Abstract
Background and aim: The first permanent molar (FPM) is the tooth most commonly and severely affected by hypomineralisation. In severe cases, affecting 1 in 5 children worldwide, the FPM can rapidly break down shortly following eruption. Pain, difficulty eating and psychosocial suffering are commonly reported concerns. Dental practitioners also face clinical challenges such as poor enamel bonding, achieving adequate anaesthesia and behavioural issues. Extraction is, therefore, considered a viable alternative to complex restorative treatment. It is beneficial to seek an orthodontist's option before planned extraction. However, anecdotally, the management of molar hypomineralisation (MH) within New Zealand (NZ) is inconsistent. Orthodontists are regularly asked for their opinion, and given the high incidence, there is a need to turn to patients and practitioners to understand their experiences and perspectives on the matter so that future improvements in management can be made.
Methods: A two-part descriptive case study was carried out from May 2021 – May 2023 to qualitatively investigate 1) the perceptions of children severely affected by MH and their caregivers using face-to-face interviews and 2) the perceptions of orthodontists regularly managing these children and the impact on orthodontic clinical practice using focus group interviews. Children aged 6 and 12 years (N=15) who either received general anaesthesia (N=10) within the past nine months or were planned to have general anaesthesia (N=5) in the next nine months from the study start date for extraction of severely affected FPMs and their caregivers (N=14) were purposely sampled using the University of Otago Faculty of Dentistry (FoD) patient database. Orthodontists (N=16) were recruited via voluntary means. Child and caregiver participants attended interviews at the FoD, and orthodontists attended one of two focus groups held across two New Zealand (NZ) locations. All interviews were conducted by a single researcher using a semi-structured format. Audio files were de-identified, manually transcribed verbatim by a third party, and analysed using a thematic analysis with NVivo Qualitative Data Analysis software.
Findings: Core themes (child = 10, caregiver = 11 and orthodontists = 5) were identified from the transcripts. This study highlighted that hypomineralised molars did not affect children's self-esteem; however, girls had negative feelings about anterior defects. Cold sensitivity and difficulty eating were the most commonly reported issues in children. Both children and caregivers felt that tooth removal was the right decision. Poor communication, lack of support and quality of care were reported system challenges among caregivers. Orthodontists frequently encounter MH, and severe cases usually present monthly, with the majority of referrals originating from the community oral health service (COHS). There are major disparities in referral quality and reasons for referral, demonstrating the pivotal need for an orthodontist's opinion in the long-term management of such cases. The findings emphasised the need for early referrals; however, they often lack sufficient information, making decision-making even more difficult. All study participants have highlighted issues in the New Zealand healthcare system, such as uneven distribution of the COHS workforce, poor communication between providers, specialist shortages, and the impact of COVID-19. Solutions, including a standardised referral process, funding for orthodontic opinions, and interdisciplinary collaboration across NZ have been proposed.
Conclusion: The management of children severely affected by MH requires a nationwide reassessment to reduce inequalities, barriers to care and inconsistency in treatment planning. The orthodontist plays a significant role in managing children who have been recommended extraction, and all children must have access to an opinion to ensure favourable clinical outcomes. To better support children and families affected, there needs to be improved integration between providers, access to funding, training amongst practitioners, interdisciplinary management and standardisation of services throughout NZ.