Oral Health Is Closely Linked With Overall Health

Dental health and general health cannot be separated. Oral diseases are among the most common noncommunicable diseases, affecting over 3.5 billion people. Worldwide, tooth decay in permanent teeth affects over 2.3 billion people and in milk teeth affects over 530 million children. Severe gum disease affects around 10% of the world, and milder forms of gum disease affect almost half of the population.

A person with a healthy mouth is comfortable, able to eat the foods that they choose and is less likely to have other disease including cardiovascular diseases, cancer, chronic respiratory diseases and diabetes. We know that our self-esteem, dignity and appearance are all linked to a healthy mouth. If you have any of these conditions, then reducing any disease in your mouth could help you be healthier in general.

World Health Organisation and Centers for Disease Control and Prevention

Dental treatment may involve a risk of transmitting COVID-19 as it often involves aerosols from drills and cleaners, and it is not possible to keep a physical distance between people during care. The risk can be reduced with expensive Personal Protective Equipment (PPE) and spacing the number of people treated during the day.

For most people, access to dental care in Ireland is not straightforward. A number of barriers exist, not limited to, but including:

-Financial             -Bureaucratic                      -Phobia                 -Geographic

Dental care here is delivered in three main ways:

1. Hospital Dental Service

• Dublin and Cork Dental Hospitals. Patients may be seen either by supervised student or by consultants. The care may carry a charge or may be provided free if the person has a medical card for the areas that hospital accepts.
• Oral Surgery Units at General Hospitals might care for patients who need difficult wisdom teeth removed or orthodontic surgery.

The waiting lists can be long. In most cases, people are referred to the hospital once they have seen a dentist in practice.

2. HSE Dental Clinics at Primary Care Centres

Mainly see children under 16 and possibly care for vulnerable adults

The service is free but there is a need for more access. Children are seen either through;

• The Emergency Clinics, or
• The School Screening Service in 2nd, possibly 4th, and 6th class in certain areas.

The waiting lists can be long.

3. Private Dental Practice

These are independent small businesses or corporate businesses that do not receive financial support or PPE from the government. They employ or contract an estimated 10,000 people as receptionists, dental nurses, practice managers and dentists, hygienists and clinical technicians.

The forms of payment for the treatment are:

• Dental Treatment Services Scheme. The HSE contract care for people who have Medical Cards and are over 16 years old, to self-employed dentists.
• Treatment Benefits Scheme. Dentists are able to claim for an annual exam and cleaning if the patient has enough PRSI credits and is over 18 years old.
• Private payments that may be paid in full by the patient or supplemented by some types of health insurance.

The waiting lists are often short as there are lots more dental practices than either dental hospitals or HSE dental clinics. Not all dentists sign up with the Dental Treatment Services Scheme or the Treatment Benefits Scheme for a variety of reasons. The fees that the dentists receive will likely not cover the cost of the highest level of PPE and allow for the business to continue to be sustainable.

The Solution? A Universal Dental Care System

Reducing oral health issues calls for a reform of dental care systems to shift the focus from invasive dental treatment, which has failed to combat the global challenge of oral diseases, to minimal invasive treatment and oral diseases prevention. 

World Health Organisation

We need a dental health care system that:

• provides for everyone
• is free at point of access
• is safe for all involved
• promotes health, instead of treating disease
• uses techniques, materials and equipment that are minimally invasive when possible and up to date with best evidence
• is sustainable for our environment

A two-tier health system does not provide for everyone’s general health. Oral health is no different.

Dentistry cannot continue in the same way it did before COVID-19. Huge changes need to be made in how people are scheduled, in PPE and how care is provided. These must be done with the input of dental healthcare workers and patients, the Irish Dental Association, the Irish Dental Council, the Irish Medical Association and Council.

For the health and wellbeing of our population, we need dental care to be provided in a comprehensive way for everyone. Oral health care should be provided as part of a National Health Service. Children should be seen as early as needed, and certainly before their first birthday. Prevention should be the most important aspect, and given the time and funding needed for us to be able to succeed in protecting health, rather than trying to ‘fix’ disease once it begins. Oral health in older populations and Nursing Homes needs to be prioritised as our elderly loved ones are keeping teeth longer than they would have in the past. We need to develop systems for delivering Teledentistry to allow dental healthcare workers to diagnose and provide people with advice in a safe environment and to improve access for all kinds of people.

Everyone deserves healthcare. We have to remove the barriers and put the provisions in place, otherwise the gap widens between people who can pay to be healthier and people who can’t afford to see a doctor, dentists, optician or any healthcare provider. Let’s have a system in place where everyone has the opportunity to be comfortable and free from preventable diseases.

5 Care Planning for the Future: What is the best way to improve care?

In this climate of COVID-19, dentistry as a business is not feasible.

5.1 Short term – During COVID-19

As a matter of urgency, we need Emergency Dental Centres to be set up.

The Scottish Dental Clinical Effectiveness Programme (SDCEP) Guidance is an excellent format to base our model on.

http://www.sdcep.org.uk/wp-content/uploads/2020/03/SDCEP-MADP-COVID-19-guide-300320.pdf

PPE is in short supply. As a profession, we cannot deflect this precious resource from the Hospital staff fighting for patients’ lives. These staff must be protected. Teeth are obviously not a higher priority than life. Dental practices are finding it difficult or impossible to acquire PPE of the quality and quantity needed to care for patients safely. Emergency Dental Centres will make most efficient use of available PPE.

• Lack of PPE is only half of the picture. Small Private Dental Practices are not set up to care for patients with the present risk of aerosols transmitting from patient to patient. We need centralised care to allow for more rooms, as well as separate entrances for Covid-19 positive and negative and status unclear patients, with negative pressure rooms and adequate ventilation and air exchange systems.
• Clear guidance is needed from experts who are taking the risks of the unknowns seriously to ensure the safety of all people involved.
• It is crucial that after the COVID-19 pandemic, Emergency Dental Centres continue. We need to have provisions in place so everyone who has a dental emergency can be treated in a safe manner to prevent serious dental emergencies putting extra strain on hospital resources during times of uncertainty.
• Legislation would need to change to allow for patients to be seen in HSE Dental Clinics, or to allow insurance cover for private practices to act as Emergency Dental Centres.
• Oral health care advice should be advertised to the public to help slow or prevent issues from arising. Prevention of disease needs to be invested in. Radio and Television Campaigns and videos on HSE website are important so the public have access to clear and evidence-based advice.

5.2 Long term – Post-COVID-19

We need a dental health care system that

• provides for everyone
• is free at point of access
• is safe for all involved
• promotes health, instead of treating disease
• uses techniques, materials and equipment that are up to date with best evidence
• is sustainable for our environment

A two-tier health system does not provide for everyone’s general health. Oral health is no different.

Our oral health is linked to our quality of life, our overall health, our ability to digest food, our speech and our appearance. No one should be left behind.

To give everyone access to high quality and safe dental care, we must remove the barrier of cost to the patient. Especially in a post-COVID-19 world, it is not fair to pass on the cost of PPE, aerosol management and increased surgery time to patients.

Everyone should have access at the point of care to dental care that enhances health.

• Examinations
• Xrays and Photographs
• Prevention consultations
• Prescriptions
• Nightguards and Sportguards
• Gum treatments: Scale and Polish and Root Debridement
• Fissure sealants
• Fluoride varnish
• Restorations (Fillings) utilising minimally invasive techniques to reduce aerosols
• Incision and drainage of abscesses
• Extractions: simple and surgical
• Endodontics (Root canals)
• Orthodontics (Straightening)
• Dentures

Cosmetic treatments such as whitening and aesthetic work, and expensive procedures such as Implants, Crowns and Bridges and complex Orthodontics may not be possible at the beginning, until an increased staff force was available, but could be added in as funding increases.

The financial cost of PPE will decrease when purchased in bulk.

The financial incentive to be reimbursed for drilling teeth will be removed, and so prevention will be encouraged.

I suggest a working group and focus groups to ascertain what will be most beneficial for us all. A suggested solution would be to expand the HSE system to employ more dentists, dental nurses and admin staff, in a not for profit system.

5.2.1 Increase capacity

Oral health is not separate to our overall wellbeing. It is closely linked to our overall health, the connection is especially clear with regards to cardiac health, diabetes and during pregnancy.

For our current population of 4.9 million people (and 1.8 million in Northern Ireland) there is a need for more comprehensive dental care. At present, there are around 2,000 dentists and an estimated 10,000 people employed by dental practices in Ireland.

The government has a duty of care to provide dental care under Section 67 of the Health Act, 1970.

It is not feasible to continue to contract out this care to private practices.

5.2.2 Dental therapists

Dental therapists are registered dental professionals who carry out most types of dental treatment direct to patients or under the prescription of a dentist. They provide most kinds of dental care, except for dentures, crowns or bridges, endodontics or orthodontics, or extraction of adult teeth. They currently work in UK, but there is no option for them in Ireland. They could be a valuable asset to a Universal Dental Care system.

5.2.3 Dental Hygienists

Dental Hygienists are already an important part of the dental team in Ireland. Many of the closest connections between dental and overall health are due to health of the gums (periodontium). We must ensure continued support of the Irish Dental Hygienist’s Association.

5.2.4 Clinical Dental Technicians

Ireland already trains CDTs. They often work as self-employed contractors through private practice or employees in dental hospitals. They make dentures to give directly to the patient, without requiring a dentist to be an intermediate.

Dental technicians without the clinical qualification cannot see the patient directly to make records by impression etc. They require a dentist to send these impressions and records to them. This adds another layer of costs.

5.2.5 The way forward

We have the opportunity to be world leaders in providing all people with comprehensive healthcare. Many countries provide dental care free at the point of service for children under 18 or 19 years old e.g. Denmark, Finland, Spain, Sweden and the UK. What changes at 19 years old? Don’t we all deserve to have the support needed to keep us healthy and comfortable? Our population is growing in age as well as number. It is well known that preventive dental care is essential later in life to maintain comfort and function.

Few countries currently provide dental care for adults. We should look to Germany and Japan. There many beneficial protocols in their dental care systems.

Dentistry cannot continue in the same way it did before COVID-19. Huge changes need to be made. These must be done with the input of dentists, nurses and patients, the Irish Dental Association, the Irish Dental Council, the Irish Medical Association and Council.

For the health and wellbeing of our population, we need dental care to be provided in a comprehensive way for everyone. It makes sense that oral health care should be provided as part of a National Health Service.