Shaun Sellars continues this series on ethical dilemmas in dentistry which appears in every second issue of the BDJ.
The Lancet recently published a letter from Professor Richard Watt of University College London asking to use the unique opportunity of the COVID-19 crisis to refocus dental care to be as clinically effective as possible.1
The driving force for this is clear. The NHS is more stretched than ever, and if we're going to use public funds to improve the health of the nation, we should be allocating those funds most beneficially.
Professor Watt gives, as an example of this, the suggestion to drop the scale and polish (S&P) from routine dental care. While the push for more effective treatments and an emphasis on prevention is absolutely the right thing to do and should be encouraged, could the potential loss of the S&P lead to unintended consequences?
Ignoring the arguably outdated terminology, it is clear that for patients who have a healthy periodontium, routine scaling and prophylaxis is of little to no clinical benefit.2 But when assessing the value of an intervention, should we be thinking of more than merely the clinical worth? Our responsibility as dentists is to look after the oral health and wellbeing of a patient. Arguably, the cosmetic appearance of the teeth fall under this remit and prophylaxis forms a significant part of this. Would the dropping of the S&P affect patient wellbeing in the long term?
Importantly, it's worth considering what the S&P means to the patient. For many, the routine cleaning and polishing of the teeth may be the driving factor for their attendance. If we remove this, then the chance to assess dental health and screen for oral disease may be lost. So while the elimination of the prophylactic S&P may not appear to have any direct consequence, the removal of this simple provision may have an unexpected knock-on effect to the health of patients. And in England at least, the physical cost of the S&P (for the NHS) is borne by the practice providing the care.
During the coronavirus pandemic, many dental professionals have been redeployed successfully into other healthcare roles. Many have developed new skills, and further integration into mainstream healthcare should be encouraged. Assuming this is to continue, the dental examination is likely to transform in the future, further incorporating dental professionals into the main body of healthcare.
Imagine the scenario where dentists can provide an enhanced dental examination thanks to the improved technical skills dental professionals have developed throughout the pandemic. We can pursue a more holistic approach because of our extended knowledge. But because a basic factor that drives patients into the practice has been cut (the S&P), we're seeing fewer patients.
Would patients come to the dentist for an improved examination without the cosmetic carrot of the S&P? Or would providing a little bit of (clinically unnecessary) sparkle to patients improve their overall health? The S&P, along with many other health interventions, may benefit patients in more ways than just the direct clinical outcome.
Watt R. COVID-19 is an opportunity for reform in dentistry. Lancet 2020; 396: 462.
Ramsay C R, Clarkson J E, Duncan A, et al. Improving the Quality of Dentistry (IQuaD): a cluster factorial randomised controlled trial comparing the effectiveness and cost-benefit of oral hygiene advice and/or periodontal instrumentation with routine care for the prevention and management of periodontal disease in dentate adults attending dental primary care. Health Technol Assess 2018; 22: 1144.