 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/560973/ROI_oral_health_interventions.pdf

 

 

 

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?

CORE20PLUS5 comprises:

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: media@bspd.co.uk

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.

References: 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

 

 

Dear Members

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 media@bspd.co.uk.

With best wishes

Jenny