Main

P. Evans, N. Pearson and D. Simons. British Dental Journal 2013; 215: E14

Editor's summary

This research paper makes fascinating reading for some of the wrong reasons, in my opinion. The detail is exemplary both in terms of the methodology and the reporting but what a terrible shame that it had to be carried out at all. In addition, it is quite amazing the lengths society now demands us to go to in order to look after disadvantaged children.

The caring and thorough approach to enabling the provision of fluoride varnish for three- to six-year-old children is certainly to be applauded and the authors have left no stone unturned in their quest to get consent for as many children to be treated as possible. However, despite their very best efforts after three years of such a comprehensive programme still less than half the youngsters are enrolled.

As I wrote in my previous editorial the answer so screamingly, obviously shouts water fluoridation.1 Why, oh why, is nobody listening? The hurdles that these researchers have had to jump to get even this far really defy common sense and the idea that link workers are required to liaise between the school and the vulnerable families for the purpose of placing fluoride varnish seems to me at least to suggest that somewhere along the line things have taken a turn for the worst.

Additionally, I cannot be the only reader to notice that the hygienists and the extended duties dental nurses engaged in this study, whilst of undeniable value were part of a team and carried out their duties after inspection from a dentist. What lessons for direct access from this?

Overall, a very instructive paper which illustrates so clearly the difficulty of trying to grapple with the problems of tackling what is so correctly, but so tiresomely, continually referred to as 'a wholly preventable disease'.

The full paper can be accessed from the BDJ website ( www.bdj.co.uk ), under 'Research' in the table of contents for Volume 215 issue 8.

Stephen Hancocks

Editor-in-Chief

Author questions and answers

1. Why did you undertake this research?

Although fluoride varnish applications have been shown to reduce the incidence of decay in children, previous research has indicated that poor uptake of school programmes may compromise outcomes. Children identified with a continuing treatment need following their initial dental screening were targeted for a further intervention – Back2school – using a mobile dental unit (which we have used successfully in this community in the past) to help reduce barriers to accessing dental care. Health interventions, which work successfully in disadvantaged communities, are more likely to be successful in the general population therefore our model could be used as a framework for other parts of the country.

2. What would you like to do next in this area to follow on from this work?

In the future, we would like to increase participation, particularly from children of vulnerable and hard-to-reach families, in the school dental screening, fluoride varnish application and uptake of dental treatment by working closely with the schools and communities. We would like to collect more qualitative data on the uptake of dental screening and fluoride varnish applications and to follow individual children's progress through successive years of the programme.For the Back2School access project, we would like to also like to undertake an RCT with larger numbers to evaluate the use of the mobile dental unit in reducing barriers to the access of dental care of vulnerable children who have been identified with a treatment need.

Commentary

Reform of NHS dental services are aimed at focusing on prevention and reorientation of the service away from the 'drill and fill' approach suited to a previous era. However, there is still a cohort of young children whose first presentation to a dental professional is when they have toothache. Usually these children are from deprived communities where the spectre of dental caries continues to roam freely. For these reasons, there is a need for school- and nursery-based interventions that target 'high-risk' children. I have recently described approaches to community-based fluoride programmes across the United Kingdom and how there is a need, in the absence of water fluoridation, to facilitate programmes that result in contact of teeth with fluoride and which move beyond traditional and outdated health education approaches.2

This paper describes the implementation of a school-based fluoride varnish programme in Hackney and Tower Hamlets, East London, two of the most deprived boroughs in England. Over a three-year period the local community dental service implemented twice-yearly fluoride varnish applications and increased coverage from 3 to 17 schools. The paper describes in detail the practicalities of implementing the programme. Important features included the involvement of a 'key school contact' and of a 'home-school liaison worker' or member of the early years' teaching staff. These individuals provide important local knowledge of individual children's life-circumstances and can play an important role in facilitating recruitment and parental consent to application of the varnish. In the boroughs involved in this programme the teams experienced language issues that complicated the consent process, and also found that there were cultural issues due to the fact that fluoride varnish contains alcohol.

It is somewhat disappointing that in the third year of this programme there were still 47% of the target population who had not consented to participate. If they are to be clinically effective and provide value for money, then school-based programmes really need to be achieving higher participation rates than were achieved here. However, it takes time for the snowball effect of such programmes to be established and the efforts described to increase programme uptake should continue.