Dr Katharine Julia Hurry considers how we can work together to understand the dental needs of asylum-seeking and refugee children in north central London.
As the cost of living crisis makes routine dental care unaffordable and experts warn of exacerbated inequalities in dental decay (Lacobucci, 2023), the rights of the child to oral health have never been more pertinent. Dental decay is socially patterned, disproportionately affecting families living in deprived areas and children from ethnic minority backgrounds (Rodd et al, 2014).
As families find purse strings tightening, many are facing the choice between buying toothbrushes and toothpaste or providing food and heating for their families (Lacobucci, 2023).
Unsurprisingly, tooth decay prevention may not be a priority for many families across the UK.
Asylum-seekers and refugees (ASR) are particularly vulnerable to health inequalities (Paisi, 2020). In the year ending September 2022, 85,902 asylum applications were made to the UK. Of these, 17% were from children aged 17 years and under, according to Home Office statistics.
On arrival in the UK, ASR are placed in initial accommodation centres (IAC), and each person is provided with £40.85 per week to spend on food, clothing and toiletries including toothbrushes and toothpaste (with additional payments of £3-£5 per week for pregnant women and children under three-years-old).
Urgent priorities
ASR placed in accommodation where meals are provided receive less than £10 per person.
ASR face significant barriers to accessing healthcare. This includes competing and more urgent priorities around ill health and social need, language barriers, affordability, awareness of and difficulties navigating the complexities of the NHS system, and transience of accommodation and location (Paisi, 2020, 2022).
Research has found higher rates of dental decay in ASR children (36-87.8%) (Sarri et al, 2012, Coyle et al, 2016, Banerjee et all, 2019) compared to the national average in England (23.4% of 5-year-olds had visible decay in the school year 2018-2019).
A school-based study in a deprived area of the UK found that ASR children (ASRC) have high rates of dental neglect (58.5%), and greater requirement for dental treatment (58.3%); compared to non-refugee children where it was reported as 39.5% and 44.9% respectively (Sarri et al, 2012).
Despite being entitled to free NHS dental treatment like all children in the UK, ASRC have greater rates of unmet dental disease.
Outreach services
Inclusion health services aim to meet the needs of people who are socially excluded, experience multiple overlapping risk factors for poor health (such as poverty, violence and complex trauma) and are subjected to stigma and discrimination. These people are often not consistently accounted for in electronic records (such as healthcare databases).
Respond, an inclusion health service based at University College London Hospital (UCLH), has collaborated with the Dental Wellness Trust (DWT), to provide outreach dental services to ASRC in IAC across North Central London (NCL).
Respond offer holistic health screening to ASR of all ages placed in contingency accommodation across four boroughs. Individuals are screened by a health care professional for physical and mental health needs, as well as social and safeguarding issues; they are also asked about access to dental care, oral health adjuncts and presence of dental pain (Farrant, 2022).
Active signposting to NHS dental services is provided, as well as direct referrals into DWT ASRC clinics at either the Greenwall Dental practice or via outreach dental work in IAC sites.
Lack of dental visits
Of the 78 children screened by Respond between July 2021 and 2022, only 34.6% of children met the NICE recommendation of having seen a dentist in the last 12 month; lower than the national figure of 48.5% of children having visited a dentist in the previous 12 months.
More than one in five ASRC had not seen a dentist for more than 36 months (23.1%). Most children had access to a toothbrush (71.8%). However, just above half reported regular tooth brushing (53.8%).
Furthermore, 6.4% reported to being in dental pain with two ASRC being sign posted to emergency dental help. During just one half-day clinical session for the Respond cohort, the DWT team were able to provide 14 examinations, 32 restorations, 24 fissure sealants, eight fluoride varnish applications and two extractions, as well as six applications of sliver diamine fluoride.
The unmet dental need within recently arrived ASR children is deeply concerning for all those working in child medical and dental health. Respond and the DWT feel strongly that access to dental health services is a basic ‘right of the child’, regardless of migration status.
While Respond is an NHS service, the DWT relies on the time and effort of their dental care professional volunteers to offer free sessions to address dental needs and ‘save the teeth’ of this patient cohort.
Services that rely simply on the good will of volunteers are rarely scalable and sustainable in the long term. Respond and the DWT are united in their belief that tackling dental health inequalities in the most vulnerable populations can only be achieved through innovative cross-healthcare collaboration systems.
Medical teams must work alongside dentists, third sector professionals and policy makers to design and deliver inclusive and integrated care.
‘Pivotal role’
By involving and engaging individuals with lived experiences of exclusion in service development, optimal pathways can be developed with a focus on overcoming the barriers faced by the populations who use them.
Inclusion oral health frameworks to help people marginalised by social exclusion have also been recommended and can assist commissioners in future planning (Freeman, 202).
The NHS England national initiative ‘Core 20 plus 5’ aims to tackle health care inequalities. It focuses on the most deprived 20% in England plus ICS-chosen population groups, eg inclusion health groups and five clinical areas requiring accelerated improvement.
Tooth extraction under general anaesthetic is the most common reason for hospital admission in five to nine year olds. Oral health has been selected as one of these five clinical areas.
‘Core 20 plus 5’ is targeting the backlog for tooth extractions in hospital for under 10s. It priorities collaboration, including within dental services and providing enhanced prevention to vulnerable or high-risk children including ASRC (Holland, 2023).
Dentists and their teams play a pivotal role in recognising and responding to the dental needs of asylum-seekers and refugees. As the UK finds itself amid unprecedented need, now is the time for dentists to volunteer. Not only for their expertise but also their voices to address inequalities and advocate for more inclusive models of care.
References:
- Iacobucci G (2023) How the cost of living crisis is damaging children’s health, BMJ 380:o3064
- I felt weird and wobbly.’ Child-reported impacts associated with a dental general anaesthetic. Br Dent J 216, E17
- Iacobucci G (2023) Children’s oral health is ‘national disgrace,’ says head of royal college, BMJ 380 :p5
- Paisi, M, Baines, R, Burns, L, Plessas A, Radford P, Shawe J, Witton R (2020) Barriers and facilitators to dental care access among asylum seekers and refugees in highly developed countries: a systematic review. BMC Oral Health 20, 337
- Paisi, M., Baines, R., Wheat, H, Doughty J, Kaddour S, Radford P J, Stylianou E, Shawe J, Witton R (2022) Factors affecting oral health care for asylum seekers and refugees in England: a qualitative study of key stakeholders’ perspectives and experiences. Br Dent J
- Sarri G, Evans P, Stansfeld S, Marcenes W (2012) A school-based epidemiological study of dental neglect among adolescents in a deprived area of the UK. Br Dent J, 213(10):E17
- Coyle R, Bowen S, Mullin S, Sayer N, Siggers G, Bennett S (2016) Physical and mental health needs of unaccompanied children seeking asylum: a descriptive analysis in Kent, UK Vol. 388, The Lancet
- Banerjee T, Ajmal S, Khan A, Arora R (2019) Health needs of unaccompanied asylum seeker children- observations from initial health assessment in community paediatric clinic, British Association for Community Child Health and British Paediatric Respiratory Society
- Farrant O, Eisen S, van Tulleken C, Ward A, Longley N (2022) Why asylum seekers deserve better healthcare, and how we can give it to them? BMJ, 376: n3069
- Freeman R, Doughty J, Macdonald ME, Muirhead V (2020) Inclusion oral health: advancing a theoretical framework for policy, research and practice, Community Dent Oral Epidemiol, 48(1):1-6.
- Holland, C (2023) A new dawn for oral health services for children and young people? Br Dent J 234, 211–212
