Written evidence submitted by The Wrigley Oral Healthcare Programme (DTY0076)

The Wrigley Oral Healthcare Programme has worked in partnership with the dental profession for over 30 years to promote better oral healthcare. We are proud to support initiatives to promote education and engagement, including highlighting the role of preventative oral health tools to tackle poor dental outcomes.

Executive summary:

In the current environment where there is significant pressure on access to NHS dentistry, we believe it is imperative for the Government and NHS England to focus on the role of prevention in oral health.

Preventative oral health tools and interventions, such as chewing sugarfree gum, can support the general public in maintaining good oral health while their access to clinical dental services is reduced, and help to promote good oral health outcomes in the long-term.

To deliver this, there is a role for Government, NHS England and local ICSs to play in ensuring that preventative oral health practises are promoted. This can be achieved in a way that raises awareness, meets the needs of communities, and reduces oral health inequalities.

As part of this work, the NHS dental contract needs to be reformed to emphasise the role of prevention, and incentivise dentists to provide a more holistic approach to how they deliver care – one which includes public education around the use of preventative oral health tools.

Part One

What steps should the Government and NHS England take to improve access to NHS dental services?

Accessing dental services in the UK is a key issue – with certain regions being described as’ dental deserts’ due to a complete lack of access to NHS dental services. A survey by the BBC in August 2022 showed that 90% of dentists in England are not accepting new NHS patients.[1] Further, nearly 60% of people feel that it is harder to access NHS dentists now than it was 10 years ago.[2]

The access issue has been exacerbated due to the halting of services during the COVID pandemic, causing a significant backlog of patients.[3] The General Dental Council found that by October 2021, half of patients had not been back to their dental practice since COVID restrictions were eased, meaning they had not seen a dental professional for at least 18 months.[4]

This is supported by the Wrigley Oral Healthcare Programme’s own data. Our 2022 Oral Health Index[5] has found that 67% of survey respondents agreed that there is a crisis in the provision of dental services, and 77% of people believed the Government could do more to promote oral health.

Given the scale of the challenge, now is the time for the Government and NHS England to place greater focus on the role of preventative oral health interventions to maintain and promote good oral health.

Preventative oral health interventions improve oral health outcomes and reduce the incidence of problems such as tooth decay (caries), build-up of plaque and tartar, and gum disease. These problems often require treatments such as fillings, root canals, crowns, or tooth extractions. Improving oral health will reduce the need for dental treatments, which in turn lowers the cost to the NHS in dental practices and hospitals. It is estimated that the NHS pays over 70% of the total costs of dental treatments provided by NHS dentists.[6] In total, NHS England spends around £2.3 billion on dentistry each year.[7]

Reducing the overall need for dental treatments means that dental capacity can be concentrated on those who require urgent care, and long-term savings can be reinvested into dental services. Importantly, it means that while people might wait longer for NHS dental check-ups, they have preventative oral health tools available to support them. There are a range of preventative oral health tools and interventions that could be promoted and implemented while access to clinical dental appointments remains reduced, for example:

• Supervised toothbrushing: Evidence from the Childsmile programme in Scotland indicates that supervised brushing can achieve a reduction in caries of around one-third, with a higher proportion amongst highest-need children.[8] Local Government working in collaboration with NHS England, should implement supervised tooth brushing programmes for young children in primary schools across the country. Expanding programmes including the Starting Well 13 programme[9] to reach more regions of the country will also enable a greater implementation of supervised toothbrushing. 
   
• Sugarfree gum: Chewing sugarfree gum can support good oral health by encouraging saliva production, which contributes to neutralising plaque acids, maintaining tooth mineralisation and removing harmful micro-organisms such as streptococcus mutans.[10],[11] Evidence suggests that regularly chewing sugarfree gum may reduce caries by between 20% and 40%.[12] The oral care benefits of chewing sugar-free gum are endorsed by the British Oral Health Foundation.[13] In England, chewing sugarfree gum is referenced by the Delivering Better Oral Health guidelines as a dental caries inhibiting activity[14], and the Programme would like to see a stronger recommendation about the benefits of chewing sugarfree gum included in the next iteration. Working with NHS England, the Government can also ensure dental professionals are educated on the benefits of chewing sugarfree gum – the Wrigley Oral Healthcare Programme has CPD modules in place to support this effort.
   
• Water fluoridation: Fluoride can be added to public drinking water to improve dental health, as it keeps teeth strong and reduces cavities.[15] A systematic review undertaken in 2015 concluded that fluoridation is likely to have a positive impact for children: reducing caries in ‘baby teeth’ by 35% and in ‘adult teeth’ by 26%.[16] Following the transfer of power from local authority to the Secretary of State, the Department of Health and Social Care should not only continue to run current water fluoridation schemes, but also establish new water fluoridation schemes to allow for more people to reap the benefits.[17]

Part Two

What role should ICSs play in improving dental services in their local area?

There are clear opportunities for ICSs to fund and develop services to meet local needs, based on local evidence about patient need and dentists’ views on new priorities. With ICSs in charge of dentistry, there is the opportunity to coordinate across a range of normally separate dental providers and practices that can help meet the needs of the local population. Through knowledge sharing, local problems can be tackled more effectively via a collective approach – ensuring that the right mix of services are available.

Alongside of sharing knowledge between services, ICSs have a key role in raising awareness and co-ordinating oral health education for the local population about preventative oral health tools, such as flossing or chewing sugarfree gum, outside of clinical dental settings. They can ensure education is appropriate and targeted – with an emphasis on reducing local oral health inequalities. For ICSs leading on education, they will need to integrate oral health into their wider health agenda.

ICSs could enable better coordination between healthcare professions and ensure a joined-up approach between primary care and dentistry which can address complex patient needs. In addition, this coordination would facilitate the promotion oral health education across a patient pathway where needed. The involvement of oral health in ICS settings may also improve access to services, as improved communication between colleagues will result in patient referrals being made more appropriately, and a joined-up approach will ensure there is accountability to deliver education about preventative oral health tools. This in turn will reduce NHS costs which can be reinvested into improved services for dentistry.[18]

How should inequalities in accessing NHS dental services be addressed?

As an initial step to tackle these issues, the Government must identify the areas and communities that are most impacted by inequalities in access. These areas should be offered support to protect their oral health via preventative interventions, and must be prioritised when distributing funding and resources for new dental services.

Poor oral health is also exacerbated when individuals don’t regularly visit the dentist.[19] Data from the Wrigley Oral Healthcare Programme’s Oral Health Index[20] found that, when asked ‘How many times, if any, have you gone to the dentist in the past 12 months?’, 34.9% of respondents from across England answered ‘none’. However, this percentage was higher when looking specifically at the North East of England and North West specifically, at 37.6% and 37.4% respectively. This shows that there is a clear disparity in access to dental care.

Additionally, Wrigley Oral Healthcare Programme analysis of oral health outcomes across England by Local Authorities, highlights the regional inequalities that exist. We found that between 2019 - 2020, the England-wide number of tooth extractions as a percentage of the population of 0-19-year-olds was 0.4%.[21] Regions such as Yorkshire and Humber (0.7%), the North West (0.6%), North East (0.6%), South West (0.5%) and London (0.5%) had higher rates of tooth extraction than the England-wide average. These regions clearly need support to improve oral health within their communities, particularly in the North which has some of the worst outcomes in England. In more recent data taken from 2021, the rates of hospital tooth extraction have reduced by 58.4%,[22] however, it seems unlikely that this is due to reduced need. Instead, there are likely to be issues of access due to COVID and the number of dentists that left the service contributing to this change which need to be addressed.[23]

The Wrigley Oral Healthcare Programme is happy to share the complete findings from both the regional oral health outcomes mapping and Oral Health Index.

Providing targeted preventative intervention to regions with more acute access challenges and worse-than-average oral health outcomes would ensure the best use of limited funding.

There are a range of preventative oral health interventions that could be implemented to promote better oral health outcomes in these areas, including water fluoridation, supervised toothbrushing for children and chewing sugarfree gum.[24], [25], [26] For example, chewing sugarfree gum has been shown to increase the flow of saliva, thereby reducing plaque acid, strengthening the teeth and reducing tooth decay.[27] As a low-cost intervention, this preventative measure could be targeted in deprived areas or specific communities that have poor oral health outcomes.

The Government and NHS must further investigate the factors contributing to this postcode lottery and develop a plan for improving the oral health of regions with poor outcomes and reduced access. This might include through providing increased education around preventative oral methods as a first step, and where possible, increasing access to NHS dentists.

Does the NHS dental contract need further reform?

Yes, the current dental contract presents a key barrier to improving oral health in a more holistic manner.

British Dental Association data reported nearly half of dentists (45%) have reduced their NHS commitment since the onset of the pandemic.[28] This reduction is impacting access - NHS Digital’s statistics published this year show a 9.5% decrease from the previous year in the number of adults being seen for NHS dental treatment.[29] Data from the Wrigley Oral Healthcare Programme’s Oral Health Index[30] found that 67% of respondents have experienced greater difficulty in accessing dental services since the beginning of the pandemic. Potentially as a result of the lack of access indicated, a survey conducted by Healthwatch England found that more than a third (34%) of respondents from the general public said they had to pay privately to receive all their required treatment.[31]

This indicates there is still need for reforms to the dental contract to improve quality of service. We must move towards an approach which is more holistic in nature, which emphasises the role of prevention to reduce the number of treatments in the long-term – not just working on the number of Units of Dental Activity (UDA) completed.

There is less emphasis on prevention in the dental contract compared with the wider health agenda, as the current system continues to focus on the ‘drill and fill’ model.[32] There are no incentives nor clear guidelines around a dentist's role in educating patients about how to look after their oral health most effectively. Education also needs to meet the needs of hard-to-reach groups if it is to also be conducive to reducing oral health inequalities within local areas.

Current NICE guidelines for dental practitioners were last updated in 2015, and only recommend dentists to inform patients of fluoride products, and inform them of the link between general health and oral health (including the problems tobacco and poor diet can cause).[33] They do not cover the role of preventative oral health tools to improve and self-manage oral health, including flossing, chewing sugarfree gum, or supervised toothbrushing (for children). Updating the current NICE guidelines and incentivising dentists to promote preventative oral health tools as part of their contract, will drive up the promotion of good oral health.