Clear Criteria for referral of children following school dental inspection can be established

Abstract

Aim To clarify the function of the school based dental inspection

Objective For representatives of the Community Dental Service, General Dental Service and Hospital Dental Service to identify an agreed set of criteria for the referral of children following school dental inspection.

Design Qualitative research methodology used to establish a consensus for the inclusion of referral criteria following dental screening.

Setting Ellesmere Port, Cheshire, England

Materials A Delphi technique was used to establish a consensus among the study participants on the inclusion of nine possible criteria for referral following dental screening. All participants scored each criterion in the range 1-9, with a score of 1 indicating that referral of individuals with the condition should definitely not take place, and a score of 9 indicating referral should definitely take place. Referral criteria were accepted only if they achieved a group median score of 7 or more, with an interquartile range of three scale points, with the lower value being no less than 7.

Results Four of the nine possible criteria met the agreed group standard for inclusion: 'Sepsis', 'Caries in the secondary dentition', 'Overjet > 10 mm', and 'Registered & caries in the permanent dentition'.

Conclusion It is possible to agree clear criteria for the referral of children following the school dental inspection.

Key Points

• Local agreement was obtained on four clinical criteria to trigger referral following school dental inspection.

• This methodology is widely applicable with different criteria addressing local needs.

• The process leads to greater standardisation.

• This approach permits the effectiveness of the school dental inspection to be evaluated.

Main

The identification of agreed criteria for referral following the dental inspection of children in the school setting K Milsom, M Tickle, A Jenner and G Moulding Br Dent J 1999; 186: 37–40

Comment

This paper is of relevance to both general dental practitioners (GDPs) and community dental service (CDS) practitioners because it addresses a topic that has been a bone of contention between the two services for decades. This is the difficulty that can arise when a parent is notified that their child needs dental treatment following a school inspection although the child is a regular patient of a GDP.

The authors have sought to clarify the role of the school inspection and reach a consensus between representatives of all branches of the dental services on a list of disorders that all would agree indicate an unequivocal need for referral. Using a recognised scientific approach (Delphi technique) they ultimately derived a list acceptable to all parties.

The authors consider the school dental inspection from the viewpoint of a screening programme but argue, correctly, that it is not really screening as such. For example, the requirements for a disease suitable for screening suggest inter alia that there should be a recognised early or presymptomatic stage. This certainly exists for caries, traditionally one of the main concerns of the school inspection, in the form of the 'white spot' enamel lesion. However, these lesions are difficult to detect except under optimal clinical conditions and are also an unreliable indicator of future dentinal disease.

It would not seem sensible to suggest that their detection is a criterion for treatment referral. The authors rightly state that the inspection, like the screening process, is to detect disease in those who are apparently well, or believe themselves well. For a patient to self-diagnose symptomless caries in a back tooth, the lesion needs to be fairly gross. Unequivocal dentine caries identified clinically at inspection, in a young person unaware that they had such a lesion, would therefore constitute a presymptomatic stage at this level and would be a reasonable criterion for referral. However, the authors do not state what degree of severity of caries, or most of the other disorders, the Delphi respondents were asked to consider. Yet the severity of the disease detected would surely influence the decision to refer?

Undoubtedly this piece of research is a step in the right direction and points to a rational way in which the school inspection programme could develop. However, in order for the objectives to be fully achieved, the criteria for referral would perhaps need to be specified precisely and those engaged in the exercise, trained and standardised appropriately.