| Sign In to gain access to subscriptions and/or personal tools. |
Is School Dental Screening a Political or a Scientific Intervention?
1 Halton & St Helens Primary Care Trust, Victoria House, The Holloway, Runcorn, Cheshire WA7 4TH, UK; Correspondence: * corresponding author, keith.milsom{at}hsthpct.nhs.uk
Key Words: School dental screening • political • scientific "The attack on disease must not be meddlesome; the desire to do something must be guided by sure argument that good will come of it." (Gibson, 1933) School dental screening is a popular public health intervention in many countries throughout the world. It has also proved to be a particularly enduring intervention. In the UK, school dental screening has been a statutory requirement for almost one hundred years (Milsom, 2004). Why are politicians, health care policymakers, and planners so attracted to the concept of school dental screening? Is their confidence in the dental screening process well-placed, or is their faith in this dental public health intervention ill-founded? POLITICAL HISTORY OF SCHOOL DENTAL SCREENING School dental screening in England has been a statutory activity since 1918 (Milsom, 2004), and, with the exception of the 2003 Water Act, it is the only dental intervention in the UK that is supported by an Act of Parliament. The earliest call for the dental inspection of children in the school setting came in 1885, when William Fisher, a Dundee dentist, called for the "compulsory attention to the teeth of school children" (Fisher, 1885), but it was a further 8 years before political interest was awakened in this subject. In 1903, young men returning to the UK from the Boer War in South Africa were found to have poor levels of general and dental health. This observation prompted the Government to introduce mandatory school dental inspections (Department of Education, 1907). Eleven years later, in 1918, a further Education Act introduced a mandatory treatment component (Department of Education, 1918), and in 1944, the legal basis for the delivery of public dental services for children in state-maintained schools was established (Department of Education, 1944). The National Health Service was introduced in 1948. This landmark development promised health care, free at the point of delivery, for everyone living in the UK, and it held up the prospect of universal access to free dental care. It would not be unreasonable to expect that the introduction of this service, with the guarantee of free dental services for children, would have signaled the end of political interest in school dental inspections. In fact, over the ensuing 50 years, political interest in this dental public health intervention not only continued but intensified. In 1964, The Draft Model Scheme called for school dental inspections "annually throughout a child’s life" (Report of the Chief Medical Officer of the Department of Education and Science, 1962 & 1963). Fifteen years later, The Royal Commission on the Health Service suggested that, in addition to inspecting children in state-maintained schools, the annual dental inspection should include pre-school children (Department of Health, 1979). In the mid-1980s, there was a period of political reflection about the merits of this dental public health activity, and in 1986, a Government discussion paper suggested that "the need for routine school dental inspections is now less clear" (Department of Health and Social Security, 1986). However, following a robust defense by the British Dental Association (1987), the Government once again re-affirmed its commitment to the statutory school dental inspection (Department of Health, 1988), although the frequency of inspection was expected to reflect local levels of child dental health. In 1987, the term ‘school dental inspection’ gave way to ‘school dental screening’, although there was little evidence that the change of name led to any change in the nature of the activity (Milsom, 2004). A Government policy document in 1989 (Department of Health, 1989) reinforced the position that dental screening was a core activity for the public dental service, and the position was further underscored 8 years later in a revised Government circular (Department of Health, 1997). In 2000, the Government’s Health Plan identified that school dental screening was "not working at its best throughout the country", but pledged to address the shortfall by the introduction of a "new national protocol....setting out clear aims and objectives for school dental screening" (Department of Health, 2000a). It is clear that UK Government policy has been a key driver of school dental screening throughout the twentieth century. Regular reviews have examined its merits, and policy has, at various times, called for more and less activity. There has always been a sense that screening was in need of slight modification to get the process working optimally, but the overriding signal consistently sent by policymakers was that school dental screening was essentially a ‘good idea’. THE ROLE OF SCHOOL DENTAL SCREENING Despite its continuous support, the UK Government has always been unclear about the function of the school dental inspection. In 1918, the view was that dental inspections involved detection of disease to secure treatment. At this point in history, large numbers of schoolchildren had active decay, and few had access to a dentist. By 1988, 40 years after the introduction of the National Health Service, most children had access to a family dentist, and the dental inspection, instead of being ‘stood down’, was quietly reclassified as the vehicle for identifying children who were not in receipt of regular dental care. The introduction of the term ‘dental screening’ in 1987 suggested that the process of school inspection was perhaps associated with the early detection of disease—the medical model. By 1990, a national dental capitation system for children had been introduced within the National Health Service. This development created another potential role for school dental screening, i.e., the stimulation of registration with a dentist. Throughout the twentieth century, the function of school dental screening was never truly defined. In securing its continued existence, policymakers found themselves adopting a pragmatic approach, subtly adjusting its function to meet the changing needs of the dental landscape. IS POLITICAL OPTIMISM IN MEDICAL SCREENING WELL-PLACED? It is apparent that, for almost 100 years, fulsome UK political support for school dental screening has been based on a limited and shifting understanding of the process. Successive political administrations have felt that they were able to finesse the process of school screening to optimize its effectiveness, and lying at the heart of successive policy developments has been the sense that school dental screening, despite its possible failings, felt like ‘the right thing to do’. This ‘blind faith’ in the screening process is not confined to dental policymakers. Within the wider UK medical field, there is an irrational sentimentality about screening that has been identified in the scientific literature: "There is a tendency to assume that if screening is carried out, all will be well. This is a damaging fallacy. Every proposed screening programme must be rigorously examined against clear criteria....The decision to screen for any condition should be undertaken as a hard-headed professional exercise rather than a form of ‘feel good’ evangelism." (Holland and Stewart, 1990) Is this misplaced policy optimism about screening confined to the UK? In 2003, the World Health Organisation published the following statement about school dental screening: "Screening of teeth and mouths enables early detection, and timely interventions towards oral diseases and conditions, leading to substantial cost savings. It plays an important role in the planning and provision of school oral health services ..."’ (World Health Organization, 2003) At the time of this publication, there was no scientific evidence to show that school dental screening led to timely interventions, or that it led to substantial cost savings. Are we able to say that the WHO position on school dental screening is ‘hard-headed’, or is the WHO position a triumph of hope over expectation? In 2006, California legislation made school dental screening a requirement of first-year attendance in public school (California Department of Education, 2007). The goals of the screening program are:
The California legislation requires health districts to collect data on the number of children screened "in order that an annual report can be compiled", but it does not require collection of information on whether children identified as being in need of dental treatment are actually seen or treated by a dentist. Clearly, the monitoring system in California is unable to identify whether children access appropriate dental care, one of the stated aims of the program. Have the California policymakers settled for "feel good evangelism" in developing their dental screening program? WHEN SHOULD MEDICAL SCREENING BE IMPLEMENTED? Within the National Health Service, we screen for over 300 different conditions (Department of Health, 1998). Can all this activity be justified? Some commentators urge caution: "The mere existence of unrecognised cases of illness is, by itself, insufficient reason to screen. Disease has many faces and the hunt is not benign" (Berwick, 1985). Others point out the need for politicians, policymakers, planners, and health care workers to have a clear understanding of the benefits and disadvantages associated with screening before embarking on screening programs: "Some knowledge of the principles of screening and of what it entails in practice should form part of the intellectual equipment of all concerned with the control of disease and the maintenance of health" (Wilson and Jugner, 1968). There are important ethical considerations that need to be dealt with before screening programs are introduced: "Screening stands apart from traditional medicine in that it seeks to detect disease before symptoms present and before individuals decide to seek medical advice. As a consequence screening carries considerable ethical responsibilities since it has the potential to move an individual from a state of supposing himself to be healthy to a state of having some disorder" (Holland and Stewart, 1990). Some say that screening without informing participants of the risks/benefits is unethical (Skrabanek, 1988). Cochrane and Holland (1971) have perhaps captured the essence of the ethical argument that underpins any screening program: "We believe that there is an ethical difference between everyday medical practice and screening. If a patient asks a medical practitioner for help, the doctor does the best he can. He is not responsible for defects in medical knowledge. If, however, the practitioner initiates screening procedures he is in a very different situation. He should, in our view, have conclusive evidence that screening can alter the natural history of the disease in a significant proportion of those screened." THE DEFINITION OF SCREENING Medical screening traditionally has sought to identify disease or pre-disease conditions in apparently healthy individuals. Numerous definitions have been developed over the years, but perhaps the most well-used is the one proposed by the US Commission on Chronic Illness (1957): "The presumptive identification of unrecognized disease or defects by the application of tests, examinations and other procedures which can be done rapidly. Screening sorts out apparently well persons who may have disease from those who probably do not...." This definition, while tried and tested, focuses on the screening test itself rather than on the whole process of improving health via a screening intervention and as such fails to emphasize the need to measure potential health gains associated with such programs. In 1996, the UK National Screening Committee (NSC) was set up. Its role was to advise the UK Government on all existing and new screening programs. In 2000, the NSC brought forward a new definition of screening: "A public health service in which members of a defined population who do not perceive they are at risk of or are already affected by a disease or its complications are asked a question or offered a test to identify those individuals who are more likely to be helped than harmed by further tests or treatments to reduce the risk of disease or its complications" (Department of Health, 2000b). The importance of the NSC (2000) definition lies in its acknowledgment that screening is not just a test, but rather it should be thought of as a series of interlinked steps that begin with the identification of the ‘at risk’ population and ends with effective treatment for those screened positive. This definition provides a simple framework for the effectiveness of medical screening to be measured scientifically, based on the following steps:
The National Screening Committee also set out clear criteria for evaluating the mechanics of the whole of the dental screening process and in so doing provided us, at long last, with a scientific methodology for the evaluation of individual screening programs. By ‘benchmarking’ screening programs against these essential criteria, it is possible to evaluate the merits of individual screening programs scientifically:
EVALUATION OF SCHOOL DENTAL SCREENING IN ENGLAND Based on the National Screening Committee evaluation framework, it is possible to appraise the school dental screening program. In England, in the 1990s, school dental screening was organized and delivered by 300 autonomous Community Dental Services (public dental services), each led by a Clinical Director. In 1995, the Clinical Directors in post were asked several questions about the delivery of their school dental screening programs (Mander, 1995).
(1) What Do You Understand by the Term ‘School Dental Screening’?
(2) For Which Conditions Should Children be Screened in the School Setting?
(3) Is the Process of School Dental Screening Quality-controlled? Consequently, in 1995 in England, those responsible for delivering school dental screening could not agree on:
Most importantly, Clinical Directors had no evidence that dental screening improved the dental health either of the population or of those individuals screened positive. Notwithstanding this lamentable state of affairs, the school screening program in England had enjoyed 90 years of ‘blind’ policy support. Mander’s review (1995) concluded that there was:
The review’s recommendation was that there should be a formal evaluation of the effectiveness of school dental screening in terms of health outcomes. EFFECTIVENESS OF SCHOOL DENTAL SCREENING In 2002, the Oral Health Unit of the National Primary Care R&D Centre embarked on a four-arm cluster RCT to test the effectiveness of school dental screening. The aim of the study was to determine whether school dental screening reduced untreated disease in a population of children living in Northwest England. The study objectives were to:
In total, 17,000 children aged 6–9 years attending 169 schools in a deprived community in Northwest England formed the eligible study population. The results of this RCT have been published elsewhere (Milsom et al., 2006a,b); however, the study found:
The conclusions drawn from the study were that school dental screening:
The study results were considered by the UK National Screening Committee (NSC) in 2005. The NSC recommended to the Department of Health that school dental screening should not be supported in England, and in 2007, the Department published guidance to health bodies recommending that school dental screening cease in England (Department of Health, 2007). SUMMARY School dental screening has enjoyed considerable political support in the UK, and in many countries throughout the world, school dental screening is seen as a key dental public health intervention. The evidence from the UK and elsewhere is that while the concept of dental screening is attractive to policymakers, there is no scientific evidence that it leads to improvements in health, either for individual children or for the child population. It is quite possible that school dental screening may be effective in other settings within other countries, and there is now available a simple methodology for the evaluation of such schemes. If the screening of schoolchildren is to be successful, then policymakers need to be clear that this activity cannot be regarded as a ‘planning comfort blanket’, and that there needs to be a clear understanding of the strengths and weaknesses of any screening program. The scientific community has a key role to play. The evidence base for school dental screening is weak, and more country-specific research is required. Our understanding of the role of dental screening is now well-developed, and with this comes the opportunity for those countries with dental screening programs to evaluate them scientifically. Once the data become available, there is an expectation that science will begin, at last, to inform policy in this area of dental public health. Received for publication October 30, 2007. Revision received April 25, 2008. Accepted for publication June 27, 2008. REFERENCES
Journal of Dental Research, Vol. 87, No. 10,
896-899 (2008) This article has been cited by other articles:
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
 |
|
|
 |
|
Sign In to gain access to subscriptions and/or personal tools.
