The recent British Dental Conference and Exhibition was the setting for a Colgate Oral Health Network session entitled ‘Improving Periodontal Health in Practice: Preparing for care pathways and skill mix’
The session was chaired by Eric Rooney, consultant in dental public health, and chair of Pathway Review Group. Eric gave some background to the context of care pathway approaches within the ongoing pilots and what this may mean for the future.
Last October, it was announced the number of pilot practices would be increasing to around 100, and the original pilot sites will continue for a further year. Early learning from original pilots can be viewed at the Department of Health web site (www.gov.uk/government/publications/extension-to-dental-contract-pilot-scheme) and states: “Significant challenges remain, but both dental staff and patients have been overwhelmingly positive about the new approach to clinical care seen in the pilots. Further development is needed but we think a pathway approach should form a key part of any future contract.”
Eric went on to share a summary of what this means for the two groups of the population covering routine and urgent care. Routine care patients undergo an oral health assessment and receive tailor made prevention advice, dependant of the level of risk, using Delivering Better Oral Health guidance document for evidence based patient home care and dental professional interventions.
Anousheh Alavi,specialist in periodontology and Colgate scientific affairs manager, UK & Ireland then delivered the main session. Anousheh was involved in training the phase one pilot practices with regards to the perio pathway, and is also a member of the group reviewing care pathway outcomes after the first year.
She said she was looking to take the audience on a journey specifically in relation to periodontal care, and how to make use of skill mix.
The Periodontal Care Pathway builds from three domains of information:
- Medical and social history, such as level of diabetes control and whether the patient is a smoker.
- Clinical examination, including basic periodontal examination.
- Other key factors which influence level of risk, such as plaque score and extent of bleeding on probing (BOP).
Since pocket depths are historical, BOP is a more a current reflection of the extent of inflammation present. Using the traffic light system, the measurements taken will determine the patients overall level of risk.
All patients, irrespective of risk, require motivation and oral hygiene instruction. The latest Adult Dental Health Survey gives us broad measures at a population level and shows 66 per cent of the adult population have visible plaque. The main point of trying to prevent periodontal disease is to remove the cause, and unless we have some measure of how much plaque there is to start with, we cannot assess risk and make a correct diagnosis. Also the treatment plan will not reflect the true level of risk that patient has.
Anousheh asked how we are going to deliver the advice to motivate patients, and what the appropriate oral health advice is. To deliver an optimum level of care, we need to combine evidence based information, patient factors and our clinical judgment. When all three elements come together, we deliver optimal care. We all have patients who are given advice without them acting on it. The key point is not just the delivery; we have a duty of care to ensure it works for our patients. The good news is Delivering Better Oral Health guidance also states the level of evidence which should give us confidence in the likely outcome when we transfer this information to our patients.
Adapting the perio care pathway to a team approach demonstrates how different team members can play key roles in overall patient care. If we take this to be a standardised way of delivery, in order to make the most of the team, we can identify any training gaps to fulfil now and so optimise what we can deliver both now and in the future. In terms of patient outcome, focusing on prevention utilising skill mix is the best practice model.
Where do we go from here? Following feedback the pathways are continually refined. Conveying evidence based advice to patients, making it accessible to them is important for us to share and discuss in order to optimise patient delivery within our practice settings.
References available on request.