It is hard to think of an area of public health where prevention is not preferable to cure. We only need think about the country’s admirable vaccines efforts to know this is true. However, in my own area of professional expertise — dentistry and oral health — I wonder whether the penny has fully dropped.
Reflecting on progress made during another National Smile Month which ends tomorrow, I strongly suspect policy makers are still putting the cart before the horse. I cite as evidence a debate on oral health in the House of Commons to mark the start of National Smile Month.
In it, one former dentist-turned-legislator described his old profession as the ‘Cinderella sector’ in comparison to the other health services — often talked about but rarely given the priority due to it. Several opposition members noted that dental care was largely absent from the government’s closely watched health and social care bill.
There was some praise for health ministers and the chief dental officer for their efforts to put greater emphasis on oral health, or to ‘put the mouth back in the body’ as the country’s chief dentist puts it (an inelegant but important phrase that I return to below). But I wonder whether it is enough.
The costs of not according higher priority to dental care and oral health are stark in financial terms, but also in terms of equality and fairness. The MPs shared some of the grimmer statistics during the debate.
Last year, 23,500 5-9 year olds were admitted to hospital for tooth decay, and there were 177 extractions under general anaesthetic in UK hospitals — a complete waste of our services.
Nor is tooth decay is an equal opportunities disease: the toll falls heaviest on poorer households. A report from Public Health England in March revealed that, between 2008 and 20019, relative inequalities in the prevalence of tooth decay in 5 year-olds in England had got worse.
Frankly, this is shameful. As the PHE report concluded, reducing oral health inequalities is a matter of social justice — an ethical imperative and, for public bodies across the health sector, a legal duty.
The financial costs of failure are eye-watering. In 2017-18, the NHS spent £3.6 billion on dental care in England, with a similar amount spent on private sector dental care.
In 2015 to 2016, the cost of tooth extractions for 0-19 year-olds alone was over £50m, the majority for tooth decay. This represented the biggest cost to the NHS for this age group across all areas of healthcare.
The tragedy is these oral diseases and their related costs are essentially preventable. Policy makers need to put their money where their mouth is and genuinely ‘put the mouth back in the body’.
What this means is making oral health an integral part of general health. The oral cavity has the second largest microbiota after the gut harbouring over 700 species of bacteria. In addition to being the initiation point of digestion, the oral microbiome is crucial in maintaining oral as well as systemic health.
Many chronic medical conditions are evidenced in the mouth and first discovered in routine visits to the dentist. These include periodontitis, the bacteria-caused inflammation in the gums that can result in bleeding. In turn, this can provide a gateway for bacteria to contaminate the bloodstream, potentially leading to abscesses, heart valve infections and, in worse case scenarios, sepsis.
As the chief dental officer says, ‘The mouth is an integral part of the human body and directly relates to the quality of life in the long term. Every patient has a mouth and therefore every care pathway must reflect the enduring need for oral care.’
As a dentist who spent her career treating the mouths of the less fortunate, I can attest to this, and to the importance of prevention. From the simple and obvious like regular brushing, to the more ambitious and potentially problematic like water fluoridation, preventative measures will save money and lives.
Even simple, non-prescriptive, behavioural acts like chewing sugar-free gum can make a big difference. Research by the Faculty of Dentistry at King’s College London in 2019 found that people who regularly chew develop 28% fewer cavities than those who do not. The equivalent percentage for using fluoride toothpastes and supplements was 24%.
As is so often the case, the key to prevention is education. Parents and children need to be taught effective brushing routines. Clinicians need to understand the impact of poor oral health on general health; trainee doctors are not taught this at undergraduate level currently.
The coronavirus pandemic has amply demonstrated the value of prevention in public health. It is time for politicians to start thinking more broadly and acting on prevention, rather than talking about. The mouth would be a very good place to start. By the time of next year’s National Smile Month, I hope we will have seen some progress.
