Cinderella of public health braces itself for a cultural shift
New plans are in place to target the long waiting lists for orthodontic treatment
The public health orthodontic service has been hit hard by the recruitment embargo in the health service.
In some areas children requiring orthodontic intervention, and even surgery, are being placed on waiting lists that have no end. There are no dates given for the commencement of treatment, or even for a consultation appointment with an orthodontist.
This is certainly the case in the area the HSE calls Dublin North East (DNE), which covers not only the northern half of the Dublin area but also counties Meath, Louth, Cavan and Monaghan.
In letters sent to parents of children in the Dublin area who have been identified as having orthodontic needs, which have been seen by The Irish Times , managers state, “I am therefore unable to advise you of how long X will remain on our waiting list before being offered a treatment place. Please note that at this point, we have children in X’s category awaiting treatment since January 2008 . . .”
The general impression given by this letter was not improved by the fact that although the child concerned had an identifiably female Christian name she was referred to at the outset as “your son, X”.
The parents of this child acknowledge her case is not of the highest medical priority. Nevertheless she is a teenager with a prominent jaw and overcrowded teeth.
In fact, this teenager has been recommended for surgical realignment of her jaw.
In preparation for that operation, braces must be worn for several years, but she has not yet been given a date, or even a year, in which the operation might take place, or in which the fitting of braces might begin.
Her mother would like the opportunity to talk over the treatment options for her daughter. She is worried at the prospect of an operation and would like to discuss an alternative to surgery. “But there’s no prospect of an appointment to do that,” she told The Irish Times .
It is generally accepted that the DNE region, with its burgeoning young population and lower income levels, is at the sharp end of the problems facing the public orthodontic services.
Last autumn the Orthodontic Society of Ireland pointed out that children in that area can wait up to four years for treatment and bemoaned the fact that more orthodontists are not employed by the public service.
DNE has one consultant and eight specialist orthodontists working full-time, with a ninth working part-time. But the whole system is struggling, with varying degrees of success.
“Not too bad,” said one orthodontist working outside Dublin. Another said she was sick of the negative picture of the service being painted, while positive patient outcomes were ignored.
“We have a good manager who does her best. Parents should not be panicked by waiting times,” this orthodontist said.
Willing to travel
As well as juggling the waiting lists, staff can sometimes use less busy, outlying surgeries in their area if patients are willing to travel. DNE, for example, refers Dublin patients to its surgeries in Navan and Dundalk.
Patients can be referred to the private sector for some procedures and patients can be referred to hospitals and dentists in Northern Ireland; this is already happening in the Sligo area.
It’s hard to measure the orthodontic problem using any tools other than the number of specialists – or lack of same – and the length of waiting lists.
For example, according to HSE South, in the Cork and Kerry area which, for many years, was a black spot, it has two consultant orthodontists, four and a half specialists and a connection to dental post-graduates at University College Cork dental school.
All staffing levels are under pressure.
According to the statement from HSE South, its orthodontic services receive 200 referrals a month. Waiting times for treatment extend from three and a half to seven and a half years. Areas, such as DNE in which initial assessment is fast, have more children on their lists.
And with the system of grading patients’ needs, it is the less compromised who are a long time on the list.
Dympna Kavanagh, who was appointed chief dental officer at the Department of Health last year, wants to look at the whole dental system a little differently.
She is more worried about adults than she is about children. Some years ago a colleague was asked to supply a denture for the corpse of an old lady, for the purposes of her funeral. The old lady had to die before she got any dental care.
“We have no information about old people. We have huge problems in nursing homes,” says Kavanagh.
“I have a real concern also for adults with special needs. The waiting list for them in some areas is up to four years.” As she says herself, “There’s nothing sexy about adult special needs in the profession.”
Cohort of specialists
By contrast, the orthodontic beat seems well patrolled, not least by its cohort of specialists.
Dentistry is the Cinderella of public health.
“Oral health wasn’t even in the National Service Plan until January 2014,” says Kavanagh. And orthodontics is an island within public dentistry. It’s not all bad – for many years, on its island, orthodontics made its own arrangements, unsupervised and unintegrated. For example, Fiona Murphy, as operations manager for the Louth region, is responsible for orthodontics but not dentistry.
But in the absence of a national plan for dentistry as a whole, resources were allotted piecemeal or, as Murphy and Kavanagh frankly put it at a meeting with The Irish Times at the Department of Health, “To whoever shouted loudest.” It was here, in the allocation of resources, that D N E suffered .
However, DNE’s crisis may be the national public dental service’s opportunity. Or one of its opportunities.
First of all there will be new information gathered, using new key performance indicators; not least, information about those waiting lists.
“I want a footfall figure,” says Kavanagh. “We want to know waiting figures. Nationally, 7-10 per cent of children with orthodontic needs are not even seen within a year. No one is happy with that.”
The problem is getting into the system. Once in the system, both parents and children are satisfied, if not downright impressed, by the service. “But,” acknowledges Murphy, “there is this cliff fall before you’re seen.”
According to Kavanagh, “Parents want to be seen faster – even if it is bad news – so they can start saving.” She is talking about the parents whose children may not be eligible for public health dentistry, and have to stump up the the heavy price of private orthodontics for their children.
But there is a new plan to break the log-jam in public orthodontic waiting lists.
In other European countries, including the UK, orthodontics is much more integrated into general dentistry.
More specifically, a specially trained orthodontics therapist – not a dentist – can perform the routine maintenance work that takes up so much of the orthodontist’s time. There is a plan in place now for dental nurses and hygienists to train as these new therapists.
The idea of orthodontic therapists has been around since 2003, but never acted on. Since the economic disaster though there has been what Kavanagh calls “a cultural shift”.
In other words, new, perhaps lower-key attitudes to getting things done. An orthodontic specialist costs the taxpayer €140,000 to €160,00 per annum. One of the new therapists will cost between €40,000and €60,000.
It is no wonder then that Kavanagh says “the Minister is enthusiastic” about the new scheme.
The first to volunteer for the pilot scheme, under which dental nurses and hygienists will be given a year’s supervised training in orthodontics, was Dr Pat McSherry, the consultant orthodontist in DNE. The Mid West area followed. The two trainees from Dublin North will begin in September, with McSherry as their mentor.
Case study: Jason Sheridan
Jason Sheridan is now 20, and studying environmental science at Dublin City University. He doesn’t look like a boy who had his upper jaw pulled apart and then put together again. But this is exactly what happened to him. Jason is a success story from the extremely pressurised area of the orthodontic service, Dublin North East .
Despite all its difficulties Jason’s father, Mark Sheridan, says he cannot praise the service given to Jason enough.
Jason had what is known as a negative overjet – or severe mandibular prognathism – which the public health dentists were worried about. “It didn’t bother me that much, I kind of got by on it,” says Jason. “It’s in the family, it’s on my mam’s side.” His mother, Lucinda, nods as she sits in the Swords family home .
Jason is the second youngest of five children . Jason has two older sisters who had similar orthodontic problems which were handled differently. One sister was treated privately and ultimately did not have surgery; one sister went public, needed only bands, and was treated fairly successfully. “So by the time we got to Jason, we knew what to do,” Lucinda says.
Jason was put on the list for surgery to realign his jaw. He was referred by the HSE to a dentist in the private sector to have his four wisdom teeth removed. He had to be fitted with bands before the operation could happen. This involved his father, Mark, driving him to regular appointments at the Ashtown Gate Clinic on the Navan Road. “But then Dundalk came on board and things moved faster,” says Jason.
Patients at the extremely busy Ashtown Gate facility are offered the option of being seen in the less crowded facilities at Navan and Dundalk, which are part of the Dublin North East area. Many parents baulk at the prospect of driving children to clinics outside the city during the working week. But Jason’s father, Mark, who works as a sales representative, was on the road anyway.
“When I was 16 or 17 they put on braces,” says Jason. The braces were adjusted every three to six months at first, then left at the last stage “for a good year”.
By now Lucinda was driving Jason to see his surgeon, Gerard Kearns, at St James’s Hospital.
“We went through the options, whether to operate on the upper or lower jaw,” says Jason. “With the lower jaw there’s a risk of cutting the mandible nerve.” That is, of cutting it and the nerve failing to grow back.
As it was, Jason experienced numbness rather than pain after the operation as the nerves in the upper jaw mended. “It healed up quick enough,” he says. He had the operation in April 2013, and was able to travel abroad by June. “I would recommend it,” he says, and now he has a girlfriend. “ I met her a few weeks before the operation. She says she would have liked me as well if I hadn’t had it, but the type of problem I had can get worse in later life. It can progress. So I would recommend it.”
Case study: Stacey McNulty
Stacey McNulty has clear views on how you feel with unsightly, crooked teeth. “Teeth are a big factor in people’s lives,” she says.
“People are very conscious of how they look in pictures, of how they look when they smile. I don’t think they should have to wait, just because it’s their teeth.”
Stacey is a 16 year old with a dazzling smile, but she remembers the misery she felt about her teeth, with what her orthodontist, Dr Ciara Scott, describes as very severe crowding and displacement .
Stacey’s two canine teeth were high up in her gum, with no room for them in the normal arch of teeth. “Dr Scott did a fabulous job,” says Stacey. “She brought them down somehow.”
Two of Stacey’s aunts and an uncle and her mother, Carmel, all had similar problems.
It took a lot of hard work over three years from Scott, specialist orthodontist at the HSE’s regional orthodontic unit at St Columcille’s Hospital in Loughlinstown in HSE’s Dublin South region, and from Stacey herself, to change this.
The bands finally came off last summer. “I’m very happy now,” says Stacey.
Stacey is one of the success stories of public health orthodontic services, to which she was referred by the public health dentist who visited her when she was in her first year at St Tiernan’s Community School in Sandyford, Co Dublin.
Serves people well
Despite recruitment embargoes, cutbacks and an unwieldy bureaucracy, staff, parents and young patients are eager to point out that the public dental health system can still serve people very well.
“We are treating the most complex and challenging cases,” says Scott. “That makes our work very rewarding.”
Scott points out that Stacey waited two years, on a Grade 4 waiting list.
Stacey cannot praise Scott highly enough.
“She’s so nice, it’s like we’ve gained a friend,” says Stacey. “It was a long process to get where I am now but it was definitely worth it.”
Her case study was presented by Scott at the Orthodontic Society of Ireland’s annual conference case study competition and it won.