Aching for a better public dental service

THE TELEVISION mounted on the ceiling is the big attraction – or, should I say, distraction. When five-year-old Oisín McNally eagerly clambers on to the dentist's chair and lies back, he has the best view in the room of RTÉ's The Den.

The fact that he recently had a couple of fillings done here at Beechwood Dental in Dublin does not seem to have put him off. Like his older three siblings, he has been attending dentist Dr Peter Casey for check-ups since he was one-and-a-half, so he is at ease and well practised at opening his mouth.

His sister, seven-year-old Aisling, sits on the floor so she can get a half decent look at the television while Oisín is in the chair. She has needed three fillings and their mother, Sharon, puts this down to genes as she is very careful about what the family eats at their home in Rathfarnham, but her own teeth were problematic when she was growing up.

Aisling, who is in second class, is yet to be called for a first visit to a public health dentist. In theory every child under 16 is entitled to free dental care; in practice what is available is far too little, far too late.

“Where would we be if we had waited?” asks Sharon, a physiotherapist. If Aisling had a toothache, she would probably be seen by a public service dentist as an emergency case, she acknowledges. “But that is not the way it happened – these were spotted in a check-up.”

Unlike Sharon, many parents rely on the Public Dental Scheme for their children, who are likely to be at least seven before getting their first routine assessment. It is hardly surprising parents are unaware that ideally children should be attending a dentist before they start school.

“In Ireland about 31 per cent of five year olds will have been to the dentist,” says Dr Carmel Parnell of the Oral Health Research Services Centre in Cork, referring to data from a study conducted in the northeast. “In the UK, it is 94 per cent.”

Our public dental health service is so limited, she explains, it has always focused on decay in permanent teeth, rather than prevention. Dental decay is the most common chronic disease in childhood in the Republic.

It would undoubtedly be worse but for the fluoridation of the public water supply since the 1960s.

Some 37 per cent of five year olds living in areas where the water supply is fluoridated, and 55 per cent in non-fluoridated areas, have one or more teeth that are decayed, filled or extracted. The most recent survey of pre-school children, conducted in south Tipperary, found that 27 per cent of three year olds had decay.

“It is so prevalent and is taken as inevitable but it is preventable,” Parnell stresses. Information about prevention is not reaching enough parents.

The Irish Oral Health Services’ guideline initiative, Strategies to Prevent Dental Caries in Children and Adolescents, published earlier this year, says the public dental service should move from its current target group of school-age children towards a younger – ie preschool and early school age – target group.

It also wants messages on oral health to be incorporated in healthcare information given at child developmental check-ups from eight months onwards, explains Parnell who was lead researcher for the evidence-based guideline initiative.

The level of public dental service varies from region to region but generally it struggles to cope with even emergency and special needs cases among under-16s. No vacancies are being filled or maternity leave covered.

“Prevention has totally gone,” according to the new president of the Public Dental Surgeons, Dr Jane Renehan. In some areas such as Co Meath, she says, routine screening through the schools has been stopped.

Instead, public dentists are increasingly seeing children for the first time when they walk into the surgery with a “big fat face”, having been awake all night with toothache. “That is where we were in the 1950s and 1960s.”

It is not the way she and her 200 colleagues employed by the HSE want to work, she says. Back in 1999, when the population was much smaller, it was estimated that 350 dentists would be required to operate the service.

It is a vicious circle: the less prevention work is done, the more emergency cases there are, which in turn absorb the limited resources, so there is no money to help stop the dental decay in the first place.

Renehan believes the majority of parents do rely on the service, even though it is seriously inadequate. It seems the only way to ensure early and regular dental check-ups for your child in this State is to pay for them.

“We are back now where people cannot afford to go to the dentist,” she points out. However, she stresses that in most health centres, where there is a dental unit, an emergency service is available every day to children.

“That often becomes a consultation service. We would hate to think there is somebody who is out there worried and did not have access to a service.”

You can get your child assessed in these circumstances, but even if there is a cavity, it can only be filled if it is causing pain, she explains.

“We can do nothing until you have a toothache and that is the way, unfortunately, our hands are tied. It’s heartbreaking,” adds Renehan.

From the time your child has teeth, decay is possible, points out Casey, who runs Beechwood Dental in Ranelagh with his older brother David.

“From about two onwards they should be coming into the surgery with their mum, not for treatment, just for a check-up. It is really a familiarisation with the dentist and the surgery, and the whole process of looking in someone’s mouth. It’s all very gentle.”

Such early visits are beneficial psychologically and practically for both child and parent. There is no point, he says, in giving advice to parents of a child who is eight years old and has five or six cavities.

“Far better to talk to the mum or dad when the child is two or three and their baby teeth are coming through. Otherwise, they don’t get the information they need.”

Fissure sealing on permanent molar teeth, usually beginning at age six or seven, helps reduce the risk of decay. But diet and brushing of teeth are the key factors in oral health.

Most Irish children brush their teeth only once a day, although it has been shown to be much more effective if you brush twice a day, says Parnell. “When you add that to their high consumption of sweets, you have got a recipe for disaster.”

Diet is much more important than tooth brushing, stresses Casey. “If you have a high sugary diet and brush your teeth three or four times a day, you will still get tooth decay. Whereas if you don’t have any sugar in your diet and don’t brush your teeth, you probably won’t have tooth decay.”

He tries to impress on parents that it is not the amount of sugar that a patient eats, it is the frequency. “If you eat a bar of Dairy Milk it takes five minutes, and it takes five or 10 minutes to wash that saliva out of your mouth. You have sugar in your mouth for 15 minutes, no big deal.

“If you eat a packet of Polo mints or Fruit Pastilles that dissolve in your mouth, it takes five or 10 minutes to dissolve one in your mouth, and five or 10 minutes for the saliva to wash it away.

The trouble is you always eat another one.”

Like most parents, Sharon finds that trying to limit sweets is a constant battle. The children are invited to lots of parties and get jellies and lollipops, which are the worst for teeth. So she often swaps these for chocolate. “I don’t give them fizzy drinks, and treats are once a week.”

She does not relish the prospect of the upcoming sweet-feast that is Halloween. She usually lets her children gorge themselves for a day or two, and then confiscates the leftovers. To ration them and drip feed the sweets over weeks is worse, she suggests.

Casey finds parents dwell on the issue of fruit juices. “I don’t mind juices at all. There are natural sugars of course, but the nature of drinking juice is it is straight down the hatch,” he says. Although he adds that he usually dilutes with water the apple juice he gives to his own two children, more for taste reasons.

Fizzy drinks and orange squashes, with their added refined sugar, should be avoided. He recommends electric toothbrushes, partly because they encourage children to brush their teeth for a little bit longer. Two minutes’ brushing should be the aim, and an egg-timer in the bathroom can help children measure this.

As well as knowing how to try to avoid dental decay, it is also essential to try to catch things early. “A cavity always starts as a tiny little hole and it aims towards the centre of the tooth where the nerve is,” explains Casey.

Then you are looking at greater expense and children having more invasive treatments, which can put them off for life, so regular check-ups can save both money and upset.

He sees parents coming in, embarrassed that their kids have dental decay, believing it is a reflection on them.

“I always tell them my young fella had a filling last year and they are absolutely delighted!”

How to help prevent your child suffering from tooth decay

• Use a soft brush and water to clean your child's teeth as soon as they appear.
• Never put sweetened drinks or fruit juice into a baby's bottle.
• Do not let your child sleep with a bottle or feeder cup in his/her mouth.
• Use sugar-free medicines where possible.
• From the age of two, brush your child's teeth twice a day with toothpaste, in the morning and at bedtime. As they learn to do it themselves, continue to supervise their brushing, up to at least the age of seven.
• A small pea-sized amount of toothpaste should be used up to the age of seven. Toothpaste containing at least 1,000 ppm F (parts per million fluoride) is recommended from the age of two by the
• Irish Oral Health Services guideline initiative. Some toothpaste marketed for children contain less than 600 ppm F.
• Encourage your child to spit out the toothpaste and not to rinse after brushing.
• Increase the amount of toothpaste used after the age of seven, when a child is less likely to swallow it.
• Limit the consumption of sugary foods and drinks, and try to confine these to meal times.
• Bring your child to the dentist before he/she starts school and from then on arrange a check-up at least once a year – more frequent visits may be necessary and should be determined on an individual basis.
• Toothbrushes need to be replaced every three months or so, depending on the amount of wear.