Your NHS dentistry and oral health update

Implementation tool to support NICE guidance on recall of children

The Chief Dental Officer England has produced an implementation tool to support NICE guidance which assists dental professionals in the recall of children for a dental appointment.  All risk assessment and recall should be undertaken in line with NICE guidance which can be found online. Dental professionals are strongly encouraged to read the guidance in full in ‘Appendix G – Implementing the Clinical Recommendations – selecting the appropriate recall interval for an individual patient’ online.

You can read the implementation tool on the NHS England website. 

Commissioning standard and treatment complexity levels

The NHS Commissioning Standard for Dental Specialties: Paediatric Dentistry defines the NHS England paediatric dental care pathway and sets out the minimum standards that when implemented commissioners must expect all providers of paediatric dental services to adhere to.

Guidance on prevention

Prevention should take place at every opportunity. This should be in line with 'Delivering better oral health: an evidence-based toolkit for prevention' published by the Department of Health and Social Care and Public Health England. This can be accessed online here.

NICE guidelines on babies, children and young people's experience of healthcare (NG204)

NICE has issued guidelines that healthcare professionals should involve children and young people in decisions about their healthcare in ways that are appropriate to their maturity and understanding. The guideline emphasises the need to provide children and young people with clear and accurate information which can be tailored to an individual patient’s level of maturity and understanding. Further information is on NICE's website. 

Dental professionals will find the following resources useful for patients and their families.

Public Health England's A quick guide to a healthy mouth in children is a factsheet that gives a summary of the simple steps that parents, carers and children can take every day to protect and improve their oral health. 

The NHS website has useful pages for parents and guardians on:

• how to take care of your children's teeth
• how to look after your baby's teeth

Brush DJ is a free oral health app which has been shown to lead to behaviour change and can be socially prescribed.

Paediatric dentists in Ireland produced this video on 'How to take photos of your child's teeth' on Youtube. The video is a useful resource for remote consultations. 

The British Society of Paediatric Dentistry has lined up a great team to help make tooth brushing fun for families. With Ranj, Hey Duggee, CBeebies and Brush DJ, the Society's four excellent videos (dental check by one, age -0-3, age 3-6 and age 7+) teach children how to look after their teeth. 

You can view all the videos of the society's website by clicking here and the 3-6 year olds version below.

Dental check by the age of one (#DCby1) is an important element in addressing health inequality and securing a smile for life for every child. It is recognised that early visits for children under the age of 3 years are vital for delivering key preventive messages, acclimatisation and beginning a positive, lifelong relationship with NHS dentistry.

The  2017 note from the Chief Dental Officer  'Avoidance of Doubt: Dental visits for children under the age of 3 years' details the advice and professional interventions to be given by dental professionals, as well as clarification that performers can claim for Band 1 even if they have not been able to complete a full examination.

Lap-to-lap examination

The lap-to-lap examination is a useful technique, endorsed by the British Society of Paediatric Dentistry. It's important for the child to be positioned in a way which is comfortable and safe for them, and provides a clear view of the emerging primary teeth.

The British Dental Journal has a useful step by step visual guide on the examination technique online which you can access online British Dental Journal: Did you say Dental Check by One? by Claire Stevens (2019).

©Photography by Nick Wright, owned by BSPD

Useful resources to promote dental check by one

Practices are encouraged to give parents, carers and guardians the British Society of Paediatric Dentistry's summary of how to care for a child’s teeth: A Practical Guide to Children’s Teeth.

Further resources for the dental profession can be downloaded from the Dental Check by One campaign website:

• BSPD – Dental Check by One A4 poster for dental practices
• Brush Baby – Ask About Dental Check by One A4 poster for dental practices
• Dental Check by One A4 poster for other settings
• Bickiepegs – My first Visit to the Dentist Certificate
• Dental Check By One logo

The British Society for Paediatric Dentistry has published a number of guides which represent evidence-based good practice:

• Trauma Guidelines for Permanent Dentition COVID-19
• Trauma Guidelines for Primary Dentition COVID-19
• Clinical Holding in the dental care of children (2016)
• Treatment Of Avulsed Permanent Incisor Teeth In Children (Peter Day. Revised 2012)
• Guidelines for Periodontal Screening and Management of Children and Adolescents (2012)

 You can download all the guides online on the BSPD's website.

If a child requires onward referral, please consider whether it would be possible to manage any symptomatic teeth by extraction (or if this is not possible pulp extirpation, or direct or indirect pulp treatment with antibiotic/steroid pastes), even if the child cannot be rendered dentally fit. Placement of SDF may also reduce the chance of a child developing symptoms from decayed teeth.  Please be mindful that waiting times for paediatric dental care under general anaesthetic have increased during the COVID-19 pandemic. 

If you are referring a child likely to require a general anaesthetic, it is helpful to include the following information in order to facilitate surgical prioritisation by the receiving clinician:

• Any medical condition where the stability of their medical condition is being compromised by oral disease;
• An assessment of the severity of dental pain (irreversible pulpitis) e.g. response to over-the- counter analgesics and impact on eating and sleeping;
• Any additional needs such as learning disability or autism;
• Any additional needs such as where dental pain is resulting in self-harm or other disruptive or detrimental behaviours;
• Details of treatment that has been provided or attempted in primary care including the number of times that antibiotics have been prescribed.

Please continue to practice shared care whilst the patient is waiting for definitive treatment.  If you believe that their care needs to be progressed more urgently, please communicate this to the receiving team.

Mini Mouthcare Matters is a project that aimed to empower medical and allied medical healthcare professionals to take ownership of the oral health care of any paediatric in-patient with a hospital stay of more than 24 hours. Mini Mouth Care Matters aimed to encourage all nursing, medical and health care professionals to “lift the lip” and identify common oral health/dental conditions and to include oral health care as part of basic general health care needs for all in-patients.

The team developed an oral health screening tool to identify patients who may be at a high risk of developing dental decay, which has been shown to lead to long-term detrimental effects in children leading to pain, sepsis and compromised growth & development.

A simple measure to ask if a patient has brought their toothbrush with them (and if not- to provide one) may make all the difference to how the oral health of that patient is maintained whilst in a hospital setting, with a view to continue good oral health practices at home.

Mini MCM was developed and led by Dr Urshla Devalia of the Royal National ENT and Eastman Dental Hospitals, working in collaboration with Birmingham Children’s Hospital and Royal Manchester Children’s Hospital.

For a wide range of resources including guides and patient facing posters are available online.

Public Health England published the oral health survey of 3 year old children, showing that 10.7% of 3 year olds had experienced tooth decay.

Public Health England's research into the relationship between dental caries and obesity in children finds that there was an association between children’s weight and dental caries prevalence and severity.

The Royal College of Paediatricians and Child Health have published their webinar  'Putting Children’s Oral Health on Everyone’s Agenda' on Youtube, focusing on the key issues facing children's oral health and successful interventions from across the UK.  

It is a statutory requirement for all healthcare professionals to contribute to safeguarding children by working with social care and other agencies as set out in Working Together to Safeguard Children.

Clinical input to safeguarding children by dentists falls into three domains:

1. Making child protection referrals to children’s social care where a child is thought to be experiencing or at risk of significant harm because of maltreatment. Wider measures contributing to safeguarding children’s health and wellbeing, such as the identification and referral of children who may benefit from social care assessment and early help.
2. Communication with other professionals (including writing reports) regarding children already identified as at risk or maltreated (identifying persistent failure to bring children for dental care should be considered a safeguarding issue)
3. Communication with other professionals (including writing reports) regarding children already identified as at risk or maltreated:

(a) Children who are undergoing medical examination for suspected neglect. 
(b) Children subject to a child protection plan. 
(c) Some looked after children (annual dental visits for looked after children are a requirement and are already subject to monitoring). 

The dental team has a statutory duty of care to all patients which includes ensuring that safeguarding arrangements are in place.

Dental professionals should refer to the dentistry's dedicated safeguarding guide, Safeguarding in general dental practice: a toolkit for dental teams. This document reinforces the importance of safeguarding to dental teams and makes them aware of the different forms of abuse. It provides an overview of safeguarding as a whole for the dental team by:

• clarifying the roles and responsibilities of the dental team in promoting the safety and wellbeing of children, young people and adults at risk of abuse;
• signposting useful safeguarding resources, including access to free training opportunities
• outlining the pathways to be followed in cases of concern;
• providing guidance on training requirements.

Further advice and guidance is online:

The Care Quality Commission has published detailed explanations and information on what they expect from NHS dental teams on child safeguarding and the criteria and framework for inspection in this regard. You can find this online at Dental mythbuster 29: Safeguarding children and young people at risk

The General Dental Council's expectations of registrants are detailed at 'Guidance on child protection and vulnerable adults' 

The British Dental Association has a wealth of resources on its website, including flow charts for action if you are worried about a child and tailored advice for dental therapists, hygienists, nurses and practice managers and officials. You can access them online at 'BDA: Child Protection'. 

The Royal College of Paediatricians and Child Health (RCPCH) has published the following useful pieces of information on Child Protection Evidence. These resources are available for clinicians across the UK and internationally to inform clinical practice, child protection procedures and professional and expert opinion on the legal system. 

• Child Protection Evidence: Systematic review on Dental Neglect: This systematic review evaluates the scientific literature on abusive and non-abusive dental neglect in children published up until November 2014 and reflects the findings of eligible studies. The review aims to answer one clinical question: What are the parent/carer characteristics of a child with dental neglect, and what oral features are present in these children?
• Child Protection Evidence: Systemic review on Oral injuries: Facial and intra-oral trauma has been described in up to 49% of infants and 38% of toddlers who have been physically abused.  A torn labial frenum (often referred to as frenulum or phrenum) is widely believed by paediatricians to be pathognomonic of abuse, and has been described as the most common abusive injury to the mouth. This systematic review evaluates the scientific literature on abusive and non-abusive oral injuries in children published up until June 2014 and reflects the findings of eligible studies.