Inequalities in access to NHS primary care dental services in Scotland during the COVID-19 pandemic

This study covers dental contacts with NHS dental primary care services across Scotland between January 2019 and May 2022. The data show that the level of dental contacts fell to a record low shortly after March 2020 during the national lockdown and by May 2022 was still only 64.8% of the pre-pandemic level, with the child population having a slightly higher overall level of recovery (68.6%) compared with the level among the adult population (64.1%). Our findings also show that there was an initial slight widening of relative inequalities in early 2022, with those from the most affluent areas being more likely to receive the more limited available dental contacts. However, by May 2022, this was not quite back to pre-pandemic levels of inequality observed in the levels of dental contacts.11,12

The closure of dental services as part of the initial public health measures taken in response to curb the spread of COVID-19 infection was a widely utilised approach internationally.17 This inevitably resulted in dramatic falls in dental access in many countries. Our results, showing near zero dental access during the first national lockdown, was consistent with data published for England14 and reports from other countries, including Germany,18 France19 and Australia.20 Okike et al. reported that an estimated 365,000 infants in the UK from the previous year birth cohort missed their first dental visit because of the pandemic in 2020.21

There are several potential implications associated with reduced access on this scale. There were several reports of changes in reported oral health risk behaviours during the pandemic,14 including increases in sugar consumption from 8% to 15% in UK households,22 with the corresponding associated potential increases in oral diseases and need or demand for dental services coming at a time of dramatically reduced dental services. However, there is still not sufficient empirical data to assess the full impacts of the pandemic on oral health at the population level.23 Our study begins to contribute to this data and evidence gap providing detailed analysis of access to NHS primary care dental services in Scotland, which, before the pandemic, provided over 90% of dental services in Scotland.12

The assessment of inequalities using the area-based deprivation index has been reliably established in the literature.24,25 The pattern shown from our results suggest that there was an initial widening of relative inequalities in dental access, which have begun to return to the pre-pandemic levels. A USA study reported that the distribution of caries preventive services became less accessible to children from low-income families (39%) during the pandemic compared to those from the higher-income families (46%).26 The Childsmile national child oral health improvement programme for Scotland provided preventive services in multiple settings, including community, nursery, and school, as well as via NHS dental practices.27 These have all been substantially impacted by the pandemic13 and are likely to also have knock-on impacts on child oral health and further exacerbate persistent child oral health inequalities.

In addition to dental service supply side factors, there are multiple other factors likely associated with the reduction in dental care utilisation during the pandemic, which are also interlinked with the root causes of health inequalities.28 Aside from public health-related restrictions during the lockdown, the worsening socioeconomic situation for many individuals and other factors, such as perceived barriers and changes in health behaviours, might have also contributed to the reduction in dental access.29 The ability to access and travel to healthcare services during the pandemic was influenced by individuals' perception of need and risk.29 Even when there was a provision for urgent dental care, people were caught in between the decision to attend dental services or stay away to avoid getting infected with COVID-19.

Overall, our results describe the trends in access to primary care dental services in Scotland and associated inequalities during the pandemic. The strength of our study lies in the high quality, completeness and national coverage of NHS Scotland primary dental care services and its associated claims data,12 which were available for analysis on a monthly basis. However, this study is limited in not including other types of dental contacts that were increasingly utilised during the pandemic, such as the NHS 24 services, hospital dental services, urgent dental care centres, and tele-dentistry (internet or web application communications).30 Moreover, there are no available data on the levels of private dental services provided during or indeed before the pandemic, which are likely to vary for different socioeconomic groups. Analyses also did not include information on the nature of dental treatment provided within the contact.

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