30/11/16 – Children’s Oral Health

Speakers: Professor Nigel Hunt, Royal College of Surgeons; Sara Hurley, Chief Dental Officer for England; Claire Stevens, University Dental Hospital of Manchester; Dominique Tillen, Brushbaby

30 November 2016 – meeting notes

All-Party Parliamentary Group on a Fit and Healthy Childhood

Children’s Oral Health

Chair: Jim Fitzpatrick MP

The meeting was opened by Jim Fitzpatrick who welcomed the speakers, the group members and guests.

Professor Nigel Hunt, Royal College of Surgeons

There is a strong relationship between oral health and good general health. Poor oral health leads to problems with nutrition, growth, development and psychosocial problems. Clearly evidenced by the literature, good oral health in children lasts a lifetime, and the opposite is also true.

The headline statistics for child tooth decay are shocking. The figures for 5-year-olds nationally show that 1 in 4 suffer from tooth decay; usually more than one tooth. There is national and social variance.

In the year to July 2016, 25,000 children had all 20 baby teeth extracted under general anaesthetic. 176,000 teeth were extracted from children in the year. It’s an appalling experience all round, often scarring the child for life, and it comes at a cost. For hospital-based extractions, £35M p.a. In the five years to 2015, the spend was £139M.

Worst of all, it’s 90% preventable. Simple measures, e.g. regular brushing with a fluoride toothpaste, dental visits and commonsense with regard to diet will make all the difference. The average 5-year-old eats their own weight in sugar each year, on top of drinking the equivalent of a bathful of sugary drinks.

Through the Royal College and our partners, we see three areas that we need to focus on:

  • improving access to dentistry
  • better education, not only of parents but also of health professionals
  • better preventative policy

Claire Stevens from the University Dental Hospital of Manchester and Vice-President of the British Society of Paediatric Dentistry

Adding to the key statistics just identified by Prof. Nigel Hunt, it’s important to highlight the inequality.  A child from a lower income families is almost twice as likely to have decay, is much more likely to have toothache, and has more difficulty in finding an NHS dentist.

There are also regional inequalities: we know that overall, 1 in 8 3-year-olds has decay, but that can be as much as 34% in Leicester and as low as 2% in South Gloucester.

If we leave preventative strategies until school age, it is already too late.

So, how can we improve children’s oral health? There are five points.

The first priority is to put prevention first and stop our NHS departments fire-fighting. A typical afternoon’s work for me involves taking out 100 teeth from eight children – one of whom was only two years of age and she lost all 20 of her teeth.  My skills are being utilised treating a preventable disease.

And the solutions are already out there. Let’s look north of the border, to Scotland, where “Child Smile”, a successful national prevention programme, has been in place for 10 years, at a cost of £17 per child. In Wales, “Design for Smile” has also been successful.  So I’m not asking for anything radical – just to look at the evidence that is already out there and to work out what we can do for England, because there shouldn’t be these differences between countries.

As a profession we are united about what we are asking for, and we have a determined Chief Dental Officer to lead us. We have launch a commitment for “Smile4Life” starting September next year. Although there will be some differences with Scotland because we are organised differently, local authorities will be responsible for commissioning oral health prevention programmes.

However we can’t do this by ourselves: we need the involvement of nurseries, health visitors, schools – it needs a whole culture shift where we value children’s oral health. When a child is born he is registered with a GP. Why not a dentist as well?

The second point is sugar intake reduction. Public Health England published a document in October 2015 called “Sugar Reduction – The Evidence for Action”, but how many of its recommendations have been implemented? It should not be possible to go into a school and buy a sugary drink that contains more than the daily recommended level of sugar.

The third point is to increase water fluoridation. There were 45% fewer hospital admissions of children aged one to four for dental caries (mostly for extraction of decayed teeth under a general anaesthetic) than in non-fluoridated areas.

The Hull area will be testing this and, if successful, it could be implemented elsewhere.

Evidence for the financial effectiveness of fluoridation is shown in the handout of an infographic from Public Health England, entitled “Return on Investment of Oral Health Improvement Programmes for 0-5 year olds”. Apart from fluoridation, it shows the successful strategies and includes the costs and returns of each and supports the evidence from elsewhere. Investing in prevention pays.

Fourth, we need to improve access to dentistry for children. If we can get them as babies we can prevent a lot of the later problems by supporting them through the early years. A general anaesthetic should not be a child’s first experience of visiting the dentist.

And we also need to reinforce the education. Via Smile4Life and otherwise, everyone needs to be involved. If you are involved in any kind of publication that is looking at overall health and wellbeing, have you considered oral health as part of that document? As clinicians we are trained to look at the whole person, but we don’t do that with policy. In the childhood obesity strategy, how many mentions of children’s oral health were included? One! What a missed opportunity.

But there’s a lot underway, and my take-home message is that children’s oral health is everyone’s business. We can’t do it on our own – we need your support. We are judged as a nation on how we treat our weakest members, and we are failing our children.

Sara Hurley, Chief Dental Officer for England

There is huge injustice and inequality. We have raised the level of health care for a lot of people, but the third still at the bottom need bringing up to the top.

In 13 weeks spent on the road visiting every NHS region, I have met some greatly dedicated people, but also heard some sad and tragic stories – about lack of access, ignorance of prevention, and poor training amongst health care professionals (e.g. GPs who “don’t do teeth”). Health visitors and GPs and other professionals see children from an early age, and when children arrive to have all their teeth out, those health and social care professionals should be ashamed of themselves – because they didn’t make every contact count.

We are going to do something about this. I want to put responsibility back onto all healthcare professionals, but unfortunately the shutters do come down when I talk to them, so your assistance in knocking on these doors will be really useful. We need to be commissioning for prevention. I would love to go out and run “Child Smile” as they have in Scotland. I look at Scotland and Wales with jealousy, because the Chief Dental Officers in those countries can talk directly to their authorities, whereas if I want to do that I have to talk to 349 different authorities.

Three are many campaigns that can be replicated nationally, e.g. the “give up loving pop” month in Blackpool. Blackpool are also putting fluoride in milk. These are the initiatives that I believe we can lead at a national level.

I am angry at the injustice – every child has a right to smile for life. The directors of Health Care Commissioning need to stop targeting dentistry for cuts. This year there is an £11M strengthening primary care pot. How much do you think will go to support Smile4Life? Nothing!

I have spoken to people who are doing things about tackling obesity and preventing diabetes – and they get it – common risk factors, etc. I went to a meeting on mental health in children and they get it too – so if I can’t find money where I should be finding it, I will try to find it somewhere else.  But I’ve lost time trying to find money this way and it would have been easier to have had some political support.

We will do this. But we need to work multi-agency, multi-strand and reach the hard-to-reach parents.

Dominique Tillen from Brushbaby

The company was founded 10 years ago because I could not find suitable products to care for my infant daughter’s teeth. Brushbaby has been working with Harriet Thomas from Boogie Mites (also present) which is a company that educates nursery children about brushing. Together we believe that teeth-brushing in nursery should become a requirement for all nurseries in the UK. An informal Facebook survey (256 responses) revealed differences in the level and source of early years dental advice to parents. Interestingly, 95% thought that dental care education should be compulsory in primary school, and 76% thought teeth-brushing should be compulsory in nursery.

The care of gums is important even before teeth appear, and new products coming through are beginning to change. There are products to help parents care for baby gums and teeth, with dental-style teethers, etc. We promote gum care to provide a strong basis for teeth coming through, but also to reduce teething pain. Children should be encouraged to brush twice a day for two minutes (2 by 2 campaign which will start in January) and even to do interdental care to establish the habit for later on.

Harriet Thomas was invited to contribute.

Boogie Mites works with early years and targetted families, mainly in children’s centres. Evidence shows that habits have to be formed early. Funding is a problem because a lot of the families do need a lot of help. Before the financial crash, outreach workers would go one-to-one to visit homes to give advice.

There is a role for partnerships between commercial approaches and public health, because we have to reach people in the light of absence of funding from traditional sources. It is also important to be innovative about getting the message across. Boogie Mites uses music which works very well – parents and children do it together.

Questions and comments

At this point, questions and comments were invited from those present.

Question from Professor Yvonne Kelly, UCL: What evidence is there for the smile prevention strategies reducing the inequalities around oral health linked to general health? What are the estimates?

Response from Dr. Philippa Whitford (SNP Group Leader on Health):  To point out the success of Child Smile, they had areas with appalling rates of decay and Glasgow has seen a decrease of 56% (saving £5M). There are a lot of different strands: all children are registered with a dentist from birth and they get teeth-brushing at nursery and school and are given brushes and toothpaste. They still have higher levels than England but the decrease has been transformative, and £17 per child was the cost. We know that tooth decay leads to heart disease, and psychological problems if you lose your teeth, etc. Part of the success is changing the contract: dentists in Scotland have rewards for prevention in their contracts.

Response from Claire Stevens:  It is true that the reduction in Scotland was not to the extent that they had hoped, but we can jump in 10 years later and start after the team in Scotland has done all the hard work . Scotland’s focus is now on the next 10 years, as they are at the 10 year review stage. As for the links between oral health and general health, the risk factors for obesity are exactly the same, so by default, improve one and you improve the other.

Questions from Judy Moore, Infant & Toddler Forum: Lots of lower income families use sugary products to reward their children. Has anything been suggested about how children could be rewarded differently, e.g. with attention from a parent?

Response from Sara Hurley: We worked really hard to produce ideas for the Child Obesity Strategy but although they were included in the draft, they didn’t get into the final version, which was disappointing.  We continue to apply pressure, e.g. sweets at checkouts, etc.

Question from Judy Moore, Infant & Toddler Forum: Is the evidence from Moynahan still valid? Is there any more up-to-date evidence related to frequency (of intake of sugary food)?

Response from Claire Stevens:  Moynahan’s evidence is up to date. Please ask us as we are happy to help get the consistent message across. It’s got to be joined-up and evidence-based so that the money we do invest gets the best possible return.

Comment from Sara Hurley: In my 13 week tour I picked up seven different packs prepared by different professionals, but they hadn’t been able to do it collectively. What a waste of intellectual time! We need one portal so that everyone can access material, collectively buy brushes, etc. We need to do things at scale.

Comment from Prof. Nigel Hunt: The consistency of the message is so important, and one of the biggest hurdles we have. Thankfully, Public Health England has set up an Oral Health Improvement Board, of which we are all members, so that all the health professionals say the same thing.

Question from John Herriman, Greenhouse Sports: What is the best vehicle to promote messages that sugar intake leads to obesity?

Response from Prof. Nigel Hunt: The Eastman Dental Institute has done a lot of work showing that sports performance improves in professional athletes when their oral health improves. Regarding school lunches, we have been in consultation with the Department of Education and other agencies and improvements are being introduced in lunches and breakfast clubs.

Comment from Sara Keel, Babycup Ltd: We promote sipping not sucking to encourage oral health, and I like the consistency of the message and the idea of promoting teaching in primary schools. However, it is not just a case of what is taught – what is fed to the children is important too because for five days a week they have a sugary pudding. There needs to be a connection between teaching and eating in schools.

Response from Sara Hurley:  To promote sipping not sucking, speak to Jasmine Murphy (Public Health Consultant for Leicester City Council) who delivered beautiful little cups as part of a co-ordinated campaign. (NB: Sara Keel already knew about this as they were her cups).

Question from Georgia Leech, Newham Early Start Group: I see a lot of toddlers still using bottles. How can we promote cup use from six months?

Question from Glynis Jones, Association of Nutrition: Can you reassure us that you will include nutritionists working with you, because it is really worrying sometimes when the messages are mixed,  for example hearing that people intend to cut out fruit on the basis of it being “bad for teeth”.

Comment from Jillian Pitt, Mytime Active: We are working with three boroughs in West London and next week we are having sessions about oral health. How can we bring that joined-up approach across the country?

Response from Sara Hurley:  Tell the local dentists when initiatives like this occur so that they can expect and be prepared for an increase in contact.

Comment from Harriet Thomas of Boogie Mites: Preventative dental care should be part of the early years curriculum.

Comment from Dominique Tillen: Ella’s Kitchen (commercial organisation) are promoting vegetables for babies to get them used to the tastes very early on.

The meeting closed at 19:05.