Dental Dean Update - Access to Dentistry

It is a well-known fact that good oral health is a fundamental component of overall health and well-being. Cardiovascular health is related to oral health, as are the risks of endocarditis and pneumonia. Pregnancy complications and psychological wellbeing, along with various other aspects of the human healthcare are also influenced by the health of the oral cavity. Despite this knowledge, access to dental healthcare unfortunately varies considerably across the globe. 

Dental access continues to be a key advocacy issue for the Faculty of Dental Surgery (FDS). As a faculty we have been lobbying for improvements in access to NHS dental care throughout the UK with our dental manifesto and sustained campaign of positive oral health messages. We are also engaging with individual governments around the world in relation to the Faculty’s work on standards for education, training, assessment and accreditation. Moreover, with head and neck cancer cases rising, we are calling on governments to improve the detection as well as lives of all of those who are affected. 

Having well-trained dental professionals working in well equipped clinics using advanced technological facilities to deliver high quality dental care across the globe is the ultimate goal. However for much of the population of our planet basic dental services with regular check-ups remains an aspirational goal. There are a myriad of factors contributing to these disparities, and whilst there are a number of strategies that can help address these, I will refrain from the obvious pun about potential solutions to bridge the gaps. 

The global landscape of dental care is primarily influenced by personal economic success with dental care being generally accessible in high-income countries. With frequent oral health checkups, dental professionals can focus on prevention in order to identify not only dental, but also malignant and premalignant diseases. Education forms part of the wider social contract for dental teams in high-income countries, with many providing various educational opportunities for schools, groups, voluntary organisations, as well as social media initiatives. Insurance coverage is often part of the overall system but is not uniform. Despite the positives, even in high-income countries, access to government-funded dental care is variable and creates inequalities in universal care provision. Routine dental care for populations of lower socioeconomic status, as well as for rural, coastal, and minority communities, means that many struggle to access dental care.

Whilst access to dental care is continually evolving in middle-income countries, there is an uneven distribution with urban areas having greater access to dental care than those from rural populations. Whilst there is a growing oral health awareness with general public health campaigns, the development of dental facilities and services are hindered by the overall cost of dental care which presents a significant barrier for many. Many of the challenges mirror those of high-income countries but it is reassuring to see many middle-income countries investing in healthcare education, including dentistry; with RCSEd often being a key partner in the development process through our wide portfolio of activities.

Low-income countries present a significant challenge for access to dental care with a scarcity of dental health professionals for care provision along with insufficiencies in training and equipment. Oral health is often blighted by poor levels of dietary and oral health education in the population and the stark reality that the cost of dental care is relatively high in relation to overall levels of income with even the basics of toothpaste and toothbrushes being an unaffordable luxury. It is of no surprise that dental health in low-income countries is relatively poor with only emergency treatment being provided for the majority. At the same time there is frequently little emphasis on prevention and detection of dental disease. Medical mission work is to be commended, but it remains that healthcare systems need to be developed in resource-poor countries for populations to have adequate access to dental care. 

Income is not the only determinant of the provision of dental care. The situation is complex. More remote areas are also challenged by geography with long distances precluding regular dental access, due to time and cost of travel. This is complicated by lack of awareness and indeed education where many in the world are not given the opportunity to be educated on the importance of preventable oral health diseases and the consequences for general health. Healthcare infrastructure significantly affects the ability to deliver dental care, with countries and regions that have weaker healthcare systems often struggling to provide adequate dental services.

War-torn countries are never far from the headlines often resulting in displaced populations within refugee camps. Invariably the charity sector seeks to do what it can to help in these situations, but inevitably emergency dental care is all that is possible at best. People working in extreme environments such as mountainous or wilderness areas, as well as those undertaking long expeditions or working in austere environments such as the Antarctic and offshore oil industry have specific challenges for oral health. Often there is a sole focus on the prevention of dental disease and the inevitable management of dentoalveolar and facial trauma in such environments. “Medevac” to transfer patients for care provision can sometimes be the only option. Endurance sporting events also alter the physiology and biochemistry of the oral cavity posing a risk to good oral health for those who are regular participants. 

Finally, cultural belief practices also create substantial influences on oral health practices. In some societies, the traditional remedies prevail over modern evidence-based dental care. I have experienced this first hand in Borneo. During a trip navigating through the mangrove and the volcanic islands, I was struck that many of the people we met had missing teeth. Our guide bemoaned the lack of basic healthcare, and paradoxically the rejection by many of tribal people of modern healthcare and their belief in alternative methods of healthcare such as the shaman, black magic and other traditional methods of healing. On discovering my profession, he told me that all we 'city dentists' do is extract teeth and we should offer much more in terms of alternative cures for dental problems. I remain open to the opportunity for non-conventional treatment but for the vast majority of oral conditions there is no evidence to support the use of such ritual-based healthcare. 

Solutions and innovations for access to dentistry have been discussed by many over the years. Mobile dental clinics are used in many countries to allow essential dental services to be provided for underserved and remote communities. These clinics, often run by charities, social enterprises and third sector organisations are equipped with basic dental equipment allowing the provision of preventive and emergency care. Interestingly, in the UK, there has been quite a bit of discussion about the possibility for mobile dental vans to help address the access ‘gap’ with the third sector helping those most in need. My calculations on this proposal show a significant disparity between the concept and the reality of addressing the need to the UK population through dental vans. 

Teledentistry offers an ideal opportunity for triage, assessment, advice and directing patients to the appropriate care provider for those in remote and rural locations. I regularly use teledentistry extensively to connect with patients for assessment and diagnosis, particularly those locations where travel presents an additional financial hurdle, not forgetting the sustainability aspect of reduced patient and clinician travel. Community health workers can provide basic dental education in areas with a low ratio of dentists to population. In some countries, such community health workers can also be trained to provide some basic dental care and international aid organisations are well-known for sharing resources and knowledge in this aspect of care.

As noted above, access to high-quality dental care is a key aspect of general health and wellbeing that needs to be addressed across the globe. The barriers to, and the solutions for, the provision of care, need to be addressed. 

As a College, our Faculty of Dental Surgery and the Faculty of Remote, Rural and Humanitarian Healthcare (FRRHH) offer an opportunity for those involved in providing dental care for populations that are geopolitically, geographically or through no fault of their own, disadvantaged to form a wider community of healthcare workers working to improve population oral and general health. The use of technology, community involvement, education and co-operation from various stakeholders can help in the development of dental services for dental health care to be a universal right rather than a luxury. We have a long way to go, but through the FDS and FRRHH, our College is supporting the drive towards better oral healthcare and consequently, better health and wellbeing outcomes across the globe.

Your views on the Faculty of Dental Surgery matter dental@rcsed.ac.uk.