Abstract
Dental caries is one of the most common childhood diseases and is the cause of poor oral health, and general health, in children. Many of these children are treated successfully in dental clinics with local anaesthesia; however, an increasing number of children are being referred to hospital for their dental caries to be treated under general anaesthesia (GA).
In 2003, a working group was set up to review and report on the services provided by District Health Boards (DHBs) for children under GA, and to use the information gained to develop a set of national guidelines, which the working group intended to be used by the Ministry of Health (MOH) as a requirement for DHBs to follow. The report of this working party (Lingard et al., 2008) was to include: a review of the current situation; guidelines for referral and treatment of children for dental treatment; and guidelines for post-operative follow-up and continuing risk management. To date, there has been no formal review of these 2008 recommendations and guidelines from this extensive survey. The MOH did not recognise these recommendations and guidelines, as wished, but it is still hoped that DHBs have followed them.
Initially, a questionnaire was developed and sent to all DHBs to seek information on access to GA services, with regard to operating theatres and personnel, the numbers and ethnicity of children, aged 0 to 13 years of age, who have received GA for dental treatment, the range of services available, assessment protocols, follow-up protocols and waiting times for assessment and treatment.
In addition to a review of the 2003 survey, a second questionnaire was developed and sent to all clinicians who treat these children under GA and gather information on their training, experience, treatment provided and their own thoughts on the guidelines and protocols. Further insight was gained from interviews with 7 clinical head of departments, or clinicians throughout New Zealand (NZ) representing a range of positions, experience, geographical location and size of DHB.
The aims of the current study were to provide a situational analysis of the dental treatment on children under GA in NZ. This is required to provide evidence that will be used as a reference point for health service planning and implementation of dental care for children under GA and to report on whether DHBs have followed the working party’s recommendations.
The current study reports that the numbers of children receiving dental care under GA have increased significantly. Hospital dental departments are reporting difficulties meeting demand. The guidelines produced by the working group (Lingard et al., 2008) have been widely used by hospital dental units in treating children under GA. Information (on access to GA, assessment, post-operative care, waiting times, clinicians and their training and experience, materials used and procedures undertaken) has been obtained from clinical directors and clinicians.
The increase from 4,646 in 2004/2005 to 7,650 in 2016 is disappointing, especially since caries is a preventable disease. Resources (both in the community oral health services and the hospital dental services) have had to increase; first to attempt to prevent, and second to treat those who develop decay. This has been at some considerable cost to the health system. However, still many DHBs are struggling to meet the increasing demand.
This study reinforces the inequality of access among DHBs that was reported by Lingard et al. (2008). While most clinicians accept that this undesirable, there is a general belief that it cannot be changed. However, there is no appetite for change from the system of universal access for any child who requires dental care under GA.
All clinical directors and clinicians believed that reducing demand for dental care under GA should be an explicit goal of the Government and DHBs. The most common ‘upstream’ approaches suggested are: the taxing of sugar; healthy food policies in schools; reducing the marketing of sugar; reducing child poverty; healthy warm homes; and community water fluoridation. All of these initiatives require Government support.
There are also differences on how collaboratively some hospital departments work with their community oral health service counterparts. If demand for dental treatment under GA is to be reduced; it cannot occur without these services working together for a common goal. The community oral health service and the hospital dental service need to be in regular dialogue to assist one another.
The guidelines recommended by the working group of the NZ Society of Hospital and Community Dentistry (Lingard et al., 2008) were intended by the Society to be adopted by the MoH as a standard for all DHBs to implement. While this has not happened, it is apparent that all DHBs have taken steps to follow these guidelines. They have been viewed positively by both clinical directors and clinicians. These guidelines are still relevant in this current environment; however, there are several additional points which could be added to these guidelines.