Nothing to smile about: Children's dental health suffers due to under-resourced public systems

With the public dental service under-funded, many parents have little option but to pay for private care, says Helen O’Callaghan

JOANNE’S nine-year-old has never been seen by the school dentist. The dental team is due in this year. “But I’m not holding my breath,” she says. “I’ve been taking her yearly to my own dentist since she was four, at €30 a visit.”

Karen believes her daughter — now in third class — won’t see the school dentist for another two years. “This is far too late, for this reason, she has attended privately.”

Alice brought her little boy for an oral health check aged two. It cost €30. “He already has some tooth decay.”

Just some experiences shared by mothers on when asked their thoughts on the HSE school dental check and what they’ve done faced by long waits for screening.

Under the 1994 Dental Health Action Plan, children are entitled to three routine screenings: in first or second class; third or fourth class; and in sixth class (this final check also includes orthodontic screening). But Irish Dental Association (IDA) president Robin Foyle says in practice very few HSE regions have the resources to provide all three screenings. A dentist in Wexford, Foyle says in his area two assessments are generally offered — in third and sixth class. “That’d be pretty common around the country. A HSE source says parts of the Midlands are only getting one screening — in sixth class/first year.”

Cork-based HSE dentist Catherine Lambe confirms second and sixth class are the classes predominantly screened in Cork. “In some areas of the county, we’re getting to fourth as well. In Kerry, second and sixth classes are screened, not fourth — it’s down to staffing levels.”

Foyle says cutbacks are due to recession and — in the last decade — 20% increase in the under-16 population and 20% decrease in numbers of dentists working in the public dental service.

Explaining why seven was chosen as the debut age for public screening, Lambe says most children have their first permanent molars by then. “We can also see whether the front teeth have grown into the mouth appropriately.”

But Foyle says age seven/eight is too late. “If they’re lucky enough to get in then, it’s still too late. Decay could have started at age three or four — by seven it has gone too far.”

Paediatric dentist Jennifer McCafferty says 20% of eight-year-olds have decay in their permanent teeth — this climbs to 50% for 12-year-olds and 75% for 15-year-olds. “There’s very little research on pre-schoolers, though a study some years ago found one in four three-year-olds had tooth decay,” says McCafferty, one of 20 specialist paediatric dentists in the country — half work in full-time private practice, half in HSE/hospital practice.

Tooth decay is “absolutely” the single most common chronic disease of childhood, says McCafferty, citing American Academy of Paediatric Dentistry findings — five times more common than asthma, four times more common than early childhood obesity, 20 times more common than diabetes.

“I see early childhood caries all the time — it’s increasing,” says Carrigaline-based dentist Dr Anne Twomey. “I saw an 18-month-old, whose front teeth had all rotted. He had to go to hospital for general anaesthetic to remove them. I frequently see three and four-year-olds with full-blown abscesses in their teeth because they’re decayed. There was a six-year-old who’d put up with years of pain and abscesses. She had to have 12 teeth taken out. At Christmas, her parents sent a card, saying it was the first Christmas they weren’t running for antibiotics.”

These are children malingering on HSE waiting lists.”

Lambe says there are “pockets in Cork and Kerry where children have high decay rate”.

Under-16s are entitled to HSE-provided emergency service if they’re in pain. “If a child’s in pain, they’re offered an emergency appointment the day they call. We get a couple of these calls every day, predominantly about pre-school and primary schoolchildren,” she says.

High rates of childhood tooth decay is “totally dietary” in origin, says Twomey. “It’s because of frequent exposures to sugars. There are 56 different words for sugar. How does a parent figure that out — will they recognise maltose as sugar, for example? Parents also get caught out by foods marketed as healthy, by dried fruit like raisins — I’d prefer to see children eating grapes. Petits Filous has up to three teaspoons of sugar per pot. Granola’s high in sugar — it’ll say ‘no added sugar’ but it’ll have honey.”

Parents are unaware of the WHO guideline: no free (added) sugars for children under two.

Foyle says the common practice of putting young children to bed with a bottle of milk

is hugely problematic and

can lead to loss of upper front teeth. “Give milk before bed, then brush teeth and nothing in bed — except for water,” he recommends. Sports drinks are another culprit.

“I saw a 13-year-old with no cavities. Two years later, he had three or four, all because of sports drinks. He gave them up and has had no cavities since.”

Foyle recommends plain tap water for children doing lots of sports. Aside from sugar content, acidity of drinks also contributes to tooth decay. “The acid attack is proportionate to amount of sugar in the food you’re eating,” says McCafferty.

When children are constantly snacking — going to the fruit bowl, having berries, eating again half an hour later — the mouth gets no chance to recover from an acid attack. “The saliva doesn’t get a chance to neutralise — the teeth don’t get a break.”

McCafferty recommends parents keep fruit to mealtimes and consider alternative snacks — chopped carrots with hummus or rice cakes with Philadelphia cheese. “Eat in a timely manner and encourage children to have food-free times so their mouth gets a break.”

Fluoride helps re-mineralise areas of teeth that have been de-mineralised by acid. It also makes teeth more resistant to acid attacks in food. A study found 55% of five-year-olds in non-fluoridated areas in Ireland had dental decay in their baby teeth compared to 37% of five-year-olds in fluoridated areas. Anne Twomey sees more tooth decay in children who drink bottled water — and in rural children whose families have their own well.

Laura Erskine of MummyPages says mums on the forum are confused about when they should start their children’s oral health routines. “Many believe they don’t need to do anything ’til they start consuming solid food. Even then, they’re unsure about what cleaning practices are appropriate by age and how often they should do this.”

Twomey finds parents wrongly believe it’s fine for children to wait for oral health check until the school dentist visit. “This is the wrong message to give parents,” she says. “Best international practice is bring children around age one.”

In her practice, she sees plenty of 12-month-olds, having made parents aware of its importance. “It’s a quick, easy, cheap visit at one year old. It costs between €20 and €40 — health insurance gives some back.”

Foyle says getting children seen young is all about prevention. “It’s about giving advice to stop something progressing that’d need treatment in the future.”

It’s also about emphasising the importance of baby teeth, which many parents don’t realise. “Losing baby teeth early causes other teeth to drift forward into the space. It creates crowding and later orthodontic problems. Dental decay causes pain. Losing teeth affects ability to eat,” says Foyle, adding that young children, all their baby teeth removed, are “going around gummy ’til they’re seven or eight. It’s a negative experience and can have a social impact”.

Pointing out that decay in baby teeth races through teeth, causing abscesses very quickly, Twomey says worst case scenario a child can die from infection. She says severe dental decay has a knock-on effect on education, self-esteem and food choice.

Once children get their HSE dental check, they’re offered preventative treatment — fissure sealants and topical fluoride to prevent healthy teeth decaying. They’re also entitled to fillings if needed, though for permanent teeth only in most HSE regions. “Parents are informed if baby teeth need filling but would be advised to go privately if they want it done,” explains Foyle.

Dental extractions are the most common cause for general anaesthetic in children — “above appendix and fractured arm”, says Foyle. The IDA estimates the HSE does around 10,000 extractions annually on children under general anaesthetic. “It’s a very large number for what’s a preventable disease.”

Adding to the discomfort are waiting lists for general anaesthetic appointments — in the Cork area, the current wait time is eight to nine months. It falls far short of Sweden’s publicly-funded service, which offers children an appointment between age two and three — they’re seen free until they’re 20. “The dentist assesses how often they need to be seen — six months to a year if low risk,” says Foyle.

And yet, there are scatterings of good news. A new oral health strategy document for the school screening service is due. Lambe says it’s imminent and will have “feed-in from new evidence-based research — it may well change our target age groups”.

In the Cork area, since September, the HSE has visited 20 preschools and have several more booked in over upcoming months, giving talks to parents on promoting children’s oral health.

For McCafferty, it’s doing children no service if their first exposure to the dentist is prompted by having spent the night in agony with toothache.

“It’s so wrong — our children’s attitude to the dentist is already on the back foot. That first exposure to the dentist should be a positive, pleasant experience.”

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