In her last interview for Dentistry Scotland before she retires, we speak to Margie Taylor about the Oral Health Improvement Plan and her time as chief dental officer.
Dentistry Scotland (DS): What was the driving force behind the Oral Health Improvement Plan (OHIP)?
Margie Taylor (MT): Much has been achieved since the last Dental Action Plan in 2005 but over 10 years later it was time to reassess the situation, consider if the priorities have changed and pave the way for the future. it is something that doesn’t happen very often so we want to get it right.
The title gives the obvious message of what we are trying to achieve – to improve oral health.
DS: There are good intentions mentioned in the OHIP, but some of the points lack detail andthe decisions lack evidence. For example, how you’re planning to fund the changes, the removal of scale and polish and the evidence behind this.
MT: That’s not what OHIP is saying. If you put a strategy together, you need sufficient detail in it to make the system move in a particular direction. If you put too much detail in it the document will be too thick and people will complain that all the decisions have been made. The balance is getting something that provides sufficient direction of travel, but gives opportunity to negotiate some of it with the profession.
Scale and polish is a perfect example. When a person is a regular attender at the dentist and can show they’re able to clean their teeth themselves, the additional benefit of a dentist doing a scale and polish has not been shown. Is it better that the dentist gives the oral hygiene instructions to the patient, so they can do it twice a day, over 700 times a year? We’re talking about the supragingival scale and polish, not treatment of periodontal disease.
The recent IQuaD (Improving the Quality of Dentistry) study was designed several years ago to answer the question of whether a simple scale and polish works. If you have somebody who has not attended for years and has a poor oral condition, you’re going to give them a scale and polish. Everybody who needs scale and polish will still be able to get them. There’s no blanket removal of scale and polishes. But what I have to realise is what the impact will be on a practice and I have made the point often, as did the Cabinet Secretary in the foreword to the OHIP, that the sustainability of the practices is crucial.
We speak to experts putting this together and they say, in relation to periodontal disease, disturbing the biofilm is what we need to do. My feeling is that we’re probably not addressing that part of the disease spectrum sufficiently. So what this will do is in recognising that, make the point that the emphasis should be on where it makes the difference.
DS: In OHIP you mention extra investment, there’s no mention of where that extra funding will come from, apart from a ‘realignment of existing funds’.
MT: Shortly after this came out we announced there would be an occupational health service for practices and their teams across Scotland. This has been implemented and is a sign of financial commitment to dentistry.
In relation to realignment from other things, yes of course, we have to make sure we’re using the resources in the best way before we ask for more. Once that has been done, we would anticipate investment to be made, for instance in domiciliary care. I can’t say too much on that at the moment, but that’s where we expect the next bit of additional investment to be made.
DS: So, you are expecting further investments?
MT: Yes, we’re expecting extra investment.
DS: Moving to a two-year check-up is mentioned in OHIP. By doing that, do you feel you’re ignoring the increasing risk posed by oral cancer?
MT: We’re not moving to a two-year check-up. There has been quite a lot of misreporting of this issue causing unnecessary uncertainty for the public. At the moment, the way dentists are paid, patients can come in every six months for check-ups. That may well suit some patients but it won’t suit all. NICE guidelines say it’s possible to leave some patients for two years but it will have to be based on the needs of the patient. Some patients may require to be seen more often than six monthly, this will be determined by their dentist and a new system will allow for this.
DS: Should it therefore have been suggested in OHIP?
MT: We have to recognise the evidence. We have to base what we’re saying on that. It could well be that there are patients in Scotland that could be left for two years, according to the evidence that’s possible. But I think you have to be realistic about this, it is not what we are suggesting for the vast majority of patients in Scotland.
This is about evolution not revolution. What we’ll be doing is launching an oral health risk assessment (OHRA). Recall frequency will be based on that. Part of the reason we didn’t put a whole lot of detail in about the risk assessment is because that’s one of the things that we need to discuss with everybody and get them on board.
DS: Factors mentioned in the plan all increase the chances of developing oral cancer, but there are other contributing factors. Oral cancer can develop in non-smokers and non-drinkers.
MT: It has to be based on the risk. The likelihood is the older smoking, drinking male, is the one that is going to develop oral cancer. If you look at how often people tend to attend now, the most common is once a year. I think the bigger issue is identifying the older smoking, drinking male, for example, and bringing them in more often.
This is designed to make sure that people are brought in with the right regularity. It’s not going to be imposed, it’ll be done with the involvement of the profession and experts who know about risk assessment.
DS: Is there anything more you’d like to do to reduce oral cancer rates?
MT: Oral cancer, being multifactorial, one of the things mentioned in the OHIP is that we’ll put it on other people’s agenda. Strategies involved with reducing alcohol consumption, smoking etc will help with the issue.
The OHRA should also help. There’s quite a lot that should all come together.
DS: Is this a missed opportunity to introduce water fluoridation?
MT: Water fluoridation is a difficult one. This is where realism and idealism crash in the middle. Looking at various people who have embarked on the water fluoridation journey, Southampton for example, they’ve campaigned for years and every time they get near a conclusion something happens to thwart it.
Although ideally you reduce decay with fluoridation, I’m not entirely convinced that it’s practical to implement. We have to decide whether we’re going to embark on things that we’re confident we could do and introduce as opposed to running an enormous campaign and maybe not achieving anything at the end, whilst missing the opportunity for other things. It’s a judgement call.
DS: Record numbers are registered with a dentist, but the numbers actually attending are falling. How do you hope to reverse that?
MT: I don’t think it’s the numbers that are falling, it’s the participation rate, the percentage of people registered going to the dentist within two years, that looks as if it’s plateauing.
I don’t know why. It could be because the rate of increased registration is high and people who are registered haven’t been registered for two years and therefore haven’t gone back yet. Or it might be another reason. It’s something we’d be interested in finding out. Some of the dental practitioners might be best placed to tell us.
DS: So, are you asking dentists to tell you why it’s happening?
MT: We’ve approached it slightly differently. We know 90% of the population is registered. We know that many of the practitioners encourage their patients to come back, but the group I’m most concerned about are the 75-year-olds and over. About 20% of those are not registered at all. That’s the group I think we need to concentrate on.
All the others, the dentist could be in touch with them. The ones who are not registered at all, maybe nobody is in touch with them.
DS: So, you’re putting the onus on the dentist to recall and see those who are registered with them?
MT: I think it’s a bit of a partnership really. Once a patient is registered, that patient knows they’re registered with the dentist. In my practice you book an appointment to go back for a check-up and they send a text to remind me. With the best will in the world, there will be some patients who will not come back. That’s the behaviour we don’t understand. That’s where we need some feedback from the dentist.
The numbers registered are still going up. We don’t fully understand the plateauing of the participation percentage. Part of the OHRA will be recognising that the patient has a significant part to play in this and giving them some guidance and explaining when they need to come back.
DS: Is there anything else you’d like to mention about the OHIP?
MT: One of the issues that concerned me during the roadshows was the fact that we didn’t get many representatives of associates, particularly from the younger female ethnic minority associates.
Associates are the principals of tomorrow and they’re the ones contributing significantly to the provision of service today. We need to get them involved and we need to know what they feel about it.
DS: You’ve decided to step down as CDO. What’s brought this about now?
MT: Old age actually. I’m going to be 63 in November. I’ve done the job for 11 and a half years. As much as I enjoy it, I don’t think I can hog it any longer.
Clearly, we had to get the OHIP done, but it really needs somebody who is going to be here for the next few years to take it forward and at the age of 63 that’s not going to be me.
DS: What are you most proud of during your time as CDO?
MT: I always say in answer to questions like that, the CDO never achieves things on their own. They need a whole lot of people around them and a lot of buy in from lots of folk. It’s easier to say I’m proud of the GDPs and the way they addressed the decontamination issue for instance. For every general dental practice to accommodate a decontamination room, some of them had to move practices. It was a major disturbance, so I’m proud of them for having done that.
Clearly, it’s lovely to see the fact children’s oral health has improved, but I can’t take a whole lot of credit for that, that’s to do with an awful lot of people out there prepared to help.
DS: What are your plans now?
MT: I’m getting a lot of advice on retirement and how it can affect people.
The advice I’m going to take is – not to do anything for the first few months. The only thing I’ve done so far is buy a saxophone. I’m thinking playing that will get me through the winter evenings. And I’m also looking forward to living in my house rather than visiting it.
After that I’ll assess the situation and decide what I’m going to do next.