Not introducing water fluoridation in the Government’s Oral Health Improvement Plan is a missed opportunity, Robert Donald says.

The Scottish Government (SG) published its long awaited Oral Health Improvement Plan (OHIP) in January. The document sets out the SG’s direction of travel for oral health improvement and NHS dentistry for the next generation. According to the promotional publicity on the Scottish Government website: ‘The OHIP has a strong focus on preventing oral health disease (sic), meeting the needs of the aging population and reducing oral health inequalities.’

Some of the profession’s initiatives were recognised within the strategy. These included the roll out of Childsmile for all child groups, funding of occupational health for all dental staff, implementation of consistent pathways for oral cancer across Scotland, addressing the care of the elderly in both care homes and in their own homes and the provision of local resolution rather than sending cases to the GDC initially. It also included proposals to develop the Oral Risk Assessment, preventive care pathway and simplification of the Statement of Dental Remuneration (SDR).

There are also elements of the plan that will cause the profession some major concerns, however. In particular, the proposals around reducing the number of routine six-monthly dental exams and the suggestion that scales and polishes will be phased out. The profession is alarmed at the lack of evidence-based data to support the latter in particular.

I am sure there will be a lot of debate in the coming months and years about the pros and cons and the challenges awaiting my colleagues. However, one of the key flaws in this plan is around how Scottish Government intends to reduce the oral health inequality gap. Here, the evidence, and the solution is staring them right in the face, but they still refuse to see it.

The Cabinet Secretary for Health and Sport called for ‘innovative’ ways to tackle oral health inequalities in Scotland (page three) yet on page eight, the focus on prevention contradicts this call by refusing to use water fluoridation, which the OHIP correctly states would improve oral health. The introduction of targeted water fluoridation would really demonstrate that this Government is serious about prevention. Hands up those of you who think that spending ‘up to £1/2 million pounds on a community challenge fund’ is going to address the problem? So, let’s be true to the spirit of innovation. Why not put some resources into a targeted water fluoridation scheme? Unlike some of the contentious proposals put forward in the OHIP, we certainly have lots of evidence to support its introduction. Not only is it safe, it’s also cost effective, which should be music to any government’s ears in these challenging financial times of declining budgets. Furthermore, six million people in England already benefit from it – that’s one million more than the population of Scotland.

Scotland needs its introduction urgently if this Government is serious about tackling our long-standing and shameful oral health inequality gap.

Read more blogs from Robert Donald:

The evidence?

Published data by the Information Statistics Division (ISD) for under-18s in Scotland shows that in the latest figures (2015/16), of 61,577 operations on Scottish children, 7,944 (12.9%) were for the extraction of teeth, which is still the common reason for a child being admitted to hospital for treatment under a general anaesthetic in Scotland. It does not include sedation or local anaesthetics so the real level of extractions is far, far higher.

Extractions are more common in children than broken bones, skin grafts, tonsils, heart problems etc. Over the last five years alone that adds up to almost 40,000 Scottish children having a GA for tooth extractions and after a small drop over the last three years the figures now show a disturbing rise. The cost of inpatient treatment varies across NHS boards in Scotland again from ISD. In 2016/17, the average cost per inpatient case ranged from £2,114 in NHS Borders to £5,878 in NHS Orkney.

This variation is caused by a number of factors including the additional costs associated with providing healthcare in remote and rural locations. Whilst the cost can be measured in financial terms, don’t forget that a child going into a hospital for a general anaesthetic for the extraction of teeth will have suffered pain, misery, sleeplessness, disruption of school and family life, disfigurement and embarrassment, which is far more important than money.

Recent data from the National Dental Inspection Programme also shows that the gap that exists between the most deprived and the most affluent Scottish children has remained unchanged in the past four years. The absolute difference (21%) in children who are free from caries in 2017 is exactly the same as it was in 2013 and 2015.

The Childsmile (nursery tooth brushing scheme) has been successful, but only because Scotland had such poor child dental health over 10 years ago. Despite the improvement, we still lag behind most other northern European countries.

In all of the countries with water fluoridation (including England, Eire, Australia, Canada, USA, etc) they all use fluoride toothpaste and their dentists use fluoride varnish. Water fluoridation should be in addition to all of the other preventive approaches and we should do the same in Scotland.

What improvements could we have expected if we did have a targeted fluoridated water scheme? Look no further than Public Health England’s evidence that shows there are 45% fewer hospital GA admissions of children from ages one to four for tooth decay, and 28% fewer five-year olds in deprived areas with tooth decay in fluoridated areas.

The Scottish Government continues to be obsessed with ‘trumpeting’ record numbers of Scots having access to an NHS dentist. This statistic is meaningless, particularly when 1.5 million of these same patients haven’t even seen a dentist for at least two years or more. If we had fluoridated water in Scotland, we might have prevented almost 20,000 Scottish children having a GA in the last five years and thousands of unnecessary extractions in dental surgeries up and down the country, not forgetting the benefits for older adults as well. Now that would certainly be something to trumpet about. 

Put simply, this OHIP is just another missed opportunity in a long line of missed opportunities.

The opinions and views expressed here are personal to the author and do not reflect the policy of any organisation with which he is associated.