This project aimed to increase preventive activity by primary dental care providers through the introduction of a local award scheme. Key performance indicators within the award scheme focused on delivering better oral health during routine dental examinations by offering brief oral health promotion advice and clinical prevention in line with Delivering Better Oral Health: an evidence based toolkit for prevention.
As recommended in NICE guidance NG30 ‘Oral Health Promotion Approaches for Dental Teams’, dental teams were encouraged to give all patients (or their parents and carers) brief advice in relation to oral hygiene practices and the use of fluoride products, as well as advice about the links between oral health and smoking, alcohol use and diet.
Aims and objectives
The aim of the initiative was to build capacity for health promotion in primary care dental teams. The main objective was to encourage primary care providers to participate in the ‘Delivering Better Oral Health: Prevention in Practice Award’.
This involved developing the dental team’s knowledge and skills through tailored topic based training sessions, fostering commitment to delivering routine brief advice in oral health promotion and if necessary adopting new structures and systems to support delivery of brief advice.
Reasons for implementing your project
The starting point for this project was the Oral Health Improvement Toolkit (Delivering Better Oral Health (DBOH) (2009) with 76 NHS primary care dental providers included in the scope of the project, all located within the City of Manchester.
Opportunities for making prevention work in practice were evident in Manchester. The latest evidence was that at least 23% of 3 year olds had one or more teeth affected by decay with at least 39% of 5 year olds experiencing caries, compared with 28% in England as a whole (Joint Strategic Needs Assessment, 2014).
In terms of adults’ oral health, 9% of adults in the North West had severe conditions linked with dental decay, 51% had symptoms of reversible gum disease and 43% with signs of progressive periodontitis. Also in terms of lifestyle, it is estimated that 22% of adults in Manchester drink alcohol above recommended limits (approximately 100,000 adults in the city) which increases their risk of a range of serious health conditions including mouth and throat cancers.
In addition, 27.2% of the adult population in the City of Manchester smoked. This figure rises in adults who are employed in manual work, where 38.3% of over 18s smoke and 14.6% of women having babies in Manchester were smokers. Making ‘Every Contact Count’, delivering routine brief advice in oral health promotion to patients (as well as parents or carers) was therefore a key driver for this project to improve access to advice and self-care support.
How did you implement the project
The oral health improvement service employed a full time oral health improvement practitioner (OHIP) to plan and devise the ‘Delivering Better Oral Health’ (DBOH) Prevention in Practice Award, to ensure practices were developing, encouraging and delivering a prevention agenda for their patients. Initially this project was developed by Manchester Primary Care Trust (PCT)and jointly funded by the PCT and dental commissioning. Initial contact and subsequent visits with the practices, capacity building for all Dental Care Professionals (DCP’s), and evidence based literature on all aspects of DBOH was provided.
Standards were developed around the evidence base produced in the Department of Health’s document and Primary Care Dental Services Governance Workbooks. The criteria were developed into a Bronze, Silver and Gold award and used as an audit tool to assess delivery. A key element was for each practice to have an oral health champion to co-ordinate and liaise with the OHIP to achieve the criteria and develop skills within the practice. Each dental practice, due to various factors, had a different starting point within the criteria, resulting in a tailored approach, agreed between the practice, champion and OHIP.
The practice could also opt to attend the ‘Making Prevention Work in Practice’ courses to develop knowledge and clinical skills, accredited by Primary Care Commissioning (PCC) and supported by the Northwest Deanery.
Other training was pivotal to this programme, for example a series of alcohol identification and brief advice training sessions were offered to dental teams via the OHIP and delivered by the local Alcohol Identification and Brief Advice Trainer. Six practices took part with 49 members of staff participating in training.
This joint approach had reciprocal benefits to both the OHIP who were encouraging practices to routinely ask about alcohol use and offer brief advice, as well as the Alcohol Prevention Team who were trying to increase access to alcohol intervention and brief advice IBA in a range of primary care settings. While the dental teams were familiar with routinely asking patients about their alcohol use, the most common question asked was “how many units a week do you drink?” rather than the use of validated alcohol screening questionnaires as recommended in NICE guidance (PH24 recommendation 5).
Therefore a major focus within the training sessions included introducing new alcohol screening questions for consideration, as well as the knowledge and skills on how to deliver 5 minutes of brief advice.
Dental practices were measured against the set criteria and once the baseline criterion was achieved the practices were supported to progress to the next level, with 28 practices receiving a Bronze Award, 17 receiving Silver and 17 Practices reaching the Gold Award.
Training evaluation highlighted what dental staff found most useful such as
(1) understanding how to identify the different risk levels of drinking (Increasing risk, higher risk and possible dependence) – “not just ‘non-drinker’, ‘drinks’, ‘dependent’”;
(2) understanding about units of alcohol ‘what drinks contain what’;
(3) new methods on how to assess someone’s alcohol use using a screening tool; and
(4) learning how to speak to patients offering 5 minutes of opportunistic brief advice using the FRAMES model. Additional feedback also suggested that staff found that the alcohol training session increased personal awareness of their own drinking as well as friends and family.
Additionally, three ‘Making Prevention Work in Practice’ courses were delivered, 26 students attended with 100% pass rate.
Key learning points
- Having an oral health improvement practitioner lead the project was pivotal to its success.
- Support dental teams to update their health questionnaires with the latest evidence based screening questions. This can guide the delivery of personalised brief advice and support staff in their approach.
- The standards set were very useful as an audit tool to allow the DBOH prevention in practice award to continuously develop and generate other projects such as dementia awareness training and to increase dental access for 3 and 4 year olds.
- Ensure the lifestyle screening questions are brief and suitable for time-limited settings such as routine dental examination appointments. For example, if the abbreviated alcohol questionnaire AUDIT-C (three item tool) is considered still too lengthy for busy dental settings, the Single Alcohol Screening Question (M-SASQ) could be suggested as an alternative to replace the current “units per week” question.
- Offering dental practices topic based training in the form of bespoke, tailored sessions was popular. Also delivering training on-site, in protected learning time for staff, was most convenient.
- Provide dental practices with a range of visual aids to support the delivery of brief advice. Visual aids can increase the confidence of staff in their approach as well as provide patients with information to take-away.