Brexit - Consequences for the UK's Oral Health Workforce?

On Friday, 20 December 2019, after three and a half years of discussion the Parliament of the United Kingdom (UK) voted decisively that this country should leave the European Union (EU). For many of us this was a sad day. However, this political decision has been made and intensive negotiations will now take place between the UK and the EU's negotiating teams to agree the details for the UK's future relationship with the EU. It is still far from clear exactly what the consequences of the resulting deal will be for both parties. A number of previous articles and editorials have speculated on the possible consequences for health and oral health in the UK. Key areas include workforce, research and regulations for medicines and medical and dental equipment. This editorial will consider the implications for the UK's Oral healthcare workforce.

The healthcare system and the provision of oral healthcare in European Union member states. Part 9: Sweden.

Equally accessible and affordable dental services for all population groups have been a political goal in Sweden for almost a century. All political parties have shared the idea that a person's social background should not have consequences for his or her dental status. Strategic tools to achieve this ambitious goal have been the wide use of publicly provided oral healthcare services, covering even sparsely populated areas, focusing on preventive care and significant subsidies for necessary treatments. Besides free care for children and young adults, oral healthcare is reimbursed from public funds. The public subsidy was particularly generous in 1975-1999 when a 'full clearance' of adults' dentitions was undertaken both by the public and private providers under fixed prices and high reimbursement levels for all treatment measures. Today, preventive oral healthcare for the elderly is given higher priority as most Swedes have been able to keep their natural teeth.

The healthcare system and the provision of oral healthcare in European Union member states. Part 8: Italy.

In Italy healthcare is provided for all Italian citizens and residents and it is delivered mainly by public providers, with some private or private-public entities. Italy's public healthcare system - the Servizio Sanitario Nazionale (SSN) - is organised by the Ministry of Health and administered on a devolved regional basis. It is financed by general taxation that provides universal coverage, largely free of charge at the point of service. The central government establishes the basic national health benefits package, which must be uniformly provided throughout the country, through services guaranteed under the NHS provision called LEA - (Livelli Essenziali di Assistenza [Essential Level of Assistance]) and allocates national funds to the regions. The regions, through their regional health departments, are responsible for organising, administering and delivering primary, secondary and tertiary healthcare services as well as preventive and health promotion services. Regions are allowed a large degree of autonomy in how they perform this role and regarding decisions about the local structure of the system. Complementary and supplementary private health insurance is also available. However, as in most other Mediterranean European countries, in Italy oral healthcare is mainly provided under private arrangements. The public healthcare system provides only 5-8% of oral healthcare services and this percentage varies from region to region. Oral healthcare is included in the Legislation on Essential levels of care (LEAs) for specific populations such as children, vulnerable people (medically compromised and those on low income) and individuals who need oral healthcare in some urgent/emergency cases. For other people, oral healthcare is generally not covered. Apart from the national benefits package, regions may also carry out their own initiatives autonomously, but must finance these themselves. The number of dentists working in Italy has grown rapidly in the last few years. In December 2014, there were 59,324 practicing dentists with a ratio of one dentist every 1025 inhabitants, about 90,000 dental chair-side assistants, about 26,000 dental technicians and about 4000 dental hygienists. To enrol in an Italian dental school a student must pass a competitive national entrance examination after obtaining a high school leaving certificate. For entry in the 2015-2016 cycle, there were 792 places for dentistry. In comparison with dental schools in other EU member states, the number of dental students per school is low with an average of 20 students per year, per school and a range of 10 to 60. The aims of this paper are to give a brief description of the organisation of healthcare in Italy, to outline the system for the provision of oral healthcare in Italy and to explain and discuss the latest changes.

Compliance of referral and hospital documentation with National Institute of Health and Care Excellence guidelines for the extraction of third molars: a comparative analysis of two NHS Trusts.

To find out whether documentation for the extraction of wisdom teeth complies with National Institute of Health and Care Excellence (NICE) guidelines, we reviewed the referral letters and hospital notes of patients treated at the maxillofacial unit of two NHS Trusts (A: 314 records and B: 280) over 12 months (1 September 2012 to 31 August 2013). Compliance was assessed as unsatisfactory ("indication for extraction not mentioned", "incorrect indication", "indication unclear") or satisfactory ("correct indication implied", "correct indication explicit"). The grade of the clinician who examined the patient was also recorded. A total of 194/314 (62%) referral letters in Trust A and 126/280 (45%) in Trust B were unsatisfactory (p<0.001). Hospital notes were unsatisfactory in 168/323 (52%) and 87/297 (29%) of cases, respectively (p<0.001). In Trust A, middle grades saw 23% (75/323) of the patients, as compared with 53% (157/297) in Trust B. In both, junior staff produced the highest percentage of satisfactory documentation, but in Trust A they were also responsible for most of the unsatisfactory examples. However, senior house officers saw 60% (195/323) of the patients in Trust A, and only 28% (83/297) in Trust B. Consultants were responsible for significantly more unsatisfactory documentation (p<0.001). One referral letter (0.2%) and seven hospital records (1%) explicitly and accurately complied with the guidelines. We conclude that compliance of documentation with the current NICE guidelines is poor and inconsistent.

The healthcare system and the provision of oral healthcare in European Union member states. Part 7: Republic of Ireland.

The Irish oral healthcare system is a hybrid model with a public/private mix of service provision, predominantly organised on the basis of fee-per-item remuneration. The system is structured around three long standing publicly funded schemes: the Public Dental Service (PDS) for all children and adults with special needs and provided by salaried dentists, the Dental Treatment Services Scheme (DTSS) for low income adults, and the Dental Treatment Benefit Scheme (DTBS) for insured persons, the latter two both provided by private independent dental practitioners. Ireland introduced systemic water fluoridation in 1963 and currently 73% of the population has access to fluoridated water. Ireland currently has a dentist density ratio of 6.1 dentists per 10,000 inhabitants and on average, 43% of the population (30% for those aged 70+ years) visit a dentist annually. In 2014, 83% of expenditure on oral healthcare was from out-of-pocket payments by patients, with less than 1% of overall government expenditure on healthcare allotted to oral healthcare. After the economic downturn of 2008 and the severe recession that followed in Ireland, substantial cutbacks in government expenditure resulted in extensive cuts to the public sector supply of dental services and to the extent of cover provided by the publicly funded schemes. The Department of Health has recognised the major post recessionary challenges facing the Irish health system, not least, significantly reduced budgets and capacity deficits, and acknowledges the need for change in Ireland's health service. In 2014, a three-year project commenced at the Department of Health, to develop a new national oral health policy for Ireland.

Pathogenesis of Colitis in Germ-Free Mice Infected With EHEC O157:H7.

Enterohemorrhagic Escherichia coli (EHEC) are strains of E. coli that express Shiga toxins (Stx) and cause hemorrhagic colitis. In some cases, disease can progress to hemolytic uremic syndrome, a potentially fatal form of kidney disease. Both enteric and renal disease are associated with the expression of stx genes, which are often carried on lysogenic phage. Toxin is expressed following induction and conversion of the phage to lytic growth. The authors previously used a germ-free mouse model to demonstrate that toxin gene expression is enhanced during growth in vivo and that renal disease is dependent on both prophage induction and expression of Stx2. In the current study, the authors document and quantify necrotizing colitis, examine the progression of enteric and renal disease, and determine the role of Stx2, phage genes, and the type 3 secretion system (T3SS) in bacterial colonization and colitis and systemic disease. By 1 day after inoculation, EHEC-monocolonized mice developed colitis, which decreased in severity thereafter. Systemic disease developed subsequently. Infection with EHEC mutant strains revealed that renal failure and splenic necrosis were absolutely dependent on the expression of Stx2 but that T3SS function and prophage excision were not necessary for systemic disease. In contrast, colitis was only partly dependent on Stx2. This study demonstrates that in germ-free mice, like in human patients, EHEC causes early colitis followed by renal failure and that systemic disease but not colitis is Stx2 dependent.

NLRP6 function in inflammatory monocytes reduces susceptibility to chemically induced intestinal injury.

NLRP6 is a member of the Nod-like receptor family, whose members are involved in the recognition of microbes and/or tissue injury. NLRP6 was previously demonstrated to regulate the production of interleukin (IL)-18 and is important for protecting mice against chemically induced intestinal injury and colitis-associated colon cancer. However, the cellular mechanisms by which NLRP6 reduces susceptibility to colonic inflammation remain unclear. Here, we determined that NLRP6 expression is specifically upregulated in Ly6Chi inflammatory monocytes that infiltrate into the colon during dextran sulfate sodium (DSS)-induced inflammation. Adoptive transfer of wild-type (WT) Ly6Chi inflammatory monocytes into Nlrp6-/- mice was sufficient to protect them from mortality, significantly reducing intestinal permeability and damage. NLRP6-deficient inflammatory monocytes were defective in tumor necrosis factor α (TNFα) production, which was important for reducing DSS-induced mortality and was dependent on autocrine IL-18 signaling by inflammatory monocytes. Our data reveal a previously unappreciated role for NLRP6 in inflammatory monocytes, which are recruited after DSS-induced intestinal injury to promote barrier function and limit bacteria-driven inflammation. This study highlights the importance of early cytokine responses, particularly NLRP6-dependent and IL-18-dependent TNFα production, in preventing chronic dysregulated inflammation.

Don't be rejected, how can we help authors, reviewers and editors?: Report of a Symposium for Editors Publishers and Others with an Interest in Scientific Publication, Held in Boston on Wednesday, 11 March 2015, during the Annual Meeting of the International Association for Dental Research.

This satellite symposium was the fifth in a series for editors, publishers, reviewers and all those with an interest in scientific publishing. It was held on Wednesday, 11 March 2015 at the IADR meeting in Boston, Massachusetts. The symposium attracted more than 210 attendees. The symposium placed an emphasis on strategies to ensure that papers are accepted by peer reviewed journals. The speaker, representing the Journal of Dental Research gave a history of peer review and explained how to access material to advise new authors. The speaker from India outlined the problems that occur when there is no culture for dental research and it is given a low priority in dental education. He outlined remedies. The speaker from SAGE publications described the help that publishers and editors can provide authors. The final speaker suggested that in developing countries it was essential to create alliances with dental researchers in developed countries and that local conferences to which external speakers were invited, stimulated research both in terms of quantity and quality. A wide ranging discussion then took place.

The healthcare system and the provision of oral healthcare in European Union Member States. Part 6: Poland.

Poland is one of the largest European countries in terms of area and population. The country's economic situation does not allow for the allocation of sufficient public funds for healthcare in general and oral healthcare in particular. The health policy of the state focuses primarily on prophylaxis and treatment of diseases, directly threatening the health and lives of the inhabitants. Currently, expenditure on oral health accounts for only 2.7% of the public funds allocated to healthcare. In this context, providing oral care financed from public funds at an appropriate level constitutes a challenge for state institutions, centres providing medical and dental services and private practices. Despite difficult financial conditions in Poland, therapeutic and prophylactic programmes are implemented, aimed at improving the oral health of the society, especially children and adolescents, pregnant women and patients with disabilities or developmental disorders such as cleft palate. In Poland, apart from the oral care system financed by the state, there is also an extremely well developed system of private practices and clinics providing clinical services on a commercial basis. In 2014, oral services, financed by the state, were utilised by about 30% of the population of children and youths aged 0-18 years (2,212,792 patients) and about 15% of the adult population (5,026,383 patients). Training of Polish dentists is conducted in ten state-owned universities, from which 700 graduate each year. Dentists work mainly in private practices or medical centres, some of which provide services guaranteed by the public insurer - the National Health Fund. The other dentists find employment in state clinics, hospitals, and universities and their associated clinics. In Poland dentistry is a predominantly female profession and 75% of the just over 40,000 Polish dentists are female. Accession of Poland to the European Union meant that some Polish dentists have taken up employment abroad. It is estimated that the most common destination is the United Kingdom (UK), where 803 Polish dentists were registered, according to the General Dental Council in 2015.

Looking after the mouth - Evaluation of a pilot for a new approach to training care home carers in Kent, Surrey and Sussex.

Objective This pilot study aimed to produce and evaluate training resources and training in oral health care, including oral hygiene, for carers in care homes in Surrey and Medway.Methods During two training days, for carers from these homes, short, interactive presentations were given on a range of topics relevant to oral health care and oral hygiene of older people, followed by practical training. Prior to any training all attendees completed a 39 question questionnaire to establish their baseline knowledge of oral health and hygiene. At the end of the training day they completed an evaluation form. Fourteen weeks later, they were visited at their place of work and completed the same questionnaire again. Differences in responses between baseline and after 14 weeks were statistically tested using the chi-squared test.Results Sixty-six carers attended the training sessions and 44 were followed up 14 weeks later. The results showed an improvement in carer knowledge at follow up. The majority of carers (36/44) spoke English as their first language. They had a mean age of 41 years, 37 were female and 7 male. They had worked as carers for a mean of 10.9 years (range 4 months-34 years). Over 90% stated that the training day fully met or exceeded their requirements and expectations.Conclusions The results indicated improvements in carer knowledge. However, the carers were atypical of carers in general, as they were self-selected and well-motivated. Nevertheless the content of the training day and the questionnaire should inform future work in this area.

The healthcare system and the provision of oral healthcare in European Union member states: Part 5: Romania.

Romania is one of the newest member states of the European Union (EU). It has 13 dental schools, 14,841 dentists and 2,935 dental technicians providing oral health care for a population, at 31 December 2014, of 21.3 million. The shift from a communist system to a democratic or capitalist society has contributed to an enormous change in the proportion of public and private sector oral health services. The lack of public funds during the post-communist years has contributed to a dependency on private oral healthcare rather than the government financed public provision. Affordability and social awareness have together established a mixed economy for oral health care costs and oral healthcare is growing slowly compared with other developed EU member states. At the same time, there has been overproduction of new dentists (currently 1500 graduate annually). This has led to un and under-employment and emigration of dentists to other EU member states. This paper explains the current oral healthcare system in Romania and changes in recent years.

The healthcare system and provision of oral healthcare in European Union member states. Part 4: Greece.

This paper presents a description of the healthcare system and how oral healthcare is organised and provided in Greece, a country in a deep economic and social crisis. The national health system is underfunded, with severe gaps in staffing levels and the country has a large private healthcare sector. Oral healthcare has been largely provided in the private sector. Most people are struggling to survive and have no money to spend on general and oral healthcare. Unemployment is rising and access to healthcare services is more difficult than ever. Additionally, there has been an overproduction of dentists and no development of team dentistry. This has led to under or unemployment of dentists in Greece and their migration to other European Union member states, such as the United Kingdom, where over 600 Greek dentists are currently working.

The healthcare system and the provision of oral healthcare in EU Member States: France.

The French oral health system is based on the provision of dental treatment and is organised around a fee-per-item model. The system is funded by a complex mix of public and complementary health insurance schemes. The system is successful in that it provides access to affordable dental treatment to the majority of the French population. However, France had the highest health expenditure as a share of gross domestic product (GDP) of all European Union countries in 2008 and rising oral health inequalities may be exacerbated by the manner in which oral health care is provided and funded. In addition, there is no organised national strategy for the prevention of oral diseases or for oral health promotion.

Variation in methods used to determine national mean DMFT scores for 12-year-old children in European countries.

AIM: The aim of this study was to investigate the methods used to identify national mean DMFT scores for 12-year-old children in all the Member States of the European Union and European Economic Area, and in 11 other European countries. METHODS: The most recent national mean DMFT scores were accessed from the World Health Organisation Oral Health CAPP and the Council of European Chief Dental Officers databanks. A literature search was then performed to access the reports of the studies that had produced these DMFT scores, cited on these databanks. The reports were then analysed to determine: the year in which the survey/study that produced the score took place, the year the results were published, the geographical area (national, regional or local) covered, the number of children examined, how many examiners took part, how they were trained and calibrated, and the criteria used for the detection of caries. RESULTS: Data and information from 43 European countries were accessed. The years when the studies were performed ranged from 1990 to 2014. There were doubts over the representativeness of some samples. A wide range of different methods were used. Examiner training and calibration were very variable both in terms of duration and reported inter and intra-examiner consistency. There were important variations in the criteria employed for the detection of caries. CONCLUSIONS: These findings support the view that most of current national caries data for DMFT levels in 12-year-old children are not comparable across Europe.

The healthcare system and the provision of oral healthcare in European Union member states. Part 2: Spain.

Spain is the second largest EU Member State with an area of 504,645 km(2) and is the fifth most populated one with a total of 46.5 million inhabitants. The number of dentists working in Spain has grown rapidly in the last 20 years. In December 2014, there were 33,346 practising dentists with a ratio of one dentist for every 1394 inhabitants. Oral health of children has improved; with a fall in the national mean DMFT index (decayed, missing and filled permanent teeth) among 12-year-olds, from 4.20 in 1984 to 1.12 in 2010. The percentage of the population that has visited a dentist within the last three months has risen from 13.5% (1987) to 16.9% (2011-2012). Forty-three percent of the Spanish population visited a dentist in the last year in 2009. The Spanish National Health System (SNS) provides comprehensive cover for general health, but very little oral healthcare for adults. Only emergency care and oral surgery (dental extractions) for adults are provided in publicly funded clinics. The vast majority of oral health care is provided in the private sector and over 90% of dental professionals work in the private sector. Nevertherless, children aged 7-15 years are covered (with some restrictions) by publicly funded oral healthcare with different care models, depending on the local health authority, and some of them are funded by a capitation system which was introduced 25 years ago.

A pilot project to improve the oral health of orphans and of the elderly in residential care in Constanta, Romania.

AIM: A pilot project to improve the oral health of Romanian orphans and elderly people in residential homes. MATERIAL AND METHODS: The orphanage and old persons' home were in Constanta. After training, 50 fifth-year dental students made 14 weekly residential home visits to improve carers' oral health knowledge and oral hygiene (OH) procedures and to monitor progress in one orphan and one old person. At baseline and after 14 weeks a local dental school staff member examined each orphan and old person's oral health using WHO (1997) criteria and the Simplified Oral Hygiene Index (OHI-S). The carers' knowledge of OH and attitudes to providing and the students' knowledge and attitudes were assessed at baseline and again after 14 weeks with a questionnaire. RESULTS: All 56 orphans (mean age 9.6 years, mean DMFT 2.39) living in the home participated and their mean OHI-S improved (1.40 to 0.80, p < 0.0001). Fifty old people (mean age 75.9 years) participated, of whom 22 (44%) were edentulous. There was no significant improvement in mean OHI-S (p < 0.10). The carers' oral health knowledge improved (mean scores from 65 to 88, p < 0.001) as did their attitude score (p < 0.013). Students noted changes in their understanding of the needs of the carers, orphans and elderly people. Their perception of their capability to provide OH education or train others to do so, or their inclination to do so remained substantially unchanged. CONCLUSIONS: This pilot study met its aims suggesting that with suitable management, senior dental students can play a significant role in residential homes for orphans and old people by training carers and improving the residents' oral hygiene. Further similar studies in other settings are indicated.

Introducing dental hygienists in general practice to research - an in-practice evaluation programme in the United Kingdom.

AIM: To introduce dental hygienists (DHs) in the UK to the principles of research through a practice-based product evaluation programme. METHODS: The programme consisted of an initial training and orientation day with presentations on evidence-based practice, research methods and the structure of research papers. The programme and its aims were explained in detail, and participants were briefed on the methods to be used. Participants then recruited seven to ten patients from their practices (offices), carried out a baseline assessment of: plaque, gingival health, calculus and staining at anterior teeth, and gave the patients a questionnaire asking about their teeth and then provided a 3-month supply of a test toothpaste. About 10 weeks later, a follow-up assessment of the same variables was performed and the questionnaire was repeated. A second training day followed during which the DHs provided feedback of their experiences and received training in literature searching and critical appraisal of literature including interpretation of results. RESULTS: Sixty-five DHs attended the first training day; 31 were able to recruit sufficient patients and attend the second training day. The DHs recruited 168 patients who received baseline and follow-up assessments. All the variables improved overall. Feedback from the DHs was very positive, and patients expressed delight with the care they had received. CONCLUSIONS: Qualitative feedback for participating DHs suggests the programme met its aim and could be used in the future as a mechanism for helping DHs who want to increase their understanding of research methodology.

How is research publishing going to progress in the next 20 years? Transcription of session for editors, associate editors, publishers and others with an interest in scientific publishing held at IADR meeting in Seattle on Wednesday, 20 March 2013.

On March 20th 2013, a one-hour session for Editors, Associate Editors, Publishers and others with an interest in scientific publishing was held at the IADR International Session in Seattle. Organised by Kenneth Eaton and Chris Lynch (Chair and Secretary, respectively, of the British Dental Editors Forum), the meeting sought to bring together leading international experts in dental publishing, as well as authors, reviewers and students engaged in research. The meeting was an overwhelming success, with more than 100 attendees. A panel involving four leading dental editors led a discussion on anticipated developments in publishing dental research with much involvement and contribution from audience members. This was the third such meeting held at the IADR for Editors, Associate Editors, Publishers and others with an interest in scientific publishing. A follow up session will take place in Cape Town on 25 June 2014 as part of the annual IADR meeting. The transcript of the meeting is reproduced in this article. Where possible speakers are identified by name. At the first time of mention their role/ position is also stated, thereafter only their name appears. We are grateful to Stephen Hancocks Ltd for their generous sponsorship of this event. For those who were not able to attend the authors hope this article gives a flavour of the discussions and will encourage colleagues to attend future events. Involvement is open to Editors, Associate Editors, Publishers and others with an interest in scientific publishing. It is a very open group and all those with an interest will be welcome to join in.