ADG: Children face ‘triple whammy’ of coronavirus dental dangers

Thousands of children could soon require hospital operations to remove unsavable teeth due to a ‘triple whammy’ of dental dangers, states the Association of Dental Groups (ADG).

Hospitals in England carried out an average 177 operations a day on children and teenagers last year to remove teeth, costing the NHS more than £40m.

Now the Association of Dental Groups is warning that lockdown will make the problem significantly worse as:

  1. Many children have stopped going to the dentist or been unable to get appointments
  2. Children are more likely to snack on more sugary foods and drinks while stuck at home
  3. Community oral health programmes for children have been interrupted

Neil Carmichael, Chair of the ADG, said: “Before lockdown, there were multiple operations being conducted every day to remove children’s teeth across the UK. Since then children have faced a triple whammy of dental dangers so it’s inevitable that things will get worse. When routine appointments restart, dentists could have their work cut out dealing tooth decay among children. In hospitals all the signs are that we’re looking at more operations than ever to remove children’s teeth.”

There is mounting evidence than millions of people have been staying away from dental surgeries or being unable to get appointments during lockdown. A major new poll by the ADG suggests that children in 50% of households across the UK have missed or decided against a visit to the dentist since lockdown began.

The UK already the lowest number of dentists per capita of any G7 country, leading to growing concerns that a backlog of care may well occur after the pandemic unless measures are taken to aid recruitment into the profession.

Dentists have also expressed concern over ‘lockdown diets’ including more sugary treats and fizzy drinks having an adverse effect on children’s oral health. One survey for a member of ADG found that 77% of dentists expect the ‘lockdown diet’ to have an adverse impact on the nation’s oral health. Other anecdotal evidence suggests an increase in sugary baking particularly at the beginning of lockdown and an increase in sugary snacking. 

Finally, dental professionals have expressed concern over community dental services which normally deliver child oral health improvement programmes through Local Authorities, which have now been disrupted. These are early intervention, preventative programmes in areas of likely poor child oral health.

Sue Jordan, Assistant Director, Oral Health Improvement for CDS-CIC, which deliver community dental services and oral health improvement across much of east and central England said: Over lockdown 90% of our outreach to the most vulnerable communities in our regions has been shut down. In normal times we support more than 2000 young children to do supervised teeth cleaning and today not one child will be receiving that help. We have helped children as old as three who didn’t know which way to hold a toothbrush. They won’t be receiving that help any more or the structure that they need to prevent dental problems. They won’t be able to get that help until post-covid routines can be normalised either.

“All the evidence we have suggests that early preventative care for dentistry has a huge return on investment. We know that our work can save up to nearly £7 for every pound spent. After Covid, that bill will eventually come due with massively negative consequences for the children and the NHS. Dentistry really is a critical preventative service, the problems that get worse for these children suffer during lockdown can only get exponentially worse over time. we are going to have a real uphill struggle getting back on track when this is all over.”

The CDS-CIC work with Local Authorities, the NHS and other Community organisations to identify the most at risk children for dental problems. Their work helps identify and educate younger people in particular to improve their oral hygiene.  https://communitydentalservices.co.uk/

Data around number of dentists taken from https://www.nao.org.uk/report/dentistry-in-england/

BSPD: Workforce is critical to tackling the unacceptably high levels of dental decay in children and young people

The current number of specialists in paediatric dentistry is insufficient to meet the oral health needs of children and young people.  More specialists and consultants are required as well as training in enhanced skills in paediatric dentistry for General Dental Practitioners (GDPs).

The British Society of Paediatric Dentistry (BSPD) voices its concern on the shortfall of specialists following on from today’s press release from the Faculty of Dental Surgery at the Royal College of Surgeons of England (FDS RCSEng). Their release highlights the unacceptably high number of dental extractions under general anaesthetic caused by dental decay.  

While supporting the call from FDS for the roll-out of supervised tooth brushing schemes in early years settings and for a renewed commitment to sugar taxes, BSPD spokesperson Claire Stevens highlights the complexity of the current challenges facing the dental profession. 

For too long, she says, the marketing of high sugar foods and drinks aimed at children and young people has accelerated. Every Christmas, for instance, the Coke Tour involves huge trucks going to some of the most deprived parts of the country where drinks are given out for free. 

Dr Stevens said: “Covid-19 has deepened the challenges faced by the dental profession. Post lockdown, dental treatment has been successfully restarted, yet there is an estimated reduction in capacity of 50-65% due to essential measures to minimise the risk of viral transmission and protect staff and patients. Sadly, the number of children requiring hospital-based treatment caused by dental decay is going to remain constant as we have no choice but to anaesthetise very young children who need extensive restorations or extractions.
 
“However, at the same time as ensuring we have the workforce to carry out these treatments, we also need prevention programmes to help families rethink children’s diets and reduce sugar consumption. We would like to ensure that all children are regularly brushing their teeth both at home while the very young should experience supervised toothbrushing programmes in early years settings. The evidence shows that such schemes deliver an excellent return on investment.”
 
Dr Stevens added: “We would like to encourage all local authorities with areas of high dental need to introduce water fluoridation schemes. 45% fewer children aged 1 to 4 in fluoridated areas are admitted to hospital for tooth decay than those in non-fluoridated areas.”
 
“Following on from its excellent green paper on prevention, we would like to see the government delivering on its commitment to extend oral health interventions, supported by all organisations involved in the care and well-being of children and young people. Children’s oral health is everybody’s business.”

References:

https://www.bspd.co.uk/Professionals/Resources/Position-Statements

https://academic.oup.com/ije/article-abstract/49/3/908/5826797

https://www.gov.uk/government/consultations/advancing-our-health-prevention-in-the-2020s/advancing-our-health-prevention-in-the-2020s-consultation-document

BSPD responds to the Local Government Association over the impact of Covid-19 on children’s oral health

The British Society of Paediatric Dentistry (BSPD) has stated that it agrees with The Local Government Association that there should be a resumption in toothbrushing schemes in early years settings as soon as practical and such schemes are essential to counteract the possible increase in dental decay as a result of lockdown.

Dr Claire Stevens, BSPD’s spokesperson, says the LGA is right to highlight the risk of worsening dental decay in children as a result of Covid-19 as well as the guidance that is now available on establishing such toothbrushing schemes. (1)  

BSPD is collecting the data to assess the impact of the pandemic on children’s oral health.  Prior to the pandemic, the figures for children having general anaesthetics for multiple extractions were starting to come down. This was thanks to the concerted efforts of many people, driving up preventive interventions and activities.

The cancellation of general anaesthetics for multiple dental extractions during COVID-19 will inevitably mean that hospitals are working through a backlog of cases once elective (non-emergency) procedures restart. There is also the possibility of increased dental caries in children, the result of being out of education and stuck at home with greater opportunities to snack.

BSPD would like to see children suffering from dental decay to be treated in primary care where possible, to reduce the need for onward referral into hospital. We have been producing resources to support GDPs provide silver diamine fluoride, a technique which arrests the progress of dental decay and may avoid the need for a general anaesthetic entirely. (2)

Dr Stevens commented: “As ever BSPD is keen to work with all stakeholders involved in the care and welfare of children to minimise the impact of Covid-19 on their oral health.”

Meanwhile, Dr Saul Konviser from the Dental Wellness Trust, also spoke on the matter: “Everyday we, as dentists, see a large number of children that require not just a simple filling but often multiple fillings or extractions which is often a result of consuming too many sugary foods and drinks. What is worse is that it is almost completely unavoidable. From the work that we do, we know strategies such as oral health prevention and toothbrushing programmes in schools and nurseries is one way of supporting this long overdue ‘prevention better than cure’ ethos. We now urgently call on the Government for more funding – especially as lockdown prevented many children from accessing a clean toothbrush and toothpaste.”

(1) https://www.gov.uk/government/publications/covid-19-supervised-toothbrushing-programmes

(2) https://www.bspd.co.uk/Professionals/Resources

BSPD releases resources to support the use of Silver Diamine Fluoride

A comprehensive set of resources to support the use of Silver Diamine Fluoride (SDF) as a treatment to arrest dental caries in the primary dentition is available on the BSPD website. The technique is expected to be more widely used in the coming months as dental teams find ways to minimise aerosol generating procedures. These resources can be found here: https://www.bspd.co.uk/Professionals/Resources.

Included among the resources is a Patient Information Leaflet (PIL) which has been made editable so hospitals and dental practices can add their own logo. A Standard Operating Procedure and a Consent Form have also been developed. A powerpoint explaining the background to the technique as well as a demonstration video to show how SDF is applied has been created and are on our YouTube channel.

The resources have been compiled by Laura Timms, an Academic Clinical Fellow at the University of Sheffield Dental School with an interest in SDF. She has just won a prestigious joint grant from RCS and BSPD to make a video to explain the SDF technique to children.

She was motivated to understand more about the technique having been troubled by the extent of decay in some of her young patients; she wanted to find a treatment that would help keep them out of discomfort.

SDF is licensed in the UK for the treatment of sensitivity but Laura was aware of research which shows it has good results when painted onto dental decay in the primary dentition. “Using SDF can buy time for children who cannot manage dental treatment by stopping the decay getting worse until they can have further dental treatment. It’s simple, quick and effective.” 

Without treatment, the children would be at risk of requiring extractions under general anaesthetic and suffering from pain and abscesses while waiting for a hospital appointment. SDF contains both silver and fluoride in a solution of ammonia. It arrests caries until the child is older and more compliant with dental treatment. 

The disadvantage of the technique is that it stains the dental decay black. Some parents find the staining reassuring, however, as it shows that the treatment is working on the decay. If the child is subsequently able to cope with more demanding treatment, fillings or preformed metal crowns may be placed over the SDF. 

There is another option for the biological management of children with dental caries and that is the Hall technique. Preformed crowns are placed over decayed teeth and will also arrest the progress of caries. These are usually well tolerated but may be more challenging to place in very young children.

Laura added: “Ideally, I hope that the new SDF resources will help dental teams treat children in the family dental practice with which they are familiar and either delay or eliminate a referral into hospital.”

Claire Stevens, spokesperson for BSPD and a Consultant in Paediatric Dentistry, said: “All paediatric dental teams working in hospital departments want to keep procedures under general anaesthetic to a minimum currently which makes Laura’s work timely. Ideally, more children will be treated in their family dental practice instead of being referred into secondary care for a general anaesthetic. We are very grateful to Laura for her hard work.“

Laura says she distilled the new guidance from pre-existing resources from Sheffield University and Sheffield Teaching Hospitals, University College London Eastman Dental Hospital, Glasgow Dental Hospital and School and Dundee Dental Hospital teams. She is now working with children on a patient-centred video thanks to the grant awarded by BSPD and RCS.

 Links to resources:

Documents: https://www.bspd.co.uk/Professionals/Resources

Powerpoint: https://www.youtube.com/watch?v=njfhmN55HWs

Video: https://www.youtube.com/watch?v=tELmH9jRvv8

Children call the shots for a new dental video funded by RCS/BSPD

A team at the University of Sheffield dental school led by Academic Clinical Fellow Laura Timms is preparing to make an information video aimed at children aged 3-10. The topic of the video is Silver Diamine Fluoride (SDF), a technique that helps arrest dental decay.

Laura has just won a grant of £5460 awarded jointly by the RCS (Eng) Faculty of Dental Surgery (FDS) and BSPD for her proposal to make a video to help explain the SDF technique to children and their parents. The video will be made by children who will be recruited to act as filmmakers and presenters and use fun activities to share information on SDF.

The University of Sheffield Dental School began introducing SDF towards the end of 2019. With significant waiting lists for general anaesthetics and very young children needing treatment and suffering toothache, the possibility of applying SDF to arrest caries in primary teeth seemed an attractive option. In some cases, use of SDF avoided the need for a general anaesthetic.

SDF is widely used overseas and at the International Association of Paediatric Dentistry (IAPD) meeting in 2019, Laura attended sessions on the technique. She remembered the simplicity of application from a student elective trip in Cambodia in 2014 and considered how useful it could be for some of her patients. She decided to research SDF and with colleagues in Sheffield and Newcastle wrote a paper published (1) in May this year, examining why SDF is not being used more widely in the UK.

SDF stains teeth black but in her experience, parents often welcome a treatment which stops the decay and may avoid extractions under general anaesthetic. Discussion with the child and parent is vital, she says.

Working with Connect Trainees she led a research project exploring paediatric dentists’ attitudes to SDF and in May she delivered a webinar on the topic to the group. Soon afterwards, she heard that she had been awarded the RCS/BSPD research pump-priming grant for the educational video.

Sheffield has an established reputation for child-centred research and the plan that she evolved with colleagues was to recruit children to help script, film and edit the video. It will be used to explain the treatment to families and also to recruit children to further research to help understand their thoughts and feelings on the technique.

Laura added: “I also want to get the views of dentists and dental therapists on SDF. It’s an easy and simple treatment with the right case selection and if it prevents children suffering with the pain of toothache and needing hospital treatment, it can only be a good thing.”

Professor Helen Rodd is a Sheffield-based Consultant in Paediatric Dentistry and one of Laura’s supervisors along with Profs Paul Hatton, Chris Deery, and Zoe Marshman. She also happens to be a member of the RCS FDS Board and was of course excluded from judging Laura’s grant entry.

She said that the impact of Covid-19 and the move to minimising Aerosol Generating Procedures (AGPs) meant that SDF was more valuable than ever for treating very young children and keeping them out of pain. She welcomed warmly the news of Laura’s grant.

Sarah McKaig, President of BSPD, commented: “We are very proud of Laura. Her work on this technique will help us understand the wants and needs of children and their families as well as the attitudes of dental practices.”

Dental surgeons call for England schools to go ‘sugar-free’

Dental surgeons say all schools in England should be encouraged to become sugar free to tackle worrying levels of child tooth decay.

The call comes as analysis by the Faculty of Dental Surgery (FDS) at the Royal College of Surgeons of England (RCS) shows more than 100,000 hospital admissions for children under the age of ten in England due to tooth decay over a three year period. This is despite the condition being almost entirely preventable. 

The FDS has published a new position statement today (15 August) on children’s oral health which is an update to their January 2015 report ‘The state of children’s oral health in England.’ The statement also calls on the new Government to stand by previous commitments in the Childhood Obesity Plan and Prevention Green Paper.  The FDS says supervised tooth brushing schemes in England should be put in place before 2022 so that more children at risk of decay can benefit.

Key statistics on children’s oral health in England:

• There were 102,663 hospital admissions due to tooth decay among children under the age of 10 between April 2015 and March 2018.
 23.3% of five year old children have visible decay.
 33.7% of five year old children living in the most deprived areas of England have tooth decay, compared with just 13.6% of those in the least deprived areas.
 41.4% of under-18s did not visit an NHS dentist during 2018, rising to 77.0% of young children aged between one and two.

As well as being distressing in itself, dental decay can have wider consequences for children, such as making it difficult for them to sleep, eat, socialise and putting them at risk of acute sepsis. Dental pain caused by decay can be detrimental to performance in school, affecting children’s concentration in lessons and potentially requiring them to take time off for dental appointments. At worst, children with untreated tooth decay may need to have multiple teeth out under general anaesthesia. 

While important progress has been made since the FDS launched its children’s oral health campaign in 2015, for example the introduction of the soft drinks industry levy, it is vital that policy-makers and the oral health profession remain focused as there is still work to be done. The FDS would like to see a national public health campaign introduced highlighting that all children should see a dentist at least once a year as recommended by the National Institute of Health and Care Excellence, and that NHS dental care is free for under-18s. 

Professor Michael Escudier, Dean of the Faculty of Dental Surgery at the Royal College of Surgeons of England, said: “It is incredibly worrying that levels of tooth decay among children in England remain so high – especially when you consider that it is almost entirely preventable through simple steps such as brushing twice a day with appropriate strength fluoride toothpaste, visiting the dentist regularly and reducing sugar consumption.

“The FDS believes that limiting the availability of surgery foods and drinks in schools is essential to reducing the amount of sugar our children consume. While the Government has committed to reviewing school food standards, we would like to see them go beyond this to encourage all schools in England to become sugar free. We would also support the publication of nutritional guidelines for packed lunches.

“The scourge of child dental decay cannot be allowed to continue. Everyone needs to play their part in ensuring our children have healthy, happy teeth.”

The dental surgeons add that it is vital to children’s oral health that the new Government stands by previous commitments on sugar reduction, in particular, proposals to restrict price and location promotions for products high in fat, sugar and salt (HFSS) and tightening regulations on TV and in online advertising. 

Other key recommendations made in the FDS position statement include:

• The new Government should maintain the soft drinks industry levy, and follow through on a commitment in the Prevention Green Paper to extend the levy to include sugary dairy drinks. Consideration should also be given to including other products that do not meet government reformulation targets. Some of the revenue raised from the levy should be used to fund oral health improvement programmes.

• Government should remove funding barriers that local authorities face to fluoridating their water supplies, as proposed in the Prevention Green Paper.

• Action should be taken to reduce the sugar content of commercial baby foods.

• There should be no further cuts to local authority public health budgets.

• The new NHS dental contract should be introduced at the earliest possible opportunity.

• The Government should commission an urgent review into the factors affecting access to primary, secondary and emergency dental care.

• Oral health should be included in pre-registration training for all public health professionals.

• The Child Oral Health Improvement Programme Board should continue to co-ordinate action to improve children’s oral health, and relevant epidemiological research programmes must be maintained.

Professor Escudier adds: “Since we launched our campaign in 2015, we have seen the state of children’s teeth improve in parts of England but worryingly, inequalities persist in different areas of the country. We know that children living in the most deprived parts of England are much more likely to experience tooth decay than those in the most affluent. There’s a real opportunity to build on the progress that has already been made and stamp out these inequalities, so that all children in England can benefit from good oral health.”