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Rapid Responses: Rapid Responses published:
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Widening inequalities
- David R Moles (2 June 2008)
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Can't get a dentist
- Hugh van't Hoff (4 June 2008)
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Changing attitudes to pain and infection
- Andrew J C Carmichael (4 June 2008)
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How can we save Britain's teeth?
- C Albert Yeung (7 June 2008)
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So what should I do?
- Philip J Hughes (9 June 2008)
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David R Moles, Senior Clinical Lecturer in Health Services Research UCL Eastman Dental Institute, WC1X 8LD
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In the latest issue of the BMJ, Thomas and colleagues draw attention to the rising number of admissions for “Drainage of abscess of alveolus of tooth” (OPCS4.2 code F16.1) to NHS providers in England over recent years.[1] They hypothesise that this may be associated with changes in dental service provision. In an editorial in the same issue of the journal, Freeman provides a review of organisational changes that have been occurring as part of the process of reforming NHS dentistry and considers where and why problems may have arisen.[2] One of the most important aims of the reformation of NHS dentistry is to ensure the equitable provision of affordable dental services as indicated in the subheading to Freeman’s editorial. Thomas et al analysed aggregate data that was downloaded from the Hospital Episode Statistics (HES) website. I have undertaken analyses on the actual individual episode records for the same procedure (OPCS4.2 code F16.1) using data obtained as an extract from HES for the period 1 April 1997 and 30 March 2006. The use of individual episode data permits a greater level of resolution to be achieved particularly when combined with other relevant details including the relative deprivation of area of residence of admitted patients (using quintiles of the Index of Multiple Deprivation (IMD)[3]). Worryingly these data indicate the presence of considerable inequalities. Figure 1 shows the numbers of admissions each year stratified by deprivation quintile. Although the numbers of admissions have risen in all groups, there is a strong deprivation gradient with the greatest increase occurring among those living in the most deprived areas. There has been an almost three-fold increase in the number of admissions over nine years for people living in the most deprived quintile based on the IMD.
Figure 2 illustrates the age and gender profile of admissions and shows peak incidence among young adult males.
Figure 3 indicates that the age of peak incidence is consistent across quintiles of relative deprivation of area of residence, but that its amplitude shows a marked socio-economic gradient.
Further analyses indicate that 86.32% of the total 8,896 admissions were classified as being an emergency. There is a socio-economic gradient such that people living in more affluent areas are less likely to have been admitted as an emergency (odds ratio per deprivation quintile = 0.946 (95%CI 0.906, 0.988, P=0.013) analysed using a Generalised Estimating Equation approach to account for clustering). Thirty five patients were admitted twice over the nine year period for the same procedure. There were thirty four episodes in which an intensive care unit stay was required and a total of three deaths. The analyses reported in this letter, much like those of Thomas et al, are unable to ascribe causality, but they do paint a bleak picture of both a worsening situation and of increasing socio-economic inequalities. 1. SJ Thomas, C Atkinson, C Hughes, P Revington, AR Ness. Is there an epidemic of admissions for surgical treatment of dental abscesses in the UK? BMJ 2008;336:1219-1220 (31 May), doi:10.1136/bmj.39549.605602.BE 2. R Freeman. Reforming NHS Dentistry. BMJ 2008;336:1202-1203 (31 May), doi:10.1136/bmj.39546.440822.80 3. M Nobel, G Wright, C Dibben, GAN Smith, D McLennan, C Antilla, H Barnes, C Mokhtar, S Noble, D Avenell, J Gardner, I Covizzi, M Lloyd. Indices of Multiple Deprivation 2004, Her Majesty’s Stationary Office 2004. ISBN 1 851127 08 9 Competing interests: None declared |
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Hugh van't Hoff, GP May Lane Surgery, Dursley, Gloucestershire, GL11 5AZ
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I can only write about my experience of seeing patients with dental abscess/infection and the hearsay experience of other GPs. The amount of dental problems we see seems to have risen over the last 10-15 years in keeping with the similar decline in NHS dental work. We are not qualified to do dental work and have to preface our treatment with advice to this effect. The (empirical) experience of my patients is that they cannot acces a dental practitioner at short notice for almost any problem. 'Emergency' appointments are often available some weeks in advance and the out of hours system seems to be difficult to access (local experience), time limited and telephone based. My overall impression is of a system which fails to acknowledge that what a patient calls an urgent problem is an urgent problem for the system. This amounts to systemic denial, it seems to me, and I wonder why it is that the government has allowed this situation to arise. Imagine pain or infection at another site - backache, PID, cellulitis - to realise that a similar scenario of (seeming) neglect couldn't any longer happen in general practice. Competing interests: None declared |
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Andrew J C Carmichael, Retired Dental Surgeon PRESTON PR2 1DY
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I read your article (Is there an epidemic of surgical admissions for dental abscess..?) with interest but little surprise. As a retired dental surgeon of 'the old school' I am constantly approached when out shopping or by people who still have the telephone number. Most approaches are for rapid pain relief which is virtually impossible to obtain today. I had a list of 6500 people who considered me 'their dentist' in the NHS. Many were described as casual patients who only attended when they felt they needed treatment – usually in acute pain. We were taught in 1960 when antibiotics were uncommon that extraction of the tooth as soon as possible was a sensible way to obtain rapid drainage and pain relief at the same time. Many were dealt with on the spot with basic general anaesthaesia or local anaesthetic. In later years excuses appeared such as 'local anaesthetics don't work in such cases' or 'antibiotics should be given for two days prior to extraction' thus ensuring at least two days more pain. The reasons for these excuses were that it got dentists off the hook of having to see to the patient straight away and thus exacerbate a full list. The fact that dental infections are almost always mixed and antibiotics are singularly ineffective in this situation was conveniently ignored. At least 'something had been done'. A new angle on this appeared about twenty years ago when it became likely that patients could be reasonably promised that the tooth could be saved with root canal therapy and subsequently a crown, often unnecessary, at least immediately. This looked good to patients and paid the dentist far better than an extraction. It still does. Patients are routinely offered treatment plans costing from £500 to £1500 to save one rotten tooth and it is little wonder that they thus allow the abscess situation to get out of hand. You have to pick up the bits in the hospital. The solution is to point out to patients, particularly the irregular ones, that one extraction is not the end of the world but it will relieve pain and get drainage in one go. I have had no cases in which I was unable to achieve block local anaesthesia despite an abscess being present. I have seen many cases where antibiotics have been underprescribed and to little or no effect other than to encourage antibiotic resistant bacteria. There is a desparate need for a proper system of basic dentistry for the urgent relief of pain. Competing interests: None declared |
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C Albert Yeung, Consultant in Dental Public Health Lanarkshire NHS Board, 14 Beckford Street, Hamilton ML3 0TA
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Data released recently by the NHS Information Centre [1] showed that a total of 27.3 million patients had been seen by an NHS dentist in England, which is equivalent to 53.7 per cent of the total population of England. There is a drop of 3.1 per cent (0.9 million) on the number of patients seen in the 24 months leading to the end of the old dental contract on 31 March 2006, where 28.1 million patients were seen by an NHS dentist, equivalent to 55.8 per cent of the population at that time. This figure is in addition to the approximately two million people that the Department of Health acknowledges wanted access but were unable to get it before March 2006. [2] The report [1] also showed wide variations across England in access to an NHS dentist, with greater disparities among adults than children. Among adults, the proportion who had seen a dentist in the 24 months up to December 2007 ranged from 38.9 per cent in the South Central Strategic Health Authority area to 58.3 per cent in the North East. The new contract aimed at simplifying the payments system, encouraging more preventive work and reducing the ‘drill and fill’ culture in NHS dentistry. The recent statistics [1] seem to show the opposite. It has become so unpopular that many dentists left the NHS altogether. Despite Tony Blair’s pledges in 1999 [3] that everyone would have an NHS dentist within two years, the recent figures confirm that access has not improved. What should the Government do to improve access to dentists? Is going private now the only way of getting good dental care? How can dentists be tempted back to the NHS? 1. NHS Information Centre, Dental Statistics. NHS Dental Statistics for England (Quarter 3: 31 December 2007). http://www.ic.nhs.uk/webfiles/publications/dental0708q3/2007- 08%20NHS%20Dental%20Statistics%20for%20England%20Quarter%203%2C%2031%20December%202007.pdf 2. Ms Rosie Winterton. Written answers for 13 March 2007: Dental Services. Hansard volume (House of Commons Debates) vol 458, col 309W. http://www.publications.parliament.uk/pa/cm200607/cmhansrd/cm070313/text/70313w0031.htm#07031414000020 3. Department of Health. Modernising NHS dentistry – Implementing the NHS plan. London: Department of Health, 2000. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4002931 Competing interests: None declared |
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Philip J Hughes, GP Eastfield Medical Centre, 14 High Street, Eastfield Scarborough YO11 3LJ
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The article raised several important points, but missed out on the opportunity to make a definitive evidence based statement regarding the management of a dental abscess. The cases illustrated the dangers of antibiotic treatment alone. While accepting that prevention is better than cure an educational campaign for dentists, general practitioners and patients would surely have an impact to reduce such significant complications, at the cost however of increasing emergency attendances at Accident and Emergency and hospital admissions. While there remain the folk health views that antibiotics need to be given before surgical drainage; Dentists cannot prescribe antibiotics; and General Practitioners are capable of dealing with dental problems then there will continue to be significant problems like the cases described. Competing interests: None declared |
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