Key Points
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Informs readers why the number of children referred to hospital for dental treatment under general anaesthetic (GA) has been reported as increasing recently in England.
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Explains why high caries risk cohorts of children are likely to experience further caries and subsequent treatment under GA.
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Of interest to dentists and oral health policy-makers, the findings have implications for children treated under GA throughout the industrialised world.
Abstract
Introduction Despite overall improvements in oral health, the number of children admitted to hospital for extraction of teeth due to caries under general anaesthesia (GA) has been reported as increasing dramatically in England. The new UK government plans to transform NHS dentistry by improving oral health.
Aim To evaluate the dental care received by children who required caries-related extractions under GA and obtain the views of their parents or guardians on their experiences of oral health services and the support they would like to improve their child's oral health, to inform future planning.
Method An interview questionnaire was designed and piloted to collect data from a consecutive sample of 100 parents or guardians during their child's pre-operative assessment appointment. This took place at one London dental hospital between November 2009 and February 2010.
Results Most children were either white (43%) or black British (41%); the average age was seven years (range 2-15, SD 3.1, SE 0.31) and the female:male ratio was 6:5. Most (84%) had experienced dental pain and 66% were referred by a general dental practitioner (GDP). A large proportion of parents or guardians (47%) reported previous dental treatment under GA in their children or child's sibling/s. Challenges discussed by parents in supporting their child's oral health included parenting skills, child behaviour, peer pressure, insufficient time, the dental system and no plans for continuing care for their child. Three out of four parents (74%) reported that they would like support for their child's oral health. Sixty percent of all parents supported school/nursery programmes and 55% supported an oral health programme during their pre-assessment clinic.
Discussion These findings suggest that the oral health support received by high caries risk children is low. Health promotion programmes tailored to this cohort are necessary and our findings suggest that they would be welcomed by parents.
Main
R. C. Olley, M. T. Hosey, T. Renton and J. Gallagher BDJ 2011; 210: E13
Editor's summary
At a time when we are busy congratulating ourselves on the improvements to oral health as reported in the recently announced results of the Adult Dental Health Survey, it comes as a particular shock to discover that there has been an increase in England of the number of children admitted to hospital for the extraction of teeth under general anaesthetic (GA).
This paper provides us with a reality check against the headlines, articles and adverts on tooth whitening, implants and make-overs, bringing us back down to earth with images of frightened children, surgically managed and bleeding mouths and psychologically damaged 'future' patients.
It is hardly surprising that the authors found a majority of parents and guardians expressing a wish for much greater preventive input in their child's oral health. Who of us wouldn't wish at the point at which a loved one, especially a child, was about to undergo a procedure under a GA, that we (or someone) had done more to prevent such a sorry state of affairs; especially as it is preventable. But therein, I suspect, lies the rub. It is human nature to wish that things might be different but it is also human nature to find that all the things we 'should do' just are not feasible in a busy life, and more particularly in a life lived in relatively poor socio-economic conditions, as many of the children in this study did. Trying to plan healthy meals, prevent grandparents from indulging children with sweets, supervising tooth brushing before bed, affording toothpaste. Easy to regret when sitting in an outpatient GA clinic.
What is to be done? As I have argued in the Editorial in this issue, inspired partly by this paper, we need a far better joining of the dots to complete a whole picture of prevention across education, service provision, social and professional attitude and government policy. Do we really want to go on forever hearing those damning words 'they're only baby teeth'?
The full paper can be accessed from the BDJ website (www.bdj.co.uk), under 'Research' in the table of contents for Volume 210 issue 8.
Stephen Hancocks
Editor-in-Chief
Author questions and answers
1. Why did you undertake this research?
Despite overall improvements in child oral health, data suggest that the number of children (aged 16 years or under) admitted to hospital for extraction of teeth due to caries under general anaesthesia (GA) has increased by 66% in England between 1997 and 2006 and that the level of dental care received by these children in dental practice has declined. At King's College Hospital Dental Paediatric and Day Case Unit, 400-500 children present for dental treatment under GA per annum. This study aimed to evaluate the dental care these children had received to date and obtain the views of their parents or legal guardians on the experience of oral health services and the support they would like to improve their child's oral health.
2. What would you like to do next in this area to follow on from this work?
Our findings suggest that oral health promotion interventions are welcomed by parents of this high caries risk cohort of children. To be successful, these interventions should include a variety of ongoing, novel, family-centred oral health support tailored to this high caries risk cohort. Advice and care must be consistent, evidence informed and based on current Department of Health policy. Care includes the use of fluoride to reduce caries incidence In addition, it is important to incentivise these interventions so that they are carried out by healthcare professionals in practice. Further work is necessary to address the effectiveness of delivering oral health improvements to this high caries risk cohort.
Commentary
This interview questionnaire paper from Olley et al. confirms long-held clinical beliefs that the oral health support received by high caries risk children and their families is low. In addition, even when caries preventive messages have been given and understood, they are difficult to enforce because of cultural and societal pressure. In 47% of families the child presenting for general anaesthesia or another sibling had had a previous GA. In Glasgow we found that nearly 50% of parents of our GA patients had had a GA when they were young - an inherited treatment?
It's difficult to understand why our society views oral sepsis differently to infection elsewhere in the body. Somehow we have allowed dental caries and dental neglect to be accepted as the status quo in the young child. Governments do make policies for healthcare but the responsibility for an individual child's teeth is with their parents. Perhaps it suits us to hide behind 'they're only baby teeth' because addressing the problem requires us to make a judgement of another adult's parenting capacity.
Children are more difficult to treat because of their behaviour and attention span but this is not an excuse to make up reasons not to treat. We should be identifying the resources to halt disease progression, repair teeth and prevent pain intervention. Denmark was in the situation we are now during the 1970s and they started a Children's Dental Service. Their children now enjoy some of the best dental care in Europe. Instead of putting money into preventing the issue we spend it on resources to extract teeth. In 2009/10 there were 7,526 dental extraction GAs in Scotland, some 21% of all GAs for children.1
What of the Hippocratic solemn promise 'of beneficence (to do good or avoid evil) and non-maleficence (to do no harm) towards patients'? By omission we are guilty, ignoring the huge treatment need, not providing rigorous intervention for all and allowing teeth to progress to extraction.
The early years of life are the time to get it right for the infant and child and there is no just reason why our young patients should be denied correct and appropriate care.
We must all work to reduce this inequality. It is every adult's and every parent's responsibility.
References
ISD Scotland. National Statistics Release - December 2010. Available at http://www.isdscotland.org/isd/6468.html
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Welbury, R. Summary of: Why are children still having preventable extractions under general anaesthetic? A service evaluation of the views of parents of a high caries risk group of children. Br Dent J 210, 360–361 (2011). https://doi.org/10.1038/sj.bdj.2011.289
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DOI: https://doi.org/10.1038/sj.bdj.2011.289