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A. Williams J. Mackintosh B. Bateman S. Holland A. Rushworth A. Brooks J. Geddes British Dental Journal 2014; 216: E6

Editor's summary

Often we find that oral health is side-lined. For example, dentists are not consulted on plans to modernise health services. Oral health is frequently forgotten in health education, in funding decisions or by patients themselves when carrying out their day-to-day routines. However, the work reported in this paper illustrates what great things can come from the inclusion of the dental profession at the heart of healthcare.

Thirteen percent of the 91,000 looked after children in the UK are in care for longer than five years.1 Evidence also shows that looked after children tend to have high levels of poor oral care and dental disease. Common sense thus dictates that dental services should be integrated into any care plan for these children. On this occasion, common sense actually won out.

The 'Raising Health and Education of Looked After Children' (RHELAC) support team in the north of England got together with dental colleagues in the community dental services (CDS) to create a designated dental care pathway (DDCP) for looked after children. This pathway has been providing care for these children since 2011 and what a success it has been.

The authors interviewed children cared for by the service and their carers, as well as healthcare professionals and social workers using the dental care pathway. 'I would go every minute!' claimed one child. 'In the past there have been gaps of 2 or 3 months...and now we can get that service almost immediately,' reported a residential carer.

These fantastic reports about the positive impact of the DDCP contrast markedly with the unhappy experiences of these looked after children in the past and under different systems. For example, one CDS clinical director commented that 'they don't want to go back to the family dentist in case there are problems with parents coming across them.' Or from one foster carer: 'I've done lots of littlies, the younger children, and sometimes they've never had a toothbrush never mind anything else...'

The DDCP that led to the reported success boils down to what the authors call 'relatively minor, mostly administrative changes'. Basically it simply stipulated that the dental health of the children entering care was discussed at the primary medical assessment; that a follow-up appointment was arranged in the CDS and that all concerned with the child's care were kept informed. It goes to show what can be achieved when dental care professionals are included at the outset.

The full paper can be accessed from the BDJ website ( www.bdj.co.uk ), under 'Research' in the table of contents for Volume 216 issue 3.

Ruth Doherty

Managing Editor

Author questions and answers

1. Why did you undertake this research?

Recognition that oral health is an important part of a person's wellbeing that can impact on overall emotional and physical health is demonstrated by the inclusion of dental attendance in England and Wales' Performance Indicators for looked after children (LAC). Despite this, the UK lacks systematic guidance to ensure dental assessments are part of children's wider health assessments on care entry. Recognition of this situation brought together key professionals from the Designated Looked After Health Team of one local authority with social care colleagues. The resultant working group designed and implemented an integrated dental care system that aimed to guarantee that all LAC had access to dental care and put in place interagency mechanisms that ensured knowledge about dental attendance and outcomes was fully disseminated. The exploratory nature of system called for an evaluation of its process and outcomes.

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

Lack of detailed statistics about the dental health of looked after children calls for an epidemiological survey of the dental health of LAC in England and Wales. The lack of a system similar to the designated dental care pathway (DDCP) elsewhere calls for a wider trial within the community dental service (CDS) in England and Wales and the inclusion of general dental service (GDS) into the corporate parent team for LAC to allow consideration of extending the system into the GDS to allow complete feedback of the dental assessment and treatment of LAC. Exploration of the feasibility of expanding and adapting the model to ensure wider health problems that commonly affect looked after children are treated, and knowledge of treatment disseminated and recorded amongst key professionals.

Commentary

This article describes a community-based designated dental care pathway that has successfully provided dental care for 'Looked after children' (LAC).

On 31 March 2012 there were estimated to be 91,000 children in care in the UK. The figures for each of the nations are given below:2

  • England – 67,050

  • Northern Ireland – 2,644

  • Scotland – 16,248

  • Wales – 5,725

The evidence in the literature confirms that children in UK statutory care tend to have relatively higher levels of poor oral care, dental neglect and disease,3,4,5 little regular dental attendance before LAC care entry, and higher needs for treatment when they attend adental surgery.6

LAC children are already socially and psychologically disadvantaged and as a profession we need to work to prevent any oral problems compounding other issues. Until relatively recently a dental examination was not included in the overall care package for these children. Bewildering but unfortunately not surprising to think that oral care was neglected by the caring professions.

We owe the authors a debt of gratitude for demonstrating that a successful referral pathway can be established despite the many points of contact and the complexity of the care system. Certainly the complexities of the care system dictate that dental care is often delivered more efficiently and successfully in the community services rather than in the GDS, but this model embraces care in the GDS if this is preferred after initial assessment and treatment. Coordinating the identification, referral and examination of LAC is key to success and this is why the community-based dental services are at an advantage especially when they are located close to coordinating community medical services.

LAC children may also be relocated within a region as a result of their individual circumstances and transference of care within the community-based dental services rather than the GDS may be easier in this scenario.

One key aspect of continuing care for LAC that the authors have identified is the education of the carer. The carer, like any member of the public, will have their own perceptions and experiences of dental care and no dental knowledge should be assumed.