A Review of Specialist Paediatric Dental Services ABMU Health Board
Author:Hugh Bennett, Consultant in Dental Public Health
Date: 28.02.11 / Version:1
Publication/ Distribution: Director of Planning ABMU HB
Review Date: N/A
Purpose and Summary of Document:
Inform Service Planning
Work Plan reference:
Support of Health Board- Service Development
Author: Hugh Bennett, Consultant in Dental Public Health / Date: 28.02.2011 / Status: Final
Version:1 / Page: 1 of 15
National Public Health Service for Wales / A Review of Specialist Paediatric Dental Services ABMU Health Board
A Review of Specialist Paediatric Dental Services ABMU Health Board
1.Purpose
1.1In June 2010, the Director of Planning of Abertawe Bro Morgannwg University (ABMU) Health Board requested that the local Consultant in Dental Public Health, Public Health Wales, review ABMU Specialist Dental Services.The review assessed the current state of these services and made a set of recommendations to inform planning.
1.2The Review was reported on 27th October and its recommendations wereaccepted by the Executive. Recommendation 9 stated that there was a need to specifically review provision of Specialist Paediatric Dental services.
2.Background
2.1ABMU Health Board has the responsibility to ensure provision of primary care dental services to its local population. It will also have the responsibility, as set out in the Ministerial Letter EH/ML/014/08 Dental Services for Vulnerable People and the Role of the Community Dental Service, to ensure –
- that vulnerable people have access to appropriate dental care through delivery of comprehensive services
2.2The Specialty of Paediatric Dentistry may be defined as-the practice, teaching and research into thecomprehensive and therapeutic oral health care for children from birthto adolescence, including care for children who demonstrate intellectual,medical, physical, psychological and/or emotional problems.
2.3Paediatric Dentistry covers allaspects of oral health care for children.The rationale for this distinction ofPaediatric Dentistry is that children areunique in their stages of development,oral disease, behaviour and oral health needs. Paediatric Dentistry emphasisesthe integration of appropriate didacticand clinical knowledge from the variousdental and medical specialties into aframework for the comprehensive oralhealth care of children.
The context of this review has recently changed with the ABMUHealth Board’sdecision to plan a phased reduction of child dental general anaesthetics provided through a contract with Parkway Clinic, SA1.
2.4In 2008 the Welsh Assembly Government published the All Wales
Neonatal Standards for Children and Young People's SpecialisedHealthcare Services.The standards in thisdocument are universal andapply to allchildren, and young people’s specialised services. It is worthwhile directly quoting what this document states on Dental Care:
It is important to recognise that oral healthcare is a significant consideration for all children and youngpeople and, because of their medical conditions, many of the children and young people requiring specialised healthcare services may:
- be at higher risk of oral disease and oral complications
-be at higher risk when treated for oral disease e.g. children with respiratory disordersrequiring general anaesthetics and children who have had cardiac surgery
-have particular problems that make the management of their dental treatment difficult,e.g. there may be associated learning disabilities.
Prevention of oral and dental disease is therefore highly desirable for this group ofchildren and thus preventative oral healthcare advice should be part of every child’s overall care plan so that families and carers are
well informed as to the specific risks for each child. Specific oral assessment and care shouldalso be available where appropriate.
To facilitate this, it is essential that the dental team is considered an integral part of themultidisciplinary approach advocated throughout this project and there should be a named dentist with specialised skillsand knowledge in the oral healthcare of childrene.g. a Specialist in Paediatric Dentistry linked to each large District General Hospitalto provide support and advice to the broader teams and ensure referral of children for appropriate healthcare.
3.The Need - Oral Health of Children in ABMU
3.1Profiles of Oral Health for the ABMU and Hywel Dda areas were compiled by Public Health Wales in December 2009, and may be accessed on the Public Health Wales website.
3.2The Key Points in regard of child oral health described within the ABMU Profile are –
Dental caries is not inevitable, it is preventable
- The rate of improvement in dental health of 5 year old children has halted.
- In 11 of the 17 Upper Super Output Areas (USOA’s) the dmft for 5 year olds is worse than the Wales average
- In 11 of the 17 USOA’s the percentage of the 5 year olds with experience of tooth decay is worse than the Wales average
- Marked correlation between levels of child dental decay and social deprivation
- At USOA level, in all 3 Locality areas marked inequalities in oral health exist
- Approximately 2100 general anaesthetics annually are given to children from ABMU area for removal of teeth.
- The distribution of dental caries in the general population is markedly skewed, with a minority of individuals experiencing disproportionate amounts of decay.
Challenges for the LHB
Addressing the inequalities in child oral health through identifying pockets of deprivation and targeting oral health improvement programmes and dental services.
Focusing on improving child dental health, to develop healthy cohorts into the future to meet WAG targets.
Ensuring NHS dental resources are prioritised e.g. in the context of high levels of child tooth decay amongst your poorest communities.
Additional information
- Cleft births per year 1 in 6-700 live births
- Craniostenosis: incidence 1 in 2000 -2500 live births per year
- Hemifacial Microsomia: incidence 1 in 5000 -5600 live births per year
Treacher Collins, Nager Syndrome, Torriello Mandibulofacial Dysostosis each about 1 in 50,000 live births.
3.3The All Wales Neonatal Standards for Children and Young People's
Specialised Healthcare Services estimated that about 1%of the childpopulation in Wales need specialised healthservicesannually.
4.Workforce
Specialist Training
4.1To qualify as a Specialist in Paediatric Dentistry one must complete 3 years of training to gain aCertificate of Completion of Specialist Training (CCST). In order to be eligible for a Consultant appointment a further 2years of training is required.
Local Workforce
4.2The Specialist Paediatric Dental service that is currently provided locally is limited to Consultant provision dedicated to supporting Cleft Lip and Palate (CLP) services within the Maxillofacial Unit at Morriston,(the Consultant “visiting” from the Cardiff Dental Hospital).It is understood that the input equates to 4 sessions for the ABMU cleft team (2 clinical sessions in Cardiff, 1 clinical session in Morriston and 1 SpA).
4.3There is no other Specialist Paediatric Dentalprovision in any of the dental services across ABMU or Hywel Dda Health Board areas. The nearest centre for Specialist Paediatric Dental Services is at the Cardiff Dental Hospital. However, that hospital does not openly acceptreferrals from west of Bridgend. Currently, some HDS Paediatric work outside of that linked with CLP is provided by the Restorative team at Morriston.
4.4Some Community Dental Officers have developed additionalskills in treating child patients (these are not Specialist).
Wales
4.5Consultants - 5 (WTE 2.8)
Specialists - 7
Pre-CCST trainees - 2
UK
4.6Currently there are 234 Specialist Paediatric dentists registered with the GDC that work in a mixture of hospitals and practices throughout the UK. It has been suggested that this number needs to be doubled.
4.7There is also marked geographic imbalance, children in large areas of the UK either having no access to such Specialist services or have to travel considerable distances to access them.This is certainly the case for ABMU and Mid and West Wales as a whole.
5.Current Activity
Maxillofacial Unit at Morriston
5.1An analysis of the activity in clinical areas of the Maxillofacial Unit,provided by the Lead Clinician shows thatthe number of new paediatricpatients seen annually is small,latest figure is127.Of these new patients seen by Restorative,50% will be trauma, about 1 case per week referred by OMFS, (there is a need for some caution regarding these trauma figures because recording methods are weak, but they do provide a reasonableestimate of the activity).
Morriston Hospital Activity
2007-8 / 2008-9 / 2009-10Restorative Paediatrics
(under 16)
i.e.excluding Consultant inPaediatric Dent
New / 95 / 115 / 68
Follow ups / 329 / 307 / 294
Consultant inPaediatric Dent
New / 11 / 7 / 0
Follow ups / 50 / 59 / 59
Source: Morriston Hospital
5.2The Restorative Department has audited its internal figures and concluded that it treats two main groups of younger patients:
a.Those that have suffered trauma to permanent dentition requiring complex endodontic/restorative management – there is an argument that these are best cared for by and under the responsibility of specialist endodontists whose training and experience includes the care of such groups. Also, because these are trauma patients there is always an element of unscheduled care related to the initial treatment. Therefore, this activity is probably best provided by the Restorative Department (RD) that already has a full-time clinical presence.
b.Congenital dental abnormalities– currently some of these cases are seen on joint clinics primarily with Orthodontics and CLP/OMFS.The Lead Restorative Consultant considers that, initially theclinical demands of these patients tend to be straightforward but then become more complex as RD provides more long term rehabilitations. Case planning isthe key issue, particularly as these patients enter adulthood. Some require only routine care and RD currently liaises with CDS/GDS for this to be provided. There might be some advantage to involving aConsultant Dental Paediatrician duringthe treatment planning,but the demands would not be substantial.
RD also reported that it is not asked to be involved in a significant number of children with complex medical histories other than Special Care Dentistry cases requiring GAs. These cases areat the extreme end of the case management spectrum, but usually theactual dental treatmentis not complex.
5.3The Consultant Dental Paediatrician’s contribution is primarily delivered through her work advising on joint clinics with Maxillofacial and Orthodontic colleagues. The number of children actually treated by the Consultant is low.That said, with regard to the cleft service for South Wales, Specialist Paediatric Dentistry has, in a short time, made a significant impact on dental disease in these children and the outcomes of their holistic care.
5.4However, the aboveis probably an underestimate of the number of children who would benefit from specialist paediatric dentistrybecause some children may not be referred because paediatricians, GDPs and GPs know the service capacity is not available.
Cardiff Dental Hospital
5.5Some children from ABMU and Hywel Dda are treated at the Cardiff Dental Hospital. Families attend form West Wales because their childrenare oncology patients in Cardiff. Others are seen because the children have a syndrome e.g. Noonans syndrome. The numbers of new and follow up patients from Swansea, Neath Port Talbot, Carmarthen, Pembrokeshire and Ceredigion are very small. Data provided for the Bridgend Locality for the first half of 2010-11,showed new patients are in the order of 20 with 100 follow ups..
5.6Recent examples of patients going to the Dental Hospital from West Wales and Swansea areas are:
- A 6 year old boy who has a medical history, including a complicated cardiac problem,needing treatment for decayed permanent teeth. He is unco-operative and will not allow a full examination by his GDP. The referral requested treatment under sedation or general anaesthesia.
- A 14 year old girl, referred by her Community Dental Officer, who has a complicated medical history of primary Sjogrens, renal problems and arthritis. This patient requires dental treatment in her permanent teeth and then treatment planning regarding the teeth she has already lost due to dental decay.
5.7It was reported that, on occasions, children from South West and West Wales who require Consultant Dental Paediatrician services cannot access them locally, and cannot access Cardiff, or have considerable problems in being seen in Cardiff.
CDS
5.8As mentioned above the CDS also cares for some children who do require additional clinical skills and experience, but it is not possible to accurately quantify that.
Parkway Clinic
5.9The Parkway issue is discussed in greater depth in Section 6.
6.Discussion
6.1Besides directly providing treatment Specialist Paediatric Dentists can:
- provide a consultation service for dentists in primary care
- work jointly with other dental Specialties and Maxillofacial colleagues
- offer professional leadership, promoting children’s oral health and enabling the development of clinical care networks for the effective and efficient provision of care for children.
- work with health care managers to develop and deliver efficient cost effective strategies for the improvement of the oral health in the child population.
- offer advice and support to healthprofessionals in other disciplines,with the aimof contributing to effective holistic careof children.
Research has demonstrated that children whose dental treatment is planned by Paediatric Dentists are far less likely to require a repeat general anaesthetic for further dental treatment.Managed clinical networks and Clinical care pathways
6.2If,over time, Specialists in Paediatric dentistry are injected into the service, backed up by non-specialist community and GDS practitioners a managed clinical network(MCN) will be required to assist delivery of high quality care to a population across a large geographical area. The All Wales National Standards for Children and Young Peoples’Specialised Healthcare Services (see page 3) views the development of MCNs asa way of ensuring that all Welsh children and young people receive equitable and high quality specialised services wherever they live in Wales. WAG wishes to see formal establishment of MCNs for children and young people in Wales requiring specialised healthcare so they may access services that are -Age appropriate, safe and effective (high quality) care delivered as locally as possible. MCNs can be defined as:
“Linked groups of health professionals from primary, secondary and/or specialistcare, working in a co-ordinated manner, unconstrained by existing organisationalboundaries, to ensure equitable provision of high quality and clinically effectiveservices.”
Parkway Clinic Swansea
6.3It would be remiss not to discuss the child services provided by Parkway Clinic. In comparative and absolute terms, the dental health of children in the region is poor. Both ABMU and Hywel Dda Health Boards have large numbers of children receiving general anaesthetics for tooth extractions. The vast majority are being treated at the Parkway Clinic Swansea through service level agreements with the Health Boards. It is estimated that the annual totals are in the order of 1700 for ABMU and 1500 for Hywel Dda.
6.4Parkway Clinic has indicated that it currently providesapproximately 50 GA sessions, for what it defines itself, as“Special Care Dentistry for Children providing restorative treatment as well as oral surgery”.These are combined ABMU and Hywel Dda numbers.Many of these children will fall into ASA1 but have complex behavioural and management issues.
6.5ABMU Health Board has taken a decision on grounds of anaesthetic risk, to plan a phased reduction of child dental general anaesthetics provided through a contract with Parkway Clinic, SA1. Early information provided to the ABMU Dental Services Strategic Planning Group indicate that the strategy of the Health Board will have three underpinning principlesmanaging the risk -
- To phase out child dental GA provision at Parkway over an 18 -24 month period
- To increase the number of children treated under sedation
- To treat allchild GA cases within DGHs
6.6There should be a fourth underpinning recognised i.e. the local programme of Designed to Smile, the national child oral health improvement initiative. This is rolling out across the whole area primarily targeted at the most deprived areas. Over the next 2-4years, this will begin to reduce the prevalence of child dental decay. The knock on effect should be a reduction in the need for child dental GA services.
6.7Some informal opinions have been expressed about the existing level of inappropriate referrals into Parkway. At one extremeit has even been suggested that the vast majority of the 3200-3500 GA cases could be treated another way.The current provider at Parkway is adamant that the majority of referrals are appropriate, a view generally supported by the wider profession.It is difficult to quantify level of inappropriate referrals without an independent retrospective audit.
6.8In general terms, a modern state of the art, and efficient establishment like Parkway may attract some additional referrals that a less efficient service might not. In addition, as was advised to Swansea Local Health Board by the National Public Health Service (now Public Health Wales) in 2008, the increased use of sedation should be encouraged. Currently all stakeholders are agreed that a proportion of the existing GAs could be treated under sedation instead.
6.9If, for arguments sake, it is accepted that 50% of the current cases could be treated under sedation, and we accept an arbitory5%for inappropriate referrals, ABMU will still face a need to provide in the order of 765 child dental GAs, and Hywel Dda in the order of 675. It should also be noted that, especiallyin a community setting, the unit cost of a sedation case may be more expensive than a GA case, and that individual children who could be treated at a single GA visit may require multiple sedation visits.
6.10Overtime the effects of D2S will further reduce the demand. Data emerging from Scotland, where a similar programme has been in place for longer, shows a marked and statistically significant reduction in the prevalence of child dental decay. This suggests that in ABMU a similar caries reduction and hence reduction in the demand for child dental GAs is probable.
6.11The decision by Cardiff Local Board a few years ago to stop commissioning child dental GAs from Victoria Park Clinic resulted in provision being provided at the Cardiff Dental Hospital and additional load also being placed on Prince Charles Hospital.