25 Jul Drilling down into childrenâs dental health
Parents who trot their children in and out of their local dentistâs surgery once or twice a year and pay for the privilege, might be forgiven for forgetting that thereâs free dental care for all under 16s â in theory at least.
In reality, the current public dental service is so chronically underfunded and limited in what it can offer children, that informed parents, with the financial means, make their own arrangements with private dentists. Thatâs not to say they donât welcome the opportunities for free examinations and follow-up care that comes their childrenâs way, probably twice during their time at primary school.
At the severe end of the spectrum, it is estimated there are thousands of children on waiting lists for teeth extractions under general anaesthetic, who may be on multiple courses of antibiotics in the meantime. Approximately 7,000 children a year, according to the Health Service Executive, are referred for this treatment in 20 acute hospitals.
The HSE reports a very high uptake of its routine dental services available through the universal school programme. âOften in excess of 95 per cent of children are screened and offered follow-up treatment where indicatedâ, according to a spokeswoman, who adds it is planned to see 162,336 children as part of the school programme this year.
But with dental decay affecting at least one in three children by the age of five and the HSE routine services not kicking in until targeted screening at second class in school (age seven/eight) and, typically, not then repeated until sixth class, itâs clearly too late and too little. (In some parts of the country fourth-class children are also invited to attend their local HSE dental clinic.)
Before and after these ages, children only have access to emergency care for the relief of pain (eg toothache) and infection in the public service. Approximately 70,000 children attend for emergency treatment annually, with figures up 4.5 per cent this year. In most of those cases, whatâs essentially a preventable disease has become a crisis at a very young age.
In this scenario, and with a quarter of a century having passed since the last dental âaction planâ, thereâs universal agreement that the National Oral Health Policy, Smile agus Slainte, was long overdue when it was jointly launched by the Ministers for Health and for Employment and Social Protection in April. Its focus on prevention is also widely welcomed.
After that, the views of the policymakers behind the document and the association representing the majority of the professionals whose job it will be to implement it, diverge sharply. Currently, more than four-fifths of all dental care is paid for privately and only 14 per cent is funded by the State.
On paper, what is proposed in the new policy is likely to appeal to parents. Eight preventive oral healthcare packages, each over two years, are promised for everybody between the ages of 0 and 16. These will focus on prevention and primary care such as examinations, preventive advice, fissure sealants and fillings.
Instead of going to the local HSE dental clinic, parents or guardians will be able to choose a dentist for the delivery of these packages to their child. The concept promoted is that of establishing a âdental homeâ early on in a childâs life.
The pre-schoolers are being prioritised in the first phase, with the Department of Health saying it aims to have the 0-6 care programme available by 2020.
âThe policy wonât be judged on what it promises, it will be judged on what it delivers,â says Dr Kieran OâConnor, chair of the general practitioners committee of the Irish Dental Association, who served as the associationâs president last year. The association argues that the â¬80 million-plus funding proposal for implementation of the policyâs services is âtotally unrealisticâ and will make it unworkable.
âPrivatisingâ the system
OâConnor, based in Youghal, Co Cork, questions what the thought process could be for âdismantlingâ a public system that, despite its constraints of under-staffing and lack of resources, has a team of dentists in 220 locations around the country, very committed to, and good at, treating children. âItâs almost privatising the system â although they wonât like that language,â he remarks.
The chief dental officer in the Department of Health, Dr Dympna Kavanagh, who has led the team developing the new policy, rejects the word âdismantlingâ. If the salaried service wasnât so good, âwe would not be in a position to move forwardâ, she tells The Irish Times.
The plan to divert routine childrenâs treatment to primary care and to assign a greater number of more vulnerable adults and some special needs children to public service dentists is not a reflection of what they are doing, she says, âbut rather that we feel they should be given a wider remit and an opportunity to use their skillsâ.
All international research indicates that âyou donât use a salaried service for primary care services, for very pragmatic reasons â they can provide much more time and energy in providing for vulnerable peopleâ, she adds.
This perspective does not seem to have been conveyed to, or at least accepted, within the ranks of the public dental service. âIf you talk to the HSE dentists, they say we will be the dumping ground for all the stuff you canât get somebody else to do â be it the children that canât find dentists to take them, or the residents of nursing homes who need to be assessed,â says one senior HSE dentist.
Whether or not there will be enough private dentists in the right places willing and able to take over the routine care of children from their public service colleagues is unknown. Nobody has asked the nationâs dentists if they would be prepared to take on children, says Gillian Smith, a general dentist working in Bray, Co Wicklow.
âLots of dentists donât treat children and if they donât want to treat children, they probably shouldnât,â she says. âThe dentistry of children isnât complicated but the behaviour management is.â
Smithâs practice has naturally evolved as a centre for children, nervous adults, special needs children and adults, so she would have more in that line than most general practice. She believes the extra time needed for treating children has been overlooked in the plan to transfer the HSEâs child cohort to private surgeries.
âThey vary immensely. You could have a six year old who hops up in the dental chair. Typically, the parents have no dental anxiety; there is great expectations about going to the dentist â no cavity, no pain. They open their mouth, you have a look, there is no treatment needed, you give them a sticker and everybody is happy.
âOn the flip side, you have a child who has pain in their mouths, who wonât even open their mouths, never mind sit in the chair. You might be talking an hour before you get a look in their mouth, after playing with them. It might take three visits to do an X-ray.â
Smith says she has tried to see the positives in the new oral health policy and, to this end, singles out the focus on prevention and the move to more involvement with general, community-based practices.
âBut the implementation of it is a disaster from start to finish and I think, unfortunately, it is doomed to failure because of that. Even if there are good ideas within it and good aspirations, I canât see it being…