Your NHS dentistry and oral health update

Friday 12th February 2021

An update from Sara Hurley, Chief Dental Officer England 

Dental professionals are likely to observe and identify injuries to the head, eyes, ears, neck, face, mouth and teeth as well as other welfare concerns.

Combating domestic abuse is not just a medical mission, its a moral mission too.

Dentistry like all other areas of the NHS and healthcare must do its bit to help the patient and each other.

So in this bulletin we've brought together the key things you need to know to spot domestic abuse, support the patient and help protect your staff and yourselves, too.

Public Health England's Sandra White reminds us of the key guidance for dental teams on domestic abuse and safeguarding, we share Professor Paul Coulthard excellent blog on identification and referral in dental settings and we've included key communications materials such as posters and social media graphics for you to use. 

Today's By Word of Mouth shout out goes to Simon Hearnshaw and the team in North Yorkshire and the Humber for their excellent work with children. The British Society of Paediatric Dentistry has awarded them with their Outstanding Innovation Award. Their work is truly excellent and forward thinking. 

Kind wishes as always,

Sara

Recognising the signs of domestic abuse 

Anyone can be a victim of domestic abuse, regardless of gender, age, ethnicity, socio-economic status, sexuality or background.

Domestic abuse is not always physical violence. It can also include:

• coercive control and ‘gaslighting’
• economic abuse
• online abuse
• threats and intimidation
• emotional abuse
• sexual abuse

The government's web page on spotting the signs has a checklist on what to look out for.

Potential signs of domestic abuse which might present at a dental appointment: 

General signs:

• Always accompanied by partner or family member, who frequently speaks for patient or cancels patient’s appointments
• Patient displays high levels of anxiety
• Delay in seeking treatment
• Presentation doesn't fit the explanation provided

Oral and facial signs:

• Facial or intraoral bruising or laceration
• Teeth lost due to trauma
• Fractures to nose, cheek or jaw
• Torn fraenum
• Bite marks
• Hair loss

Please see dentistry's dedicated safeguarding guide for more detailed information (summarised and links below).

Domestic abuse: A reminder of the guidance for general dental practices by Sandra White (Public Health England)

To protect patients who are at risk of domestic abuse and other safeguarding issues, dental professionals should read dentistry's dedicated safeguarding guide. 

Sometimes a ‘feeling’ or noticing something that ‘just doesn’t seem right’ can play a vital part in the jigsaw that can make the difference to someone in a vulnerable position. In some cases of abuse, contacts with healthcare professionals could have made a difference at key moments in time.

It is the duty of all citizens to call out abuse where they see it, and act to protect those who are being harmed. Dental teams should not feel inhibited to raise a concern. The dental team has a statutory duty of care to all patients and the wider public, which includes ensuring that safeguarding arrangements are in place and are acted on.

Dental professionals are likely to observe and identify injuries to the head, eyes, ears, neck, face, mouth and teeth as well as other welfare concerns. Bruising, burns, bite marks and eye injuries are the types of injury that suggest a concern should be raised. Dental professionals are also well placed to identify the risks to oral and general health associated with poor oral hygiene and dental neglect. A patient may also disclose abuse or other indicators of it; such safeguarding concerns should always be recorded.

Accurate record keeping is an essential part of the accountability for safeguarding.

It is recommended that:

• each dental practice have a named safeguarding practice lead
• all members of staff (clinical and non-clinical) undertake the appropriate level of safeguarding training
• there is a safeguarding reporting system in place and staff are familiar with this
• all members of staff know how to access the NHS Safeguarding app for local safeguarding contact details

The safeguarding guide for dental practices was originally developed by a multidisciplinary team in the East Midlands. It includes:

• Advice on when and how to report safeguarding concerns 
• Facial, oral and body maps to help record domestic abuse signs
• Sample dental practice safeguarding policy
• Safeguarding flowchart for dental professionals to use when suspecting safeguarding concerns
• A list of free safeguarding training opportunities

All of us deserve to be safe and away from harm. We can all make a difference. 

Sandra White
National Lead for Dental Public Health
Public Health England 

The role that dentists can play in identification and referral of domestic abuse: Advice from Professor Paul Coulthard

Professor Paul Coulthard, Dean for Dentistry and Institute Director Professor of Oral and Maxillofacial Surgery at Barts Health NHS Trust and a Honorary Consultant Advisor to the Chief Dental Officer has written a useful piece for IRISi about the role that dentists can play in identification and referral of domestic abuse.

We encourage you to read the full article online here - the key points are:

• It is useful to take advantage of working in the dental environment, which is likely to be considered less stigmatising than some other statutory services, to create an opportunity for the patient to disclose domestic abuse and ask for help. Patients are often unaccompanied during examination and treatment sessions as part of routine practice and so members of the dental team are in a unique and advantageous position to undertake enquiry about domestic abuse. 
• The dental professional should be confident and supportive in their approach, expressing concern as necessary. The appropriate time to ask is probably as part of taking the social history. Later, when examining the patient, if injuries are found that do not appear to be consistent with the stated aetiology, then the dental professional should explain this concern to the patient.
• If the dentist and team only focus on treating injuries, without asking about their cause, then they will be doing little to help the patient experiencing domestic abuse. If there are signs suggesting that a patient may be experiencing domestic abuse, then the dentist or dental care professional should ask direct and specific questions, and try to obtain evidence, if possible photographic.
• Before asking direct questions, the dental professional should begin with some indirect ones to help establish a relationship with the patient and develop empathy. Examples include: ‘Is everything alright at home?’ or ‘Are you ever afraid at home?’
• The purpose of identification of domestic abuse is referral on to the appropriate agency and so this process must be considered prior to enquiry. The referral to agencies providing direct help can be done by providing leaflets and cards with contact details to take away.  The dental team should have access to the appropriate information, and be responsible for ensuring that such information is widely available for patients, relatives and friends of women experiencing domestic abuse. 
• Displaying posters in the waiting room with a contact telephone is also useful. It provides a signal to encourage patients to disclose their domestic abuse experience.

Domestic abuse: the advice for the public

If you are worried that a friend, neighbour or loved one is a victim of domestic abuse then you can call the freephone, 24-hour National Domestic Abuse Helpline on 0808 2000 247 and further information is on the helpline's dedicated website.

If you believe there is an immediate risk of harm to someone, or it is an emergency, you should always call 999.

The NHS website has advice online for the public on spotting the signs for domestic abuse and where to go for help.

The Government has a detailed web-page 'Domestic abuse: get help during the coronavirus (COVID-19) outbreak'  where you can find out how to get help if you or someone you know is a victim of domestic abuse. In particular, the government pages have translated guidance, welfare benefits and housing advice as well as advice on how to get legal help.

They will offer the person a private space, provide a phone and ask if they need support from the police or other domestic abuse support services.

Rape and sexual assault: 

Those suffering from domestic abuse may also be victims of sexual abuse. The NHS has a help page for those who have been raped or sexually assaulted.

The NHS commissions sexual assault referral centres (SARCs) to provide medical, practical and emotional care and advice following sexual assault and abuse, regardless of when the incident occurred. SARCs are available across the country, 24-7, and continue to be open through the COVID-19 pandemic.  You can direct patients to find their local sexual assault referral centre here: Find Rape and sexual assault referral centres services

Communication resources for dental practices: You Are Not Alone campaign

The Home Office's campaign  "You Are Not Alone" encourages people to come forward for support if they are experiencing domestic abuse.

Please use these materials and share them online and in your surgeries.

Advice for practice managers and owners on how to support staff on domestic abuse

NHS Employers has produced two resources to help NHS managers support employees who may be the victims and survivors of domestic abuse:

'Domestic violence and abuse: supporting NHS staff' is designed to give organisations information about things to include when developing a domestic abuse policy. 

'Dealing with domestic violence: first steps' helps organisations take a step by step approach when looking at how they can support their staff who may be enduring domestic abuse..

As an employer, you can play an important role in reassuring employees that there is help and support available, including online support, helplines, refuges and local support services. The Government's domestic abuse during COVID-19 employer pack is a useful resource to help you do this.

By word of mouth ... the colleagues we're all talking about!

Simon is the Chair of North Yorkshire and Humber Local Dental Network. Simon impressed the judges with the ‘In Practice Prevention’ (IPP) scheme that ensured thousands more children in the region accessed preventive treatment in a dental practice. The programme was targeted at deprived areas where oral health need is greatest and at children with the highest levels of disease. A group of dental practices were funded, through a bespoke flexible commissioning approach, to offer more appointments to children.

Health Education England provided training for dental nurses to develop additional skills, such as applying fluoride varnish. The programme treated more than 17,000 children over 2.5 years. Access improved, as did fluoride varnish application rates. There was also a shift of treatment activity towards a more preventive approach.

Simon Hearnshaw said to BPSD: “This recognition is shared by all the practices which got on board as well as the brilliant dental nurses who delivered the care, helping to make a difference to thousands of children. Our programme demonstrated that, with the right approach, flexible commissioning works.”

Congratulations to Simon and the whole North Yorkshire and Humber team!

Click the button above to email the Chief Dental Officer and nominate your colleagues for By Word of Mouth. Please include a bit of detail on the individual or team, a quote and a picture. 

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Previous NHS dentistry and oral health updates 

Previous bulletins can be accessed by clicking on the links below:

• Issue 1: 27 October
• Issue 2: 2 November
• Issue 3: 27 November 
• Issue 4: 10 December 
• Issue 5: 22 December 
• Issue 6: 30 December 
• Issue 7: 4 January
• Issue 8: 7 January
• Issue 9: 27 January
• Issue 10: 4 February

NHS primary care bulletin

The NHS primary care bulletin provides resources on health policy and practice and we encourage you to sign up for this, too. It is aimed at teams across general practice, dentistry, community pharmacy and optometry. 

A reminder of the latest COVID-19 advice and guidance 

Letters of preparedness to the profession 

During the course of the pandemic, we have regularly written formal letters to the NHS dental profession with important updates and information. They are online here. 

Transition to Recovery: Dentistry's standard operating procedure

This document is the essential guidance for all dental teams in England. In it, we detail all the key things dental teams need to know about how to run their services safely, for patients and themselves. The latest version was published on Wednesday 3 February 2021. Changes to the previous SOP are in yellow. You can read the SOP online here. 

Urgent Dental Centres: Standard Operating Procedure 

If you work in an urgent dental centre or are responsible for one as a provider, or as a commissioner, then the Urgent Dental Centre SOP should be your guide. Changes to the previous SOP are in yellow. It was updated on Wednesday 3 February 2021 and is online here.

COVID-19: infection prevention and control dental guidance

The guidance is an appendix to and should be read in conjunction with the national guidance on infection prevention and control for COVID-19 . You can read the general guidance and the specialist dental appendix online here.