This paper reviews the existing challenges facing primary dental care in Wales. It then considers the five principles of prudent healthcare and how the prudent healthcare agenda can help support the future development of dental services in Wales. Each of the principles is considered in turn and illustrated with an example taken from current developments in dental health services in Wales.
Applying prudent healthcare principles in NHS general dental practice will involve meeting a number of challenges already facing the profession. These include:
- existing dental health inequalities across Wales
- a high incidence of tooth decay in children in many areas of Wales
- a high rate of children undergoing general anaesthesia for dental treatment
- a population which is aging and yet retaining its teeth
- patients with significant co-morbidities and polypharmacy affecting their oral health
- high levels of smoking in the population of Wales
- patients at risk of oral cancer
- poor dietary choices leading to tooth decay
- the need for patients to be treated, where possible in their own communities
- limited resources with which to provide services.
How can NHS dentistry in Wales meet these challenges using the principles of prudent healthcare? The five principles of prudent healthcare are:
- do no harm
- carry out the minimum appropriate intervention
- organise the workforce around ‘only do what only you can do’
- promote equity
- remodel the relationship between the user and the provider on the basis of co-production.
Prudent healthcare is as much about cultural changes within the NHS and the population it serves, as it is about changes to clinical practice. Its main principles can be readily applied to dental practice. As we have a finite amount of money with which to fund our NHS dental services, it is important that resources are used wisely and effectively. Given that there are finite resources NHS dental services are already reviewing how they can become more efficient. Prudent healthcare provides a structured approach to delivering services that meet the needs of the population of Wales within those constraints. It will help us achieve more “more bang for the buck”.
How can prudent principles be applied to primary dental service?
Putting prudent into practice in primary dental services will involve:
- the adoption of modern dental techniques for the management of disease by the application of good evidence based dentistry. This will mean using the minimum intervention appropriate for each clinical situation.
- avoiding techniques which are of limited benefit to patients
- doing no harm
- providing the most appropriate care by the most appropriate person
- preventing disease
- tackling dental health inequalities in our most at-risk populations
- helping patients to help themselves and to empower people to take more responsibility for their own dental health.
To illustrate how prudent healthcare can be applied to dentistry we will consider examples relating to each of the principles. These include reducing antibiotic prescribing, avoiding general anaesthesia in child dental services, dental nurses providing preventive care, the all Wales scheme ‘Designed to Smile and the development of a new pathway for dental services in Wales.
Do no harm: reducing antibiotic prescribing
Dental practitioners are able to prescribe antibiotics to patients, however the prescription of these drugs is often inappropriate and ineffective. Any prescription of an antibiotic carries a risk of an adverse event such as an allergic reaction or gastric symptoms; it also increases the larger risk to the population of bacteria developing resistance to that antibiotic. In October 2009 Public Health Wales reported that general dental practitioners were responsible for nine per cent of all antibiotic prescriptions in Wales. The reasons for this are complex. They may include:
- dentists’ perception of having insufficient time for providing a physical intervention
- lack of understanding about the appropriate physical intervention
- patient expectation
- lack of confidence in carrying out the appropriate intervention.
In addition, antibiotic prescription is an ingrained part of dental practice. For decades dentists have been taught to prescribe antibiotics for patients with prosthetic heart valves, heart murmurs or a history of rheumatic fever in the belief that this helped prevent the development of infective endocarditis after invasive dental procedures.
It is possible to change how dental practitioners use antibiotics and this change is now happening in Wales.
Reducing dental antibiotic prescribing in Wales
In March 2008 the National Institute for Health and Care Excellence (NICE) issued new guidance about the use of antibiotic prophylaxis for patients at risk of infective endocarditis which said that dental patients should no longer receive antibiotic cover prior to invasive dental procedures. The risk of developing antibiotic-related side effects out-weighed the risk of developing infective endocarditis. A review of the effects of this guidance on antibiotic prophylaxis prescribing in England found that dentists were responsible for 92 per cent of prescriptions for antibiotic cover before March 2008, other providers being responsible for the remaining 8%. By 2011 the number of prescriptions issued in 2011 had fallen by 78.6 per cent.
Prescribing of antibiotics for dental conditions is an area where improvement is happening. In early 2013 the dental postgraduate department of the Wales Deanery, in collaboration with the healthcare quality improvement programme, 1000 Lives Plus, invited all general dental practitioners to engage in a funded audit of antibiotic prescribing in their practices. Uptake has been good and dental practitioners are now required to declare on their annual quality assurance questionnaire whether they have undertaken the audit or not. Health boards will contact any practices not yet participating and encourage them to take part.
Carrying out minimum effective intervention: reducing general anaesthesia
Tooth decay and gum disease are by far the most common dental diseases we currently face in our communities in Wales  and yet they are readily preventable by simple measures. Water fluoridation has been shown by more than 100 studies to markedly reduce the incidence of tooth decay in pre-school and school age children. The Welsh Government understands the dental health benefits of water fluoridation .
There are, however, many varied obstacles that such a process of fluoridation would face, which, at this time, makes water fluoridation an unrealistic proposition. The dental profession, on the other hand, is in a unique position to make a significant contribution to the prevention of both tooth decay and gum disease. The application of high-concentration fluoride varnish to at-risk teeth, new tooth-brushing advice, dietary advice and helping with smoking cessation are all areas in which dental practitioners can help prevent disease. In the past there has been little acknowledgement of the important role general dental practitioners can play in this, but this preventive role is now being promoted across the NHS.
For the last three years a number of Welsh dental practices have been piloting new ways of managing patients within the NHS. This has included meeting key performance indicators related to prevention of dental disease. The NHS dental pilot has also allowed practitioners to include ‘minimum intervention dentistry’ in helping to manage patients at high risk of losing teeth through dental decay – a key principle of prudent healthcare.
There has also been a move away from treatments that are of little or no benefit to patients. This includes no longer routinely offering a ‘scale and polish’ and the application of the NICE guidance on dental recall intervals. This has the effect of freeing up surgery time and so increasing access for more patients to NHS dentistry. This allows dental services to make the most of available resources to serve the people of Wales, another goal of prudent healthcare.
Children and general anaesthesia
Table 1. General anaesthesia for children’s dental treatment by health board of provider – 2013-14
(N/A – not available)
This table showing data collected by Public Health Wales illustrates the high level of dental general anaesthesia in Wales. General anaesthesia carries a risk, albeit small, of serious complications. It is expensive, requiring not just a dentist but also an anaesthetist, appropriately trained staff and correct, safe facilities in which to carry out procedures and allow safe recovery. Added to this it is also thought to contribute to children developing dental anxiety later in life. In the 2010 NICE report, dental general anaesthetic costs were calculated to be £720 per case. There are, however, alternatives to dental general anaesthesia for many children which are safe, effective and much cheaper. These include:
- behavioural management techniques
- conscious sedation.
Both techniques help avoid the need for general anaesthesia. Dental therapists are well trained in managing children with behavioural techniques, more so than dentists in many circumstances. By adopting methods such as ‘tell-show-do’, gradual exposure to treatment and desensitizing children dental therapists are often able to build rapport with child patients, reducing their anxiety and are often able to complete dental treatment without resorting to more complex methods of anxiety management.
Conscious sedation in paediatric dentistry has been used for many years in primary care, involves the use of nitrous oxide, also known as laughing gas, mixed with oxygen, to relax the child. This causes the brain to release the natural feel-good chemicals and makes the brain more receptive to these chemicals. Treatment is then carried out in the normal way using local analgesia. Because nitrous oxide isn’t very potent, and the machine giving the gas can’t give less than 30 per cent oxygen, the process is completely safe. There are significant cost savings compared to general anaesthesia (£273 per case) so long as the success rate is above 56 per cent. Commonly quoted figures for inhalation sedation are around 90% success. Internal audits of our own primary care conscious sedation service, based in our Abergavenny practice, show a success rate of 96 per cent for paediatric cases.
Avoiding general anaesthesia at Aneurin Bevan University Health Board
As shown in Table 1 above, 1,980 dental general anaesthetics were administered in Aneurin Bevan University Health Board area in the year 2013-14. Following the development of the National Oral Health Plan, health boards across Wales were encouraged to develop their own local oral health plans for the future. In the Aneurin Bevan area, the health plan led to the development of a pathway to improve the management of children who are unable to accept conventional dental treatment.
Since May 2014 general dental practitioners in Aneurin Bevan University Health Board have been using this common referral pathway for children who, in the past, would have been referred directly for general anaesthesia with the exception of those who were referred for conscious sedation. Children referred on this pathway are seen by members of the Designed to Smile team and given preventive oral health advice. Members of the community dental team who are specialists in children’s dentistry then see the child and in many cases, with time and patience, achieve the planned treatment without resorting to either general anaesthesia or conscious sedation.
Where the child is not compliant, or the treatment is more complex, the child will be referred on to general dental practitioners who are trained in the use of conscious sedation or, in cases where treatment is too extensive, or the child is too young for the amount treatment needed, only then for general anaesthesia.
Because this pathway has been operating for less than a year there is no analysis of data available however, anecdotal reports suggest that the incidence of dental general anaesthesia has been significantly reduced. This is an excellent example of prudent healthcare in action. Risk for patients is reduced, the minimum intervention necessary is employed releasing time and resources in the service and dental teams are working together crossing boundaries and communicating effectively.
Only do what only you can do: extending the dental care team
The traditional model of the high street dentist providing dental care for all patients is increasingly being recognised as no longer suitable or sustainable for modern general dental practice. There is increasing use of allied professionals across health services, including nurse practitioners and prescribers, and dentistry is slowly catching up. A model of modern primary dental care with the dentist as diagnostician who prescribes care pathways and delegates these to appropriately trained supporting dental care professionals has growing acceptance.
For the last three years the Government in Wales has been piloting a new way of working in NHS dentistry that has involved modifying how our practice operates so deliver a robust, prevention focused approach to caring for our patients, based on sound evidence. At the author’s NHS general dental practice, which provides dental care from a four surgery practice in Abergavenny, under the NHS dental pilot the bulk of simple NHS dental care, and nearly all paediatric dental care offered at the practice, is no longer delivered by the dentist but now managed instead by dental therapists. This has enabled the dentists to spend more time on more complex treatments.
Developing the role of dental nurses
An important area of development is the use of dental nurses with enhanced qualifications. Again the dental pilot has demonstrated how dental health educators have an important role to play in providing dietary advice, oral hygiene instruction, administrating high-concentration fluoride varnish and smoking cessation. It no longer makes economic sense to pay highly-trained and expensive dentists to deliver these non-clinical aspects of dental care. By developing the role of dental nurses there is the potential for practices to be able to work more efficiently, provide better preventive care and give better access to dentistry for patients, without increasing the cost of dental services to the NHS.
The application of high-concentration fluoride varnish three to four times a year in children and twice a year in adults at risk of developing tooth decay is now a firmly established guideline. In a well-developed skill-mix team this responsibility can be devolved from dentists and therapists to dental nurses with enhanced training in applying fluoride varnish. This downward cascade of responsibility frees time, is more cost effective and is very good for team morale helping to retain good quality staff in the NHS.
Promote equity: Designed to Smile
Decayed, Missing and Filled teeth (D3MFT) is a measure of the decay experience of the average child. Data from the Welsh Oral Health Information Unit shows that there has been an improvement in this measure in Wales over the years, but substantial improvement is still possible in the incidence of this preventable disease. The incidence of dental diseases in adults and children are highest in Wales’ most deprived communities. The prudent healthcare principle to promote equity means that there should be strategies to improve those most at need in our society. From a dental perspective that would include improving the D3MFT rates in our children.
Designed to Smile
‘Designed to Smile’  is an all-Wales initiative, supported by the Welsh Government, aimed at improving the dental health of our children through the following strategies:
- structured tooth-brushing programmes in schools and at home. In schools which engage with the Designed to Smile teams there is a dedicated trained team member who supervises the brushing. Each child has their own toothbrush which is changed every term or sooner if needed
- healthy eating advice
- dental screening by teams from the community dental service. These teams identify children who may benefit from high-concentration fluoride varnish being applied to the teeth. They also identify children who may benefit from having a protective plastic coating called a ‘fissure sealant’ placed on their teeth. This can either be done by the community dentist or by the general dental practice team.
‘Designed to Smile’ ran a drawing competition and the children who won had their drawing used as the front cover of the British Dental Journal. This ran for 12 issues and was a real triumph not only for the children, but for ‘Designed to Smile’ and for Wales as well. As a longstanding reader of the Journal, can’t recall ever seeing Welsh used on the cover before.
Outcomes from ‘Designed to Smile’
It is too early to report on the effectiveness of ‘Designed to Smile’ because the data has not yet been published. However, ‘Designed to Smile’ is similar to ‘Childsmile’ in Scotland. As impact of the ‘Designed to Smile’ programme is analysed it will almost certainly show that children’s teeth are getting healthier. Recent studies of ‘Childsmile’ have shown a reduction in the incidence of tooth decay as a result of this programme and there is no reason why the same improvement should not be seen in Wales
There is no reason why these strategies should not be used to improve the dental health of other population groups too. These would include residents in residential and nursing homes and those in secure institutions such as prisons.
This anticipated improvement in the dental health of our children offers many long-term benefits, including:
- good dental health habits started early in life will become ingrained and lifelong
- a reduction in the number of teeth extracted
- a reduction in the number of teeth filled
- a reduction in tooth decay will result in a reduction in the number of general anaesthetics for children.
Remodel the relationship between the user and the provider on the basis of co-production: piloting a new pathway model for dental services in Wales.
For the last three years the Government in Wales has been piloting a new way of working in NHS dentistry that has involved modifying how our practice operates so we can deliver a robust, prevention focused approach to caring for our patients, based on sound evidence. The NHS dental pilot mentioned above, has encouraged the development of the dental services skill-mix away from the traditional one in which the dentist provides all the treatment. In the new model, the practice operates as a pathway along which patients can progress, based on an assessment of their risk. This pathway may involve care being provided by:
- a qualified and registered dental nurse with enhanced skills working as a dental health educator. They may provide dietary analysis and advice, oral hygiene instruction and application of high-concentration fluoride varnish.
- a dental therapist who will provide treatment for gum disease, place fillings in milk teeth, extract milk teeth, place simple fillings in adults, take x-rays and applying protective seals to children’s teeth.
- a dentist who may, in this model, carry out more complex fillings, root canal therapy, extraction of adult teeth, crown and bridgework and dentures.
- a dentist with further postgraduate qualifications. In our practice this would involve the provision of conscious sedation for adults and children who are dentally anxious or who may need a procedure they feel might be unpleasant. In other practices this might include oral surgery treatment previously carried out in a hospital setting.
NHS dental pilot as an example of co-production:
A new patient coming to a pilot dental practice will complete a dental care assessment questionnaire. This contains questions relating to their medical history, their dental history, any concerns they may have about their dental health; any disabilities, any feelings of anxiety and their dietary sugar intake. This forms the cornerstone of a dental risk assessment.
Following a clinical examination, including appropriate radiographs and special tests, the dentist will then be in a position to provide the patient with a report on their dental status. The dental care assessment process will then involve a discussion between the dentist and the patient. This will involve the dentist and the patient engaging together in developing a personal care plan. The plan will involve:
- highlighting areas of risk such as smoking, sugar intake, oral hygiene and past dental experience
- placing the patient in a category – red, amber or green according to those risks
- providing a written treatment plan which may vary according to risk
- signposting to other external sources of help and support such as Stop Smoking Wales or referral to dental health educator for smoking cessation if the patient is interested in stopping smoking at that moment
- a written quotation of any NHS dental charges that will be incurred.
By involving the patients closely in the decision-making process we have found that the uptake of dental care has been improved and patients, when questioned, have been positive about the engagement process. The additional benefit of this method of partnership working is that it supports the dental team in helping patients take more control of their dental health.
Prudent healthcare presents a sympathetic structure for the continued development of primary dental health services in Wales. As the service strives to shift emphasis from treatment to prevention and to streamline dental pathways based on extended dental teams that make the most of professional skills, prudent offers a more detailed map for the future development of dental care services in Wales, for a journey dental services have already begun.
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