Scottish Dental Needs Assessment Programme (SDNAP)

Oral Health and Dental Services for Children Needs Assessment Report

2017 Foreword

This needs assessment report was prepared before the launch of consultation on Oral Health Plan (September – December 2016) by the Scottish Government, which touches upon some of the recommendations made in this report.

It is anticipated that Oral Health Plan may address some of the issues highlighted in the report such as general dental practitioner remuneration by the Statement of Dental Remuneration (SDR), future delivery of the Childsmile programme and local commissioning of services.

Scottish Dental Needs Assessment Programme NHS Lanarkshire Headquarters Kirklands Fallside Road Bothwell G71 8BB

Telephone: 01698 858238 Fax: 01698 858283

© Scottish Dental Needs Assessment Programme Published March 2017

Print

Online

Cover images: Kalinovskaya, Robert Przybysz, Andrei. R, Evgeny Atamanenko, www.shutterstock.com Working Group Membership

Dr Maura Edwards (Chair) Consultant in Dental Public Health, NHS Ayrshire & Arran

Mrs Praveena Symeonoglou SDNAP Public Health Researcher, NHS Lanarkshire

Dr Barry Corkey Specialist in Paediatric Dentistry, NHS Fife

Dr Morag Curnow Clinical Dental Director, NHS Tayside

Mr John Davidson General Dental Practitioner, Lothian

Mrs Gillian Glenroy Specialist in Paediatric Dentistry, NHS Greater Glasgow & Clyde

Mr Peter King Childsmile Programme Manager – West Region

Mrs Marguerite Robertson Patient Representative

Mrs Elizabeth Roebuck Consultant in Paediatric Dentistry, NHS Lothian

Mrs Margaret K Ross Senior Lecturer for Dental Care Professionals/Programme Director BSc (Hons) Oral Health Sciences, University of Edinburgh

Mr George Taylor Dental Practice Adviser, NHS Forth Valley until 1/9/15, then Dental Legal Advisor, Medical and Dental Defence Union of Scotland (MDDUS)*

Dr Alyson Wray Consultant in Paediatric Dentistry, NHS Greater Glasgow & Clyde/Core Training Advisor, West of Scotland, NHS Education for Scotland

Mr Graeme Wright Specialty Registrar (StR), Glasgow Dental Hospital and School until 2014, then Consultant in Paediatric Dentistry, NHS Lothian

*The opinions expressed here are personal and not those of MDDUS NHS Scotland

3 Contents

1 EXECUTIVE SUMMARY AND RECOMMENDATIONS 9 1.1 Key Findings 9 1.1.1 Oral Health Improvement, Inequalities and Demography 9 1.1.2 Information 9 1.1.3 Service Provision 10 1.1.4 Workforce and Training 11 1.2 Recommendations 12 1.2.1 Oral Health Improvement, Inequalities and Demography 12 1.2.2 Information 12 1.2.3 Service Provision 13 1.2.4 Workforce and Training 14

2 BACKGROUND AND CONTEXT 15 2.1 Health Needs Assessment 16

3 AIM, OBJECTIVES AND METHODS 18 3.1 Aim 18 3.2 Objectives 18 3.3 Methods 18 Oral Health and Dental Services for Children Needs Assessment Report 3.4 Scope and Limitations 19 3.5 Ethical Considerations 19

4 INTRODUCTION TO CHILDREN’S ORAL HEALTH 20 4.1 Child Population And Demography 20 4.1.1 Child Protection Register 21 4.1.2 Child Health Systems Programme 21 4.2 Common Oral Diseases Of Childhood 23 4.2.1 Modifying Risk Factors 23 4.3 Policy And Legislation 24 4.4 Epidemiology 25 4.4.1 National Dental Inspection Programme 25 4.4.2 Primary 1 (P1) Inspection 26 4.4.3 Primary 7 (P7) Inspection 26 4.4.4 Patterns of Decay and Inequality 27 4.5 Preventive Care 29 4.5.1 Childsmile 29 4.6 Demand 29 4.6.1 Children with extensive decay 30 4.6.2 Children with Support & Care Coordination Needs 30 4.6.3 Children with High-Risk Medical Conditions, for example, Oncology, Haematology and Cardiac 31 NHS Scotland

4 5 CURRENT SERVICE DELIVERY MODEL (PATIENT JOURNEY PATHWAY) 33

5.1 Paediatric Dentistry 33 Contents 5.2 Routine Care 34 5.3 Specialist Care 35

6 CURRENT SERVICE PROVISION 37 6.1 GDS Service Provision 37 6.1.1 GDP Survey 42 6.1.2 Dental Care Professionals 48 6.2 PDS Service Provision 50 6.2.1 PDS Service Provision for Children 50 6.2.2 PDS Retrospective Referral Audit 55 6.3 Hospital Paediatric Dentistry Service Provision 60 6.3.1 Hospital Activity 60 6.3.2 Hospital Retrospective Referral Audit 61 6.3.3 Current Hospital Workforce 68 6.3.4 Consultants and Specialists 68 6.3.5 Consultant Job Plan 68 6.3.6 SAS dentists 69 6.3.7 StRs and Post-CCST Development Posts 69 6.3.8 Pre-specialist Trainees 69 6.3.9 Dental Therapists 69

7 PATIENT PERCEPTIONS OF THE SPECIALIST SERVICES IN PDS AND HDS 70 7.1 Public Dental Service Paediatric Patient Interviews 70 7.2 Dental Hospital Paediatric Patient Interviews 73

8 WORKFORCE PERCEPTIONS: PDS SPECIALISTS AND HDS CONSULTANTS 78 8.1 PDS Specialists’ Perceptions 78 8.2 Hospital Consultants’ Perceptions 83

9 HOSPITAL SERVICE STAKEHOLDERS’ AND FACILITATORS’ PERCEPTIONS 96 9.1 Hospital Service Stakeholder Interviews (Oncology, Cardiology and Hematology Departments) 96 9.2 Facilitators: Anesthetist Interviews 100

10 REFERENCES 102 NHS Scotland

5 11 APPENDICES 105 Appendix 1: Proposed national referral criteria 105 Appendix 2: GDP survey questionnaire 109 Appendix 3: Dental hygienists and therapists’ survey 112 Appendix 4: Clinical directors of PDS - Survey questionnaire 121 Appendix 5: Referral rate for GA provision and provision of alternatives to GA 124 Appendix 6: Provision of comprehensive care including restorative care under GA 125 Appendix 7: Extraction only GA provision by NHS Board 126 Appendix 8: Treatment for children who require multidisciplinary care 127 Appendix 9: ‘Out-of-Board’ referrals by NHS Board 128 Appendix 10: PDS Referral audit form 129 Appendix 11: Other categories 130 Appendix 12: Referrals received for anxiety or phobia 130 Appendix 13: Referrals received for treatment planning for children requiring extractions under GA or sedation 131 Appendix 14: Referrals received for severe early childhood caries 131 Oral Health and Dental Services for Children Needs Assessment Report Appendix 15: Cross tabulation SIMD 2012 quintile and three most prevalent conditions in the PDS 132 Appendix 16: Referral triage result 132 Appendix 17: Hospital audit form 133 Appendix 18: Referrals received by GDH 134 Appendix 19: Referrals received by EDI 134 Appendix 20: Referrals received by DDH 134 Appendix 21: Patient questionnaire - PDS 135 Appendix 22: Patient questionnaire - Hospital 136 Appendix 23: Topic guide for semi-structured interview: PDS 137 Appendix 24: Topic guide for semi-structured interview: Consultants 138 Appendix 25: Hospital service stakeholders’ interview questionnaire 139 Appendix 26: Facilitators: Anaesthetist interview questionnaire 139

12 ABBREVIATIONS 140

13 GLOSSARY OF TERMS 143 NHS Scotland

6 Tables Table 1: HNA approaches (Stevens and Raftery 1994) 17

Table 2: The distribution of children across the six-fold Urban-Rural Classification 20 Contents Table 3: Number of children active on SNS system in Scotland between 2011-2015 31 Table 4: Trends in incidence of oncology in children aged 0-17; 2005 - 2013 31 Table 5: Day case discharge rates per 100,000 population from acute hospitals by main diagnosis; children aged 18 and under 32 Table 6: Registration and participation rates of child patients in the GDS at 31 March 2014 and 2015 38 Table 7: GDS fees - total fees, cost per head of population of children 2013/14 39 Table 8: Main SDR item of service treatment claims for children from 2011/12- 2013/14 by GDS 41 Table 9: Childsmile service claims and value from 2011/12 to 2013/14 42 Table 10: Responding GDPs’ NHS Board area 43 Table 11: Preventive treatments provided by GDPs 43 Table 12: Challenges to providing the following treatments for child patients 45 Table 13: Reasons for referral to PDS 46 Table 14: Factors influencing GDPs’ decision to refer to a hospital rather than PDS 47 Table 15: Reasons for referrals to dental hospital 47 Table 16: Scottish DCP workforce August 2015 49 Table 17: Number of PDS clinics providing care for children by NHS Board 51 Table 18: Paediatric referrals to PDS by NHS Board 52 Table 19: Approximate referral rate for GA provision 52 Table 20: PDS workforce details by NHS Board 54 Table 21: Referrals received during four week audit and availability of a specialist 55 Table 22: Reason for the referral of children to the PDS (collated data) 56 Table 23: PDS clinic and SIMD 2012 quintile cross tabulation 57 Table 24: Total paediatric dental patient attendances 61 Table 25: New paediatric dental patient attendances 61 Table 26: Referrals received in the three centres over a month by condition 62 Table 27: Referrals received in the three centres over a month by condition for extraction only GA 63 Table 28: Cost of extraction only GA in the hospital setting as calculated by NICE (NICE 2010) 63 Table 29: Referrals received by GDH, EDI and DDH from within the NHS Board area 64 Table 30: Current hospital workforce 68 NHS Scotland

7 Figures Figure 1: The Wellbeing Wheel: the eight indicators of child wellbeing (SHANARRI) 22 Figure 2: Trends in the proportion of P1 children with no obvious decay experience, in Scotland; 1988-2016 26 Figure 3: Change between 2008 and 2016 in the proportion of P1 children in Scotland with no obvious decay experience, by SIMD quintile 27 Figure 4: Change between 2009 and 2015 in the percentage of P7 children in Scotland with no obvious decay experience; by SIMD quintile 28 Figure 5: Current service delivery model (patient journey pathway) 33 Figure 6: Number of children registered with a GDP (independent contractors) and PDS* in Scotland 34 Figure 7: Most common SDR IoS treatment-percentage of all claims; Scotland 2013/14 for children 40 Figure 8: Restorative treatments provided by GDPs 44 Figure 9: The dental team 48 Figure 10: Referrals received by the PDS for caries by age 58 Figure 11: Referrals received by the PDS for anxiety or phobia by age 59 Figure 12: Referrals received within the NHS Board areas of Greater

Oral Health and Dental Services for Children Needs Assessment Report Glasgow & Clyde, Edinburgh and Dundee, grouped by SIMD 64 Figure 13: GDH referrals for top five conditions with SIMD quintile 65 Figure 14: EDI referrals for top five conditions with SIMD quintile 65 Figure 15: DDH referrals for top five conditions with SIMD quintile 66 Figure 16: Referrals received by dental hospitals for all categories by age 66 Figure 17: Referrals received by GDH, EDI and DDH for caries by age 67 NHS Scotland

8 1 Executive Summary and Recommendations

This needs assessment of oral health and the recommendations arising and dental services for children was from it to improve services are listed in undertaken to assess the current service Sections 1.1 and 1.2. Lastly, this needs provision and to clarify the workforce assessment report was prepared before required to sustain the service. It was the Scottish Government Oral Health undertaken against the background of Plan consultation (2016), which touches improving child oral health attributed to upon some of the recommendations preventive initiatives such as Childsmile. made in this report. It also takes into account concerns that the age profile of paediatric- experienced dentists in Scotland 1.1 Key findings indicates a significant number will be lost from the service and from the

1.1.1 Oral Health Improvement, Executive Summary and Recommendations General Dental Council (GDC) specialist list over the next five to ten years. In Inequalities and addition, the current financial climate Demography can mean that clinical staff, experienced and trained in providing dental care for 1. In recent years child poverty has children, are not being replaced when increased in Scotland with the they either retire, or move to posts highest levels of poverty found in outwith Scotland. families with young children. Health inequalities between children living The report highlights a number of in poverty and their peers in more issues relating to the current service affluent areas of Scotland are delivery model in general dental significant and start early (Section services (GDS), hospital dental services 4.1). These have implications for (HDS), the Public Dental Service (PDS) dental health preventive initiatives and Childsmile. It also confirms that and services. inequalities still exist in relation to social and geographical factors such 2. Dental health has improved as deprivation, accessibility to services significantly, but a core of ‘hard and spread of population in rural to reach’ children, often with Scotland, and as such, these factors complex social challenges, remain, should be taken into consideration and inequalities still persist (Section when planning services. The report 4.4). There is a national oral health describes the current service delivery improvement programme for model and highlights the difficulties children (Childsmile) but there are and barriers experienced by service currently no artificial water providers, stakeholders and service fluoridation schemes in Scotland. users. In addition, national referral criteria have been developed which 1.1.2 Information could be adapted for local areas to address the more effective use of 1. While there is a wealth of evidence current services in PDS and HDS. At about the incidence of dental decay present the HDS is reported to receive (caries) in Primary 1 (P1) and 56% of referrals for the management Primary 7 (P7) school children, of severe caries, a significant proportion there is no national information of which could be treated in the PDS. about the levels of decay for children of preschool and secondary

Key findings from the needs assessment NHS Scotland

9 10 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report 3. PDS 2. 1. GDS 1.1.3 2.

Commonly, referralsweremade Dental careprofessionals(DCPs)are General dentalpractitioners(GDPs) The currentGP17/SDRsystemmay anaesthetic (GA)orsedation extraction undergeneral (61.5%), treatmentplanning for management ofanxiety andphobia reasons forreferralwere for reason. However, thecommonest to thePDSformorethanone (Section 6.1.2and6.2) provision ofdentalcareforchildren currently under-utilisedinthe (Section 6.1.1). the timetakenfortreatment ability tocooperateimpactson fees areinadequatewherechildren’s to childpatients.TheyfeltthatSDR spent onprovisionofdentalservices remunerated appropriatelyfortime believed thattheyarenot barrier totreatment.GDPs patient cooperationisamajor is unworkable.Theyindicatedthat felt thatthecurrentbusinessmodel conditions (Section8.1). palate orsignificantmedical with hypodontia,cleftlipand clinicsforchildren multidisciplinary including anyworkin carried outbyspecialistsinthePDS, not fullycapturetheprocedures (Sections 4.2and4.6). molar incisorhypomineralisation conditions seeninchildren,suchas prevalence ofotherdental national informationaboutthe school age.Furthermore,thereisno Service Provision Service

4. HDS 7. 6. Patients 5.

The commonestreasonforreferral Specialist careforchildrenin Patients preferredtobeseenlocally More thanhalf(56%)ofthe (Section 6.3.2). and haematologicalconditions children withoncological,cardiac their oraldisease.Theseincluded from thetreatmenttomanage at risk,eitherfromdentaldiseaseor medical conditions(26%)whowere group asawholewerepatientswith most commonlyreferredpatient severe caries(56%).Thesecond wasforthemanagementof service of childpatientstothehospital (Section 6.2.2). severe childhoodcaries(42.2%) (52.7%) andthemanagementof be seen(Section7.1and 7.2). busy andtheyhadto wait longerto wasgoodbut the hospitalservice easier toaccess.Theyreportedthat totheHDSbecauseitis service patients preferredthePDSspecialist Some the participantsinterviewed. by considered anessentialservice the PDSwashighlyvaluedand (Section 7.2). specialist paediatricdentalservice be unawareofthelocalPDS hospital. SomeGDPsappearedto rather thantravellingtoadental 6.3.2). Deprivation (SIMD)quintile(Section Scottish IndexofMultiple area werefromthemostdeprived Hospital fromwithintheNHSBoard children referredtoGlasgowDental

8. In some hospitals patients qualifications (Section 6.2.1 and experienced delays due to Table 20). communication or administration problems (Section 7.2). 2. Only three NHS Boards in Scotland currently employ specialists in 9. In some dental hospitals, some paediatric dentistry within their parents or carers were unable to PDS (NHS Greater Glasgow & recall the information relating to the Clyde, NHS Lothian and NHS Fife, risks of GA that had been presented whole time equivalent (WTE) 4.12 to them while obtaining consent, on March 2016). In some areas, with some parents of child patients the PDS may not be making the who had undergone GA reporting best use of staff and their skills, that they had not been made aware for example, in two NHS Boards of any risks. However, for many trained specialists are employed as Executive Summary and Recommendations of the patients referred with pain non-specialists (dental officer or and infection who were also senior dental officer) (Section 6.2.1 dentally anxious, it was recognised and Table 20). that there was no realistic option other than GA. Therefore, the risk 3. There is evidence that the number benefit ratio is very different from of specialists in training is most other areas of dentistry inadequate to maintain succession (Section 7.2). planning for current levels of service provision or for any future service 10. Parents of some children with developments (Section 8.1). additional support needs felt that their children would cope better if 4. The number of paediatric staff in treated at the familiar setting of the HDS is small, with a total WTE school rather than being referred to of 13.1 for specialists and hospital (Section 7.2). consultants in paediatric dentistry. Elsewhere in the UK an alternative 11. Dental disease and the model of consultants working in the development of anxiety can impact community has been developed, on a child’s wellbeing (Section which may help maximise access to 6.2.2). It is also recognised that this highly specialised resource the development of anxiety may (Section 6.3.3). be multifactorial and there are some children who access dental care 5. As the number of paediatric staff is but do not present to other small, they are stretched. services. Therefore, dental teams Consultants are often asked to caring for children have an integral, undertake extra clinics to meet the and increasing, role in recognising waiting time guarantee and in wellbeing concerns. some areas, prospective cover for colleagues’ leave has become the 1.1.4 Workforce and Training norm. There appears to be stress in all parts of the profession 1. Many working in the PDS are (Section 8.2). dentists with an interest in treating children and some have obtained

relevant additional postgraduate NHS Scotland 11 12 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report 3. programme. 2. 1. 1.2.1 1.2 6. Ratio Specialist andConsultant-Population

Population-based oralhealth Despite improvements,oralhealth The totalnumberofspecialistsand Population programmes should to demographicchanges, suchas be sustainableandadaptable be consideredbytheChildsmile to reduceinequalities,andshould targeting ofresources isrequired Childsmile, mustcontinue.Further carefocus,suchas primary improvement programmeswitha including oralhealth. to ensureimprovementsinhealth, of healthwhichmustbeaddressed it isthesewiderdeterminants determined bymyriadfactors,and including dentalhealth,is inequalities persist.Health, require anincreasedratio. rural areasofScotlandwhichmay not takeintocognisancethelarge UK-level recommendationdoes head ofchildpopulation.This of onespecialistper20,000 (BSPD) recommendedratio Society ofPaediatricDentistry’s population, incontrasttotheBritish specialist per52,000headofchild representing aratioofone (WTE) asonMarch 2016, (HDS andPDS)atpresentis17.2 consultants inpaediatricdentistry Demography Inequalities and Oral HealthImprovement, Recommendations

1. 1.2.2 Information inequalities. 4. surveillance. 3. 2. welcomed.

Improving dataqualityand A properlydesignedandresourced Opportunities foruseofroutine In additiontothenewinformation Services Division(ISD) shouldbe Services for submissiontotheInformation capture foralldentalhealthservices to improveoralhealthandreduce continue todeveloppolicies the meantime,NHSBoardsshould socioeconomic circumstances. In evaluate efficacyinthecurrent be conductedinScotlandto trial ofwaterfluoridationshould refugee children. recent increaseinnumberof increasing deprivationandthe (MIH), innationaloral health molar incisorhypomineralisation conditions forchildren, forexample information regarding otherdental should begiventoinclude investigated. Considerationalso shouldbe data forsurveillance school. secondary decay forchildrenatpreschooland to includinginformationregarding extended andconsiderationgiven The scopeofNDIPshouldbe delivery/improvement. and service to informtheoralhealthofchildren Programme (NDIP)ismaintained that theNationalDentalInspection gained fromGP17s,itisessential tooth specificdatafromGP17sare developments suchascollecting Recent a moreefficientservice. andensure to monitordelivery considered asapriority, inorder

1.2.3 Service Provision and non-specialists, therapists and hygienists (working to their full 1. The majority of routine paediatric scope of practice) and middle tier care should take place in the GDS. career grade PDS and HDS staff. In GDPs should proactively refer addition, a national managed patients to specialist services when clinical network should be indicated. considered to address the needs of more rural areas of Scotland, 2. The current system of remuneration for example in the north of through item of service is perceived Scotland. These networks will also to be unfavourable. Therefore need to engage with the emerging consideration should be given to Health and Social Care Partnerships make payments taking into account in relation to service delivery, to the time-consuming nature of ensure the needs of the local Executive Summary and Recommendations providing routine treatment population are being met. for many children. The Scottish Government has recently consulted 6. A number of pathways should be on an Oral Health Plan (2016) developed across Scotland, which includes proposals for future including for the following systems of remuneration. groups:

3. National PDS and HDS referral a. An accessible care pathway for criteria should be developed and dental trauma patients, including agreed at NHS Board level out-of-hours service.1 (Appendix 1 details proposals for national referral criteria), then b. A pathway of support to widely disseminated to promote promote attendance and follow- greater consistency across all up of children who are NHS Boards in how child patients identified at high-risk of dental are accepted, treated and returned disease, utilising the Childsmile to primary care providers. dental health support worker (DHSW) network, and 4. The PDS should be developed emphasising primary prevention nationally as an important part of as well as considering any paediatric care, forming the bridge underlying social factors. between the GDS and HDS. The middle grade of HDS staff should c. Dental assessment for patients also be expanded. with significant chronic medical conditions should be 5. Local managed clinical networks standardised, evaluated and (MCNs) should be established reported nationally so as to and should be based in primary improve surveillance and the and secondary care to encourage standardisation of access to service integration. MCNs should specialist-led and consultant-led include consultants, specialists care.

1 http://www.dentaltraumaguide.org NHS Scotland 13 14 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report 4. 3. technique. 2. 1. 1.2.4 7. Health Plan 2 Thisshouldbeaspartofthe dentalworkforce reviewconsideredbytheScottishGovernment Oral

There shouldbeongoingtraining DCPs arecurrentlyunder-utilised To enhancethedevelopmentof A nationalworkforce strategy The patientjourneyshouldbe DHSW roleandtheircontribution and developmentofthe Childsmile their fullscopeofpractice. and mustbeenabledtowork management andtheHall additional needs,anxiety management ofchildrenwith be offeredtoGDPs,includethe training. Inaddition,coursesshould continue tosupportPDSstaff networks, consultantsshould development. and service the needsforsuccessionplanning of trainingpostsrequiredtomeet should alsoadviseonthenumber demandsand needs.It service and specialistpostsneededtomeet a reviewofnumbersconsultant be developed. should for paediatricdentistry e-referral andteledentistry. example, forcommunication, as theuseoftechnology, for improvement indicators,aswell quality assuranceand to thedevelopmentofnational consideration shouldbegiven improved andtherefore d.

A standardisedpathwayfor allow themtobeprioritised. dental painandinfection,to onward referralforpatientswith Workforce andTraining 2 Thisshouldinclude

5.

All membersofthedentalteam considered mandatory. in theGIRFECapproachmustbe for anyanxiety. Therefore,training other potentialunderlyingreasons when caringforchildrentoconsider Child(GIRFEC)approach Every also usetheGettingitRightfor child’s wellbeing.Theyshould oral healthanddentalcareona should bemindfuloftheimpact wellbeing agenda. to thewiderchildren’s healthand

2 Background and Context

Oral health is defined as the ‘standard outcomes for children living in poverty of health of the oral and related tissues and those who do not remains wide which enables an individual to eat, in terms of standard of living, quality speak and socialise without active of life, opportunities and educational disease, discomfort or embarrassment achievement. In addition, health and which contributes to general inequalities between children living in wellbeing’ (Department of Health, poverty and their peers are significant

1994). Good oral health is an important and start early (Save the Children, Background and Context component of overall general health 2014). and quality of life. Oral disease is still a major public health problem in high- The Scottish Government investment in income countries (Petersen, 2008). In the nursery toothbrushing component Scotland, dental health is widely used of the national Childsmile Programme as an ‘indicative measure’ of a child’s to prevent childhood dental decay general health. This is because it reflects has provided savings of approximately a key ‘outcome’ of good parental care £5 million in dental treatment during the pre-school period (Scottish between 2001-2002 and 2009-2010 Government, 2014b). Dental health has (Anopa et al., 2015) and has started an impact on child wellbeing because to reduce the gap between affluent of the consequences of dental disease and deprived communities. However, such as pain, loss of sleep, reduced whilst there have been improvements quality of life and disruption to a child’s in the oral health of children, there education. remains a group of children, mostly in deprived areas, who are hard to reach. The Scottish Government’s Furthermore, there are still significant implementation of the Children and numbers of children who require Young People Scotland (CYP) Act dental extractions under GA and this (2014) has put child wellbeing at remains the most common elective the centre of health and social policy surgical procedure (Information Services (Scottish Government, 2014a). The Division, 2016). These children often CYP Act is the first piece of legislation have complicated social care needs, and since the Disability Discrimination Act therefore there can be a requirement for (2003) likely to impact on and change specialist paediatric dental services. In the behaviour of health professionals, addition, more children are now living as it makes any concerns about child with complex medical conditions than wellbeing ‘everyone’s business’. in the past, further necessitating the The links between oral health and need for the specialist paediatric dentist. deprivation are well established and one of the aims of this report was to ensure In the recent past, the North of that paediatric dental services in their Scotland (NoS) region reviewed their widest context are sufficient to support specialist paediatric dental services the aims of the Act. and found them to be inconsistent. The specialist or consultant input was In Scotland, one in four children variable across the six NHS Board (200,000) live in families whose areas of Grampian, Highland, Tayside, income is 60% below the average. Orkney, Shetland and Western Isles. The highest levels of poverty can be There was also little specialist paediatric found in families with young children. input in the PDS, although this was

The evidence shows that the gap in also the case for other specialist dental NHS Scotland

15 16 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report development. recommendations forfutureservice andalsomakes to sustaintheservice seeks toclarifytheworkforce required outwith Scotland.Finally, thereport they eitherretire,ormovetoposts for childrennotbeingreplacedwhen and trainedinprovidingdentalcare can resultinclinicalstaffexperienced the currentfinancialclimate,which list overthenextfivetotenyears,and will belostfromtheGDCspecialist dentists, asignificantnumberofwhom age profileofpaediatric-experienced the profession.Thesepertainto Government, aswellconcernsfrom preventive initiativesbytheScottish oral healthofchildrenarisingfrom such asdeprivationandtheimproving report willtakeintoaccountfactors scope ofwhichisdefinedbelow. This specialist paediatricdentalcare,the delivering in particulartheservices acrossScotland, and dentalservices within thecurrentchildren’s oralhealth Assessment willevaluatetheprovision (SDNAP), thisOralHealthNeeds Dental NeedsAssessmentProgramme Under theauspicesofScottish target. nationally throughawaitingtime the treatment,asthisismonitored not necessarilywaitinglongertostart treatment course.However, theywere were waitinglongertocompletea the needandthereforepatients levels werenotadequatetomeet staffing service paediatric dentistry Scotland alsoreportedthatspecialist Group, 2014).Otherregionsof expertise (NorthofScotlandPlanning these needs’(Wright, 2001).Stevens recommendations forchangestomeet care needsofapopulationandmaking identifying thepublichealth,health defined as‘asystematicmethodof Health NeedsAssessment(HNA)is 2.1 problems (BSPD,2009). psychological, and/oremotional intellectual, medical,physical, care forchildrenwhodemonstrate birth toadolescence,including oral healthcareforchildrenfrom the comprehensiveandtherapeutic practice, teaching,andresearch into isdefinedasthe Paediatric dentistry summarised inTable 1. The workinvolvedintheseareasis to HNA(Stevens&Raftery, 1994). corporate andcomparativeapproaches characterised astheepidemiological, needs forhealthcare.Theseare approaches toassessingpopulation described thecommon and Raftery Assessment Health Needs Table 1: HNA approaches (Stevens and Raftery 1994)

HNA approaches Work involved Epidemiological Description of the problem Incidence and prevalence Availability, effectiveness and cost-effectiveness of interventions/services Background and Context Possible models of care Outcome measures. Corporate Assessment of stakeholder perception, which includes professional and patient/public groups. Comparative Comparative study of the services/service models provided in one region with those available elsewhere.

The aim of a HNA is to maximise task in an evidence-based way. The appropriate effective health care/policy, current needs assessment used all of while minimising both the provision of these approaches. ineffective health care/policy and the existence of unmet need. As such HNA provides a systematic framework for undertaking a complex and important NHS Scotland

17 18 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report • services • • • • • • Scotland • to: The objectivesoftheassessmentwere 3.2 recommendations. andmake probable gapsinservice NHS BoardsacrossScotland,identify provisionforchildreninall services assessment oforalhealthanddental The aimistoconductaneeds 3.1 3 Aim,ObjectivesandMethods

services inScotland. services ofpaediatricdental the delivery Make futurerecommendations for Identify gapsin,andbetween,the model dentistry concerning thecurrentpaediatric usersandstakeholders of service Determine theperceptions and modelsofcare DCPs, andproposenewpathways deliveredby including services model, current paediatricdentistry providersconcerning the service Determine theperceptions of for children dental services Analyse thecurrentworkforce in children inScotland for health anddentalservice Determine thedemandfororal in Scotland provision forchildren dental service Describe thecurrentoralhealthand epidemiology amongchildrenin Describe currentoralhealth Objectives Aim

• • sources • • • A rangeofmethodswasused: 3.3 • • • • • •

consultant workforce PDS specialistandhospital with Semi-structured interviews GDP andDCPsurveys Data fromnationalreportsanddata Office forScotland) (formerly theGeneralRegister National RecordsofScotland caredata) and primary Data collectionfromISD(hospital Headline Report. Data fromChildsmileNational of disease poorest areaswithgreatestburden using NDIPdata-childrenfromthe Analyses oforalhealthinequalities including activity ofclinicaldirectors ofPDS, Survey received inPDSandHDS Prospective auditofreferrals withpatients Structured interviews hospital stakeholdersandfacilitators with Semi-structured interviews Methods

3.4 Scope and Limitations

This report addresses the oral health service provision to children within the National Health Service (NHS) and as such includes care provided in primary, secondary and tertiary care settings within the GDS, PDS and HDS. Private practice provision is outwith the scope Aim, Objectives and Methods of this report.

Cleft Care Scotland Service provided to cleft lip and palate patients is not specifically included in the report, as it is managed nationally.

The age definition of ‘child’ can vary depending on the context. For the purposes of this report, a child is anyone who is under the age of 18. However, it is acknowledged that the age range might vary from service to service, and some reports or data sets may use different age ranges.

3.5 Ethical considerations

Ethical approval was sought from the West of Scotland Research Ethics Service in November 2012. The response of the committee stated that ethical approval from an NHS Research Ethics Committee was not required as the project was considered to be service evaluation and not research.

Participants were advised about the

response from the Ethics Committee and informed consent was obtained from each participant prior to taking part in the needs assessment. NHS Scotland

19 20 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report • • Mobility &ChildPoverty: 2014 reportpublishedbySocial According totheStateofNation Source: RuralScotlandinFocus,2014(Skerratt Classification Table 2:Thedistributionofchildrenacrossthesix-foldUrban-Rural projected torisebyonlyfivepercent number ofchildrenagedunder16is five consecutiveannualdecreases.The rise inthenumberofbirthsfollowing more thanin2013.Thiswasthefirst 56,725, whichis711(1.3percent) registered inScotland2014was be under16.Thenumberofbirths of thetotalpopulationestimatedto Records ofScotland,2014)with18.5% 1,096,763 (0-18years)(National Scotland hasachildpopulationof 4.1 4 IntroductiontoChildren’s OralHealth Total %of0-16years Remote RuralAreas Accessible RuralAreas Remote SmallTowns Accessible SmallTowns Other Urban Large Urban Urban-Rural previous year poverty -alsoup30,000 onthe 200,000childrenare in absolute than lastyear poverty inScotland-30,000more 180,000 childrenliveinrelative Demography Child Populationand 18.5% 18.4% 20.0% 18.4% 19.4% 19.1% 17.4% total population Percentage ofchildren(0-16years)within

etal ., 2014) inequalities. is likelytoleadincreasing health of MedicalSciences,2016), which 2.6 millionin2009/10)(TheAcademy (3.3 millionby2020/21comparedwith numbers ofchildreninrelativepoverty The UKcanexpecttoseegreater • al Urban-Rural Classification(Skerratt under 17yearsacrossthesix-fold the distributionofScottishchildren National Statistics,2012).Table 2shows Glasgow andEdinburgh(Officeof concentrated inthecentralbeltaround Scotland’s landareaandaremainly These areascoverlessthan6%of with apopulationofmorethan3,000). population liveinurbanareas(those In Scotland,morethan81%ofthe Scotland, 2014). 2012 and2037(NationalRecordsof from 0.91to0.96millionbetween ., 2014). by localauthorities. population arebeinglookedafter 15,580 (1.4%)ofthe0-17

et

4.1.1 Child Protection Register • 19% (9,682 children) of all 27-30 month reviews recorded at least Information about children registered one concern in an aspect of the on the Child Protection Register is as child’s development follows (Scottish Government, 2015a): • Children from the most deprived • Between 2000 and 2014 the areas were more than twice as likely number of registrations has to have at least one developmental increased by 41% (2,050 to 2,882 concern identified (27%) compared respectively) with those in the least deprived areas (12%)

• Since 2008 there have been more Oral Health Introduction to Children’s children aged under five than over • Boys were considerably more five on the Child Protection Register likely than girls to have at least one developmental concern identified • In 2014 53% of children registered (24% compared to 14% were aged under five respectively) • 25% of children reported as ‘Asian’ • In 2014 there was a much larger or ‘Black, Caribbean or African’ had increase in the number of those at least one developmental concern aged five and over than has been identified compared to 19% in the seen in recent years – a 15% ‘White Scottish’ ethnic group. increase from 2013. Children’s dental status is regularly It is of interest to note that the GDC reviewed by health visitors as part now recommends child protection of the CHSP. The Universal Health training as one of the ‘core’ topics for Visiting Pathway in Scotland (Scottish continuing professional development Government, 2015b) describes the (CPD). role dental health plays in their overall assessment of a child’s health and 4.1.2 Child Health Systems wellbeing needs. This programme, Programme which is currently being implemented, consists of eleven home visits to all In Scotland child wellbeing is supported families, eight within the first year of through the provision of a universal life and three Child Health Reviews health programme to all children and between 13 months and four/five years their families, known as the Child Health of age. Systems Programme (CHSP). It consists of elements such as formal screening, The wellbeing of children and young routine childhood immunisations and people is at the heart of GIRFEC. In the a programme of needs assessments Scottish context wellbeing is described and reviews. In 2014/15, the 27-30 using the Wellbeing Wheel (Figure 1). month review for Scotland showed The approach uses eight indicators to (Information Services Division, 2015a): describe wellbeing at home, in school and in the community, which are: Safe, • 87% (50,956) of children had had a Healthy, Achieving, Nurtured, Active, review by the age of three years Respected, Responsible, Included. The indicators are commonly referred to by

their initial letters ‘SHANARRI’. NHS Scotland 21 22 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report overlapping. Whenconsideredtogether not discrete,butareconnectedand In practice,theeightindicatorsare (SHANARRI) Figure 1:TheWellbeing Wheel:theeightindicatorsofchildwellbeing young person. they giveaholisticviewofeachchildor 4.2 Common Oral Diseases • Developmental defects of enamel arise in the developing tooth from of Childhood a variety of causes, including trauma, excessive fluoride, The most common dental disease is infections and nutritional caries (decay). It is a multifactorial, disturbances Usually, there is dynamic disease, caused by the action minimal effect on the long-term of plaque bacteria and fermentable health of the mouth. carbohydrate on susceptible tooth surfaces over time. The bacteria in 4.2.1 Modifying Risk Factors the mouth metabolise dietary sugars, producing acids which dissolve the In addition to the above conditions, Oral Health Introduction to Children’s outer layers of the teeth (enamel and there are a number of modifying risk dentine). It is important to note that factors which can also impact on dental decay is an entirely preventable disease development as follows: disease. It shares common risks factors with other diseases such as diabetes • Biological risk factors such as and obesity and therefore advice to nutrition and obesity, oral hygiene, reduce sugar intake can have wider fluoride levels in water and injury health benefits. As with other chronic to teeth diseases, dental decay is more prevalent in areas of deprivation. However, • Social risk factors include lack of there is evidence to demonstrate that access to dental care and oral Childsmile has made some progress in health improvement initiatives narrowing the inequalities gap arising from geographical location (Section 4.4). and deprivation, vulnerable groups such as children from Black and Caries prevalence data are collected Minority Ethnic (BME) communities annually in Scotland within NDIP and travelling communities, those (Section 4.4). Other dental conditions with special needs, and looked after that occur less frequently in children and accommodated children are listed below, although there are no (LAAC). There has also been a prevalence data available for Scotland: recent arrival of refugee families who could also be considered • Dental erosion is the progressive

vulnerable loss of the hard component of the teeth, enamel and dentine, resulting • Medical risk factors include children from chemical action on the teeth, diagnosed with a high-risk medical other than that which is caused by condition, for example,

bacteria. Causes include carbonated haematology, cardiology, metabolic, (fizzy) acidic drinks and respiratory and psychiatric consumption of acidic fruit drinks • Behavioural risk factors include • Accidental damage to teeth is one children with special needs, for of the commonest reasons for example, dental anxiety, learning young children attending health disability, autistic spectrum disorder services for treatment of trauma (ASD) and attention deficit hyperactivity disorder (ADHD). NHS Scotland

23 24 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report • provided tothem: on thehealthofchildrenandservices pieces oflegislationwhichwillimpact There areseveralimportantpoliciesand 4.3 years ofage. intake inadultsandchildrenovertwo should notexceed5%oftotalenergy recommendation thatsugarintake disease inScotland,andincludedthe burden ofobesityanddiet-related changeneededtoreducethe dietary new goalsindicatetheextentof the intakeofsugarandfibre.These updated recommendationsconcerning Committee onNutrition(SACN) the independentScientificAdvisory Goalstoreflect the ScottishDietary the ScottishGovernmentrevised 2018. Furthermore,inMarch 2016, This willbeimplementedfrom to tackletheriseinchildhoodobesity. announced asugartaxonsoftdrinks The UKGovernmentrecently review bythe SupremeCourt(2016). age children.Thisiscurrently under pastoral responsibilities forschool teacher orsenior with pre-school childrenand ahead would likelybeahealth visitorfor young person.TheNamedPerson childand Person availabletoevery makingaNamed Person service NHS BoardsprovideaNamed proposes thatlocalauthoritiesand currently beingdiscussedwhich approach. Thereislegislation the principlesofGIRFEC impetus totheimplementationof The Actwillalsoprovidelegislative ofpolicies andservices. delivery properly influencethedesignand to ensurethatchildren’s rights People (Scotland)Act2014 The ChildrenandYoung Policy andLegislation

aims

• wellbeing • • • • It isproposedtheNamedPersonwill: • • done. • tasks to’childrenandparents. out and childrenratherthan‘carry Work inpartnershipwithparents ofchild’sHave anoverview provider service child oryoungpersonwithanother Discuss orraiseamatterabout or support or theirparents,toaccessaservice Help thechildoryoungperson, of thechildoryoungperson child oryoungperson,aparent Advise, informandsupportthe under theAct, oneofwhichisage. are nine‘protectedcharacteristics’ equality ofopportunity forall.There rights ofindividualsand advance legal frameworktoprotect the The EqualityAct2010 designing services. and principlestoreferwhen young peopleonthekeypolicies guide forprofessionalsworkingwith Valuing Young People(2009) out to: The EarlyYears Collaborative • • is knowntoworkandwhat bridge thegapbetweenwhat improvement methodologyto want tomakeimprovements experts inareaswherethey other andfromrecognised can easilylearnfromeach Community PlanningPartners Support theapplicationof Create astructureinwhich providesa sets isa

• The Protection of Vulnerable document are touched on in this Groups (Scotland) Act 2007 report, namely a workforce review, sets out the legislation compelling the development of locally governments to establish commissioned services and a review mechanisms to enhance the of the Childsmile programme, protection of vulnerable people, particularly use of national SIMD to including older adults and young target resources to those most in people, from abuse and neglect. need, with the potential for additional funds being allocated to • The Public Bodies (Joint Working) more deprived communities. (Scotland) Act 2014 sets out the

legislative framework for integrating Oral Health Introduction to Children’s health and social care, to support 4.4 Epidemiology improvement of the quality and consistency of health and social care 4.4.1 National Dental Inspection services in Scotland. It came into Programme (NDIP) being on April 1 2016 and brings together NHS and local council The inspections are carried out annually care services under one partnership in each NHS Board across Scotland for arrangement for each area. The P1 and P7 children. Caries data are Health Board and local authority collected by calibrated clinicians within delegate the responsibility for the PDS and are comparable year-on- planning and resourcing service year. While NDIP is resource intensive provision for health and social care for the PDS to deliver, the programme services to an Integration Joint provides a number of significant Board (IJB). In many areas, primary benefits. In addition to informing care services, including GDS and parents/carers of the oral health the PDS, are now ‘hosted’ by a status of their children, by gathering Health and Social Care Partnership. aggregated, anonymised data about This may have implications for children’s decay experience, it provides service delivery in the future, as a means of monitoring oral health the new partnerships seek to deliver improvement and evidence to support services to meet the needs of their planning for both policy and service local population. development.

• The Scottish Government Oral The collection of tooth-specific data Health Plan consultation from submitted GP17 forms was document (2016) sets out introduced in 2016. It is anticipated proposals for the future provision of

that, over time, this will provide a dental services and preventive source of detailed information about programmes, as well as proposals the prevalence for oral disease in all age for structural changes in the way groups across Scotland. services might be delivered. Several proposals in the consultation NHS Scotland

25 26 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report Sources: ISDNDIPDatabase,SHBDEP 62.8% (d untreated decayinthis agegroupis taken intoaccount,the trueextentof frequently underGA.When thisis normally dealtwithby extractions, or crowns).Themostseveredecayis has beentreatedbyrestoration(fillings measures theproportionofdecaythat The CareIndex(ft/d decay isuntreated. affected is3.93.Themajorityofthis dentine, theaveragenumberofteeth children whohaveobviousdecayinto throughout thepopulation.Of However, decayisnotevenlyspread over thesameperiodfrom2.76to1.21. teeth intheP1populationhasdropped of decayed,missingandfilled(d Correspondingly, themeannumber experience, inScotland;1988-2016 Figure 2:Trends intheproportionofP1childrenwithnoobviousdecay slight improvementbetween1996and was fairlystaticfollowedbyaperiodof of P1childrenfreefromobviousdecay Between 1988and1996theproportion 4.4.2

% with no obvious decay experience 100 10 20 30 40 50 60 70 80 90 0 Primary 1(P1)Inspection Primary 1988 42 3 t/d 3 1990 mft x100). 41 1992 44 3 mft x100) 1994 38 1996 41 3 mft) 1998 43 2000 45 2003 Year 45 (Figure 2). markedly from45%to69% obvious decayintodentineincreased percentage ofP1childrenwithno that between2003and2016the 2003. However, Figure2shows disease than in2005. decay in2015hasalighter burdenof experience ofdecay, buteachchildwith Not onlydofewerchildren inP7have decay experiencefrom 2.72to2.16. improvement inD distributed, buttherehasbeenan the P1children,decayisunevenly reduced, from1.29to0.53).Asseenin halved between2005and2015(D in theP7populationhasmorethan The numberofteethaffectedbycaries fiveyears. improve overtheintervening obvious cariesandthishascontinuedto 60% ofP7childrentobefreefrom NHS Boardsmetthe2010targetof from obviouscariesintodentine.All 75% ofScottishP7childrenwerefree The 2015NDIPreportshowedthat 4.4.3 2004 51 Primary 7(P7)Inspection Primary 2006 54 2008 58 3 2010 MFT forthosewith 64 2012 67 2014 68 2016 69 3 MFT The Care Index has improved from no obvious decay experience; young 36.4% in 2005 to 55% in 2015. children in Scotland are less likely to However, it should be noted that after have a history of caries than those living a significant increase between 2005 in Wales or the North West of England and 2007, improvements since then (Monaghan et al., 2014). However, have been modest. In addition, the despite overall improvements in oral data showed that 29.4% of sound health, major inequalities in dental permanent molars were fissure sealed health outcomes, reflecting social and in the Scottish P7 population, with NHS economic inequalities, persist. Board figures ranging from 18.5% to 57.5%. The NDIP reports confirm what is widely recognised, that children living Introduction to Children’s Oral Health Introduction to Children’s in relative material deprivation have 4.4.4 Patterns of Decay and consistently higher levels of decay Inequality than their more affluent peers. These inequalities can be highlighted by A decade ago, children in Scotland used mapping ‘obvious caries’ against to have the highest decay rates in the deprivation (measured by SIMD). Using UK, but since the national introduction this approach, the 2016 P1 NDIP Report of the Childsmile programme in shows that 55% of children in the most 2009/10, the oral health of children has deprived group are free from obvious significantly improved. Latest data show caries compared with 82% in the least that 69% of five-year-old children had deprived (Figure 3).

Figure 3: Change between 2008 and 2016 in the proportion of P1 children in Scotland with no obvious decay experience, by SIMD quintile

Sources: ISD NDIP Database, SHBDEP NHS Scotland

27 28 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report Government, 2016a). of childrenacrossScotland(Scottish as continuingtoimprovetheoralhealth the aimofreducinginequalities,aswell be metbyNHSBoards2022,with which hassetnewP1andP7targets,to produced anOutcomesFramework The ScottishGovernmenthasrecently obvious decayexperience. the 2010nationaltargetof60%withno the firsttime,allquintilesreached most deprivedquintiles,andin2013for inthe improvement hasbeenobserved Crucially, intheP7 populationthemajor Sources: ISDNDIPDatabase,SHBDEP Scotland withnoobviousdecayexperience;bySIMDquintile Figure 4:Changebetween2009and2015inthepercentage ofP7childrenin in SCIM10from14.49to8.22. 2016, therehasbeenanimprovement health inequality. Between2008and a smallandrecentreductioninoral Inequality Metric(SCIM10)shows In addition,theScottishCaries approach (Marmot&Bell,2012). principles arealsosupportiveofthis of MedicalSciences,2016).TheMarmot traditional healthsector(TheAcademy of thesedriversmaybeoutsidethe inequalities, bearinginmindthatsome will berequiredtotacklethesepersistent A broaderviewofthedrivershealth in overallhealth,includingoralhealth. are addressedtoensureimprovements that thewiderdeterminantsofhealth myriad factors,soitisalsoimportant therefore, oralhealth)isdeterminedby In itswidestcontext,health(and (Figure 4). proportion freefromobviouscaries has shownanimprovementinthe and 2015eachdeprivationquintile demonstrated thatbetween2009 The 2015NDIPP7report 4.5 Preventive Care dental nurses (EDDNs), trained in the application of fluoride varnish, aided by Dental decay is an entirely preventable DHSWs. All children are encouraged to disease. The 2015 Cochrane Review register with a dental practitioner and at found that water fluoridation is effective each stage, children who require further at reducing levels of tooth decay among assessment and possible dental care children although the findings were will be identified and sign-posted to a based on older studies that may not dentist. be wholly applicable today. Currently there are no artificial water fluoridation Childsmile Practice Programme schemes in Scotland. In the absence Childsmile Practice is introduced to of such universal measures, clinical families by the health visitor, who Oral Health Introduction to Children’s prevention is delivered by dental team reinforces key oral health messages, members in various care settings. In including the benefit of child dental addition to care in the dental surgery, registration by six months of age there is also a national initiative across (Section 4.1.2). For the most vulnerable Scotland for improving oral health. families, a DHSW provides home support, preventive advice and assistance 4.5.1 Childsmile in attending a primary care dentist. Once the family registers with a dental Childsmile is Scotland’s national oral practice, prevention, including fluoride health improvement programme for varnish is offered along with any children, and has three main elements. treatment the child may need.

Core Programme Every child is provided with a dental 4.6 Demand pack containing a toothbrush, fluoride toothpaste and oral health messages, The Childsmile programme is widely on a least six occasions by the age of recognised as helping to reach children five years. Children also receive a free- who, in the past, may not have accessed flow feeder cup by the age of one year. anything other than emergency dental In addition, every three and four-year- care. It may be, however, that the old child attending nursery is offered success of Childsmile is drawing children free, daily, supervised toothbrushing. into dental care pathways who were

Supervised toothbrushing is also offered previously unknown to services. While to Primary 1 and Primary 2 children in in the long-term this should improve targeted schools. the overall dental health of Scotland’s children, the demand on the more Childsmile School and Nursery specialist dental services to support these

Programme children seems to be increasing. The Throughout Scotland, children with demand for paediatric dental services is the highest levels of need are offered expected to increase as the preventive fluoride varnish application twice a year initiatives, such as Childsmile, support at primary school and nursery. Fluoride people to access dental care. varnish is applied by Childsmile dental teams. These comprise extended duties NHS Scotland

29 30 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report readily quantified. therefore thesegroupscannotbe requiring complextreatment,and who presentwithdentalanxietyor routinely collecteddataforchildren 4.6.1 to4.6.3.However, thereareno are exploredinmoredetailSections data respectively),andthereforethey categories (NDIP, SNSandSMR01 within thefirstthreeofthese are availableforchildrenpresenting given time.Nationalprevalencedata have morethanoneconditionatany It shouldbenotedthatchildrenmight treatment. • • • • categories: referred belongtothefollowing Section 6.However, ingeneral,children aredetailedin paediatric dentalservices Referral patternstothespecialist Children requiringcomplex cardiac conditions(SMR01data) oncological, haematologicaland conditions, forexample, Children withhigh-riskmedical System SNSdata) coordination needs(SupportNeeds Children withsupportandcare (NDIP data) Children withextensivedecay

extractions underGA.Thecostpercase often requirehospitaladmissionfor Children withextensivedecay schoolage. preschool andsecondary regarding decayforchildrenof PDS orHDS.Thereisnoinformation or mightbereferredeithertothelocal care, be routinelytreatedinprimary the disease,thesechildrencaneither 2016). Dependingontheseverityof Dental InspectionProgramme2015, caries canbeconsiderable(National the burdenofdecayforthosewhohave some formofdecay(Section4.4),and of P7andathirdP1childrenhave According totheNDIPreportsaquarter 4.6.1 dental treatment. the HDS,iftheirdisabilityaffects are commonlyseenbythePDSorin disability (Table 3).These children child populationhavesomeformof According totheSNSdata1.41%of disabilities andimpairmentssection. or condition,includingadetailed accurate detailsofthechild’s problem that providesthefacilitytorecord SNS isasophisticatedclinicaltool 4.6.2 costs arelikelytobesimilar. figures applytoEngland,theScottish Excellence, 2010).Althoughthese Institute forHealthandClinical sedation costing£213.01(National Excellence (NICE)as£719.90,with National InstituteforHealthandClinical was calculatedbythe for thisservice decay Children withextensive Care CoordinationNeeds Children withSupport& Table 3: Number of children active on SNS system in Scotland between 2011-2015

Year Number of Mid-year child % of child children active population population on SNS estimate on SNS 2011 15,682 1,116,059 1.41 2012 15,967 1,113,114 1.43 2013 16,132 1,110,845 1.45 2014 15,892 1,106,294 1.44 2015 15,563 1,103,149 1.41 Introduction to Children’s Oral Health Introduction to Children’s Source: Support Needs System, August 2011 - August 2015

However, SNS has not been disease can have an even greater implemented in all NHS Boards impact on children with medical across Scotland and the level of conditions, the prevention of dental implementation and utilisation of the disease is of utmost importance and system varies in those Boards that do therefore parents and carers, as well use SNS, therefore these figures are an as the wider dental team including underestimate of the true numbers. DHSWs, should be involved.

4.6.3 Children with High-Risk With the exception of children Medical Conditions, for diagnosed with oncological conditions, example, Oncology, the number of children diagnosed Haematology and Cardiac with high-risk conditions is not usually recorded. Table 4 shows the number of Children with high-risk medical children diagnosed with all cancer types conditions are commonly referred excluding non-melanoma skin cancer to the HDS for treatment. As dental (ICD-10 C44).

Table 4: Trends in incidence of oncology in children aged 0-17; 2005 - 2013

Year Registrations 2005 153 2006 124 2007 145

2008 160 2009 150 2010 124 2011 145 2012 153 2013 142

Source: ISD

Additional information can be gained by looking at discharge figures (Table 5). NHS Scotland 31 32 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report by maindiagnosis;childrenaged18andunder Table 5:Daycasedischargerates per100,000populationfromacutehospitals Source: ISD,SMR01p=provisional data (per100,000population) Diagnosis Other Mental andbehaviouraldisorders Certain infectiousandparasitic diseases perinatal period Certain conditionsoriginatinginthe intracerebral haemorrhage) heartfailure, (includes arrythmias, Diseases ofthecirculatory system system Diseases ofthenervous diseases Endocrine, nutritionalandmetabolic consequences ofexternalcauses Injury, poisoningandcertainother classified findings,notelsewhere and laboratory Symptoms, signsandabnormalclinical strabismus) (includes blindness,glaucoma, Diseases oftheeyeandadnexa involving theimmunemechanism forming organsandcertaindisorders Diseases ofthebloodand eczema) tissue (includesskininfectionsand Diseases oftheskinandsubcutaneous system Diseases oftherespiratory arthritis, osteomyelitis,Perthesdisease) and connectivetissue(includesjuvenile Diseases ofthemusculoskeletalsystem (includes otitismedia,hearingloss) Diseases oftheearandmastoidprocess testicular torsion) vescico-ureteral reflux,renalfailure, tractinfection, (includes urinary system Diseases ofthegenitourinary abnormalities deformations andchromosomal Congenital malformations, Neoplasms circumstances, awaitingfostering) respite care,disruptedfamily/home immunisation,stomacare, observation, admissions forexamination, (includes contact withhealthservices Factors influencinghealthstatusand Diseases ofthedigestivesystem All DiagnosisA00-T98,Z00-Z99 Numberofdischargesperyear

2010/11 3,252 171 103 109 133 148 174 188 213 291 391 906 11 23 61 62 79 86 94 4 7 2011/12 2012/132013/14 3,251 156 141123 128 104 162 154 204 217 288 317354 384 938 10 91 11 24 61 53 84 84 95 3 3,273 124 130 185 172 180 215 378 895 102 11 97 10 32 68 48 84 82 3 3,352 131 132 200 160 196 229 362 906 106 18 90 41 64 60 74 93 4 9 2014/15 3,397 130 125 223 146 232 219 366 918 104 101 393 17 86 26 64 62 75 99 4 7 p

5 Current Service Delivery Model (Patient Journey Pathway)

5.1 Paediatric Dentistry Children’s oral health and dental services are delivered at primary care, Paediatric dentistry is unlike any other secondary care and tertiary care level dental specialty in that it covers all within three settings, the GDS, PDS aspects of oral health care for children and HDS. Where the treatment takes including restorative care, endodontic place is based on the complexity of treatment and prosthetics, minor oral the child’s presenting condition and surgical procedures and interceptive the presence of any modifying factors orthodontics. (Section 5.3). In general, the services are differentiated into routine care and specialist care (Figure 5).

Figure 5: Current service delivery model (patient journey pathway) Current Service Delivery Model (Patient Journey Pathway)

* PDS specialist service is only available in some NHS Boards NHS Scotland

33 34 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report PDS* (salariedGDS(notincluding CDS)priortoJan14andsalariedCDSfor Jan14onwards) Figures forMarch 2014andSeptember 2014havebeenrevised Figures forSeptember2014 andMarch 2015areprovisional Source: ISD,MIDAS, dataextractedinApril2015 and PDS*inScotland Figure 6:NumberofchildrenregisteredwithaGDP(independentcontractors) • Childsmile • inScotland care dentalservices Routine careisdeliveredbyprimary 5.2 1000000 100000 200000 300000 400000 500000 600000 700000 800000 900000 in 2014,byamalgamationofthe PDS: ThePDSwasestablished treatments incorporatedby children, includingthepreventive provide routinetreatmentsfor GDP-led teamsareexpectedto treatment availableunderGDS. receive thefullrangeofNHS register withadentistandcan the GDSfundingstream.People GDS regulationsandpaidthrough underthe Board todeliverservices contractors, contractedbytheNHS GDS: GDPsareindependent 0 Routine Care

31st Mar 05 30th Sep 05 31st Mar 06 30th Sep 06 31st Mar 07 30th Sep 07 31st Mar 08 30th Sep 08 31st Mar 09 30th Sep 09 through:

31st Mar 10

30th Sep 10

31st Mar 11

30th Sep 11 31st Mar 12

30th Sep 12 GA. 31st Mar 13 registered withaGDP. the vastmajorityofchildrenbeing caresince 2008 with primary trend ofchildregistrationswithin Figure 6illustratestheincreasing setting includingtreatmentunder provide treatmentinahospital non-existent. Theymayalso arelimitedor where GDPservices routine treatmenttochildpatients some Boards,thePDSprovides Government, 2014c).Currently, in (Scottish deliver services employed bytheNHSBoardto dentists andDCPs,directly is madeupofteamssalaried ThePDS the SalariedDentalService. and Community DentalService 30th Sep 13 31st Mar 14 30th Sep 14 31st Mar 15 PDS* GDP (Independent contractors)

5.3 Specialist Care colleagues in the children’s hospitals and other general hospitals, from Specialists in paediatric dentistry dental consultant colleagues and from provide care for children whose dental the PDS. care needs cannot be met routinely in primary care. In summary, there are Secondary and tertiary care services three broad categories which require accept referrals for paediatric patients in specialist input: the following categories (British Society for Paediatric Dentistry, 2009): • Patients with complex needs, although the dental treatment may 1. Severe early childhood caries or be routine unstable/extensive caries in the mixed/permanent dentition • Complex dental treatment 2. Severe tooth tissue loss • Multidisciplinary treatment. 3. Abnormalities of tooth

Specialist paediatric care is largely morphology, number and structure Current Service Delivery Model (Patient Journey Pathway) delivered by specialists and consultants in secondary and tertiary care settings. 4. Complex dento-alveolar trauma However in some NHS Boards specialist paediatric care is also delivered by 5. Periodontal or soft tissue paediatric specialists in the PDS. It is conditions/lesions recognised however, that the skill set of the individual delivering specialist 6. Disturbances of tooth eruption care is the key factor, rather than the setting in which care is provided. 7. Advanced restorative/endodontic The volume of specialist care provided care including laboratory-made in a primary care setting is sometimes restorations limited because of the unavailability of appropriate infrastructure and 8. Complex endodontic therapies equipment, for example, GA services, including management of non-vital sedation facilities and radiographic immature teeth or teeth undergoing equipment. internal or external resorption

Where there is no availability of 9. Direct/indirect composite specialist care through the PDS, children restorations for teeth with extensive requiring the input of a specialist need tooth tissue loss or enamel/dentine to travel to dental hospitals. This can defects introduce an inequality of access to a paediatric specialist and mostly impacts 10. Non-vital or vital bleaching on children living in remote and rural techniques areas. 11. Surgical interventions outwith Tertiary care services are delivered in the competence of the primary care Scotland through dental hospitals and practitioner paediatric hospitals. These are often also training institutions. Tertiary referrals 12. Interceptive orthodontic treatment

can be made by medical consultant NHS Scotland 35 36 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report ADHD. • (LAAC) • psychiatric • care: and sometimesrequiremorespecialised factors totreatmentmaybepresent In addition,thefollowingmodifying 17. 16. 15. GA 14. 13.

Multidisciplinary care. Multidisciplinary Child protectionissues Anxiety orphobia Treatment planningandprovision Treatment planningforchildren spectrum Disorder(ASD)and behavioural disorders,autistic dental anxiety, learning disability, Behavioural factors,forexample, after andaccommodatedchildren Social factors, for example, looked and metabolic, respiratory haematology, cardiology, Medical conditions,forexample, of comprehensivedentalcareunder requiring extractionsunderGA

6 Current Service Provision

Oral health care is delivered to children within the current fee structure. A small within three settings: GDS, PDS and number of GDPs utilise the services of HDS. The service delivery model hygienists/therapists to facilitate the (patient journey pathway) was reviewed treatment of their child patients. This in Section 5. would appear to be a much under- utilised resource, and recommendations 6.1 GDS Service Provision for change in this regard are made. Current Service Provision The vast majority of dental care for In spite of the number of episodes children in Scotland is delivered by of care undertaken by GDPs, they GDPs and DCPs in the GDS, who treat also make onward referrals for dental children under capitation and an item treatment. These referrals are made to of service (IoS) fee as determined by the PDS or the HDS, depending on local the SDR. There are also a number of availability, the local referral protocols grants and allowances given to support and historical referral pathways. practice expenses, for example, Rent Reimbursement and General Dental Table 6 shows the number of children Practice Allowance (GDPA). It is entirely registered with GDS at year ends appropriate that all those children March 2014 and March 2015. who require routine preventive and Lifelong registration was introduced restorative care should receive their in April 2010 and it is recognised that treatment in this environment, as part registration with a GDP may not be an of the family’s regular dental visits. Care indicator that care is being accessed. within the GDS is regarded as the norm. To address this, the measure of ‘participation’ is now used to show the However, it is also recognised that there number of patients who have attended are a significant number of children during the last two years. It was noted whose needs are not met entirely within by ISD that there was no deprivation the GDS. The environment of general gap between registration rates for practice can be focussed on providing children (90% for children living in care for adult patients, and few both the most and least deprived practices can invest in specifically child- areas). However, children living in the friendly facilities. The remuneration least deprived areas were more likely available to dental practitioners for to have ‘participated’ i.e. attended within the last two years, than those undertaking preventive and restorative treatment for children continues to be living in the most deprived areas (91% an area of great contention. Simple compared to 82% at 31st March 2015) procedures can present huge challenges (Information Services Division, 2015b). to a practitioner when faced with a It is also noted that the registration young or anxious child, and the time rate of nought to two year-old children involved in reassuring and persuading is lowest (48%) when compared with young patients to cooperate to accept other age groups. treatment is not felt to be recognised NHS Scotland

37 Table 6: Registration and participation rates of child patients in the GDS at 31 March 2014 and 2015

All Children 0-2 3-5 6-12 Registered children 948,214 84, 396 161,864 402,317 Registration rate (%) 86 47.3 92.1 105.6 2014 Participation numbers 824,422 82,832 145,568 346,098 Participation rate (%) 86.9 98.1 89.9 86 Registered children 961,661 84,175 163,446 414,816 Registration rate (%) 87.4 48.4 91.3 108 2015 Participation numbers 822,398 82,801 145,911 351,113 Participation rate (%) 85 98 89 84

Source: ISD, MIDAS

The average cost of dental care per Scotland ranging from £45 for Western head of child population in Scotland is Isles to £81 for GG&C. Please note this shown in Table 7. The average cost is includes 107,000 courses of orthodontic £66 per year. However, this varies across treatment. Oral Health and Dental Services for Children Needs Assessment Report NHS Scotland

38 Table 7: GDS fees - total fees, cost per head of population of children 2013/14

NHS Board Total fees Child Number of Cost/head Cost/head (capitation population registrations of of + IoS) population registered (£) (£) patient (£) Scotland 68,563,684 1,035,394 950,256 66 72

Ayrshire & Arran 4,933,551 72,032 65,894 68 75 Current Service Provision Borders 1,472,539 21,703 18,419 68 80 Dumfries & Galloway 1,580,675 27,737 25,349 57 62 Fife 4,369,677 72,853 64,958 60 67 Forth Valley 3,883,247 60,576 52,880 64 73 Grampian 6,265,492 110,733 94,063 57 67 Greater Glasgow & Clyde 17,727,426 217,972 231,556 81 77 Highland 3,419,217 61,864 55,286 55 62 Lanarkshire 7,569,633 134,980 107,797 56 70 Lothian 11,499,731 162,699 149,937 71 77 Orkney 215,564 4,063 3,817 53 56 Shetland 233,531 4,940 4,754 47 49 Tayside 5,160,577 78,106 71,093 66 73 Western Isles 232,824 5,136 4,453 45 52

Source: ISD. Please note that some ‘cross-boundary flow’ exists, as people may live in one administrative area (for example, NHS Lanarkshire) but be registered with a dentist whose practice is located in another (usually adjacent) administrative area (for example, NHS Greater Glasgow & Clyde)

This can be explained in part by the Scotland, and in common with other fact that children who are treated in chronic diseases, dental decay is more NHS Greater Glasgow & Clyde live in prevalent in areas of deprivation other NHS Boards (Information Services (Section 4.4.4).

Division, 2014). The higher cost per head might also be a reflection of the The five most common types of SDR IoS fact that NHS Greater Glasgow & Clyde treatments carried out for children in has the highest percentage of deprived 2013/14 are shown in Figure 7. areas compared to other regions of

NHS Scotland

39 40 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report application offissuresealants. (‘deciduous’), includingfillingsandthe teeth was fortreatmentofprimary (17%) mostcommonSDRIoStype given underChildsmile.Thesecond treatment forchildrenweretreatments Almost onethird(28%)oftheSDRIoS 2013/14 forchildren Figure 7:MostcommonSDRIoStreatment-percentage ofallclaims;Scotland period. was alsoseenoverthesametime treatment carriedoutundersedation however thereisaslightincreasein care; treatments carriedoutinprimary Overall, therewasaslightreductionin from2011to2014. care dentalservices of treatmentscarriedoutbyprimary Table 8showsthenumberandvalue Table 8: Main SDR item of service treatment claims for children from 2011/12- 2013/14 by GDS

2011/2012 2012/2013 2013/2014 Main SDR item of Number of Cost (£) Number of Cost (£) Number of Cost (£) service treatment items items items Fillings - Items 14, 471,039 5,451,049 457,633 5,260,794 432,355 5,014,938

44(a)(e), 58(b)(c)(d) Current Service Provision (e) & 60(a) Root treatments - 9,198 380,380 9,054 368,224 8,972 380,576 Items 15, 44(c)(d), 58(f), 60(c)(d) & 63(c)(d)(e)(f) Veneers - Items 16 588 63,575 478 51,714 410 44,784 & 64 Inlays - Items 17(a)1, 43 5,394 27 3,438 19 2,513 17(f)5,1, 17(j)1,1, 17(k)1 & 51(c)1 Crowns - Items 17, 1,113 150,546 986 133,694 869 117,884 51(a), 51(b), 51(c)2 & 65 Bridges - Items 18, 259 36,729 215 30,832 129 19,510 51(d) & 58(g) Dentures - Items 27, 401 37,218 331 29,918 303 27,458 28, 55(a)(b)(c)(d), 59 & 62 Extractions - Items 97,037 1,094,395 90,509 1,028,601 90,207 996,468 21 & 52(a) Surgical treatments - 1,762 79,624 1,617 74,493 1,318 57,052 Items 22 & 52(b) Sedations - Items 25, 2,681 112,793 2,580 106,499 2,960 122,882 54 (b) & 54 (c) Domiciliary visits - 40 1,541 47 1,875 66 2,465 Items 35(a) & 57(a)

Recalled attendances 306 20,436 298 19,734 246 16,351 - Items 35(b) & 57(b)

Source: ISD

Childsmile was introduced into the SDR Interventions must incorporate: in October 2011 and all GDP practices delivering NHS care to children • Dietary advice are expected to deliver Childsmile • Toothbrushing demonstration for interventions i.e. preventive dental care parents and carers and caries management tailored to • Fluoride advice the individual needs of the child (NHS • Clinical prevention, for example Health Scotland, 2011). fissure sealants and fluoride varnish

applications as appropriate. NHS Scotland 41 42 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report for increasingGDPparticipation. andoptions looking atthewayforward of theChildsmileprogramme(2016) There iscurrentlyanationalreview Evaluation andResearch Team, 2015). between NHSBoards(Central variation acrossallthesemeasures applications. Thereisalsosignificant 16.5% receivedtherecommendedtwo fluoride varnishin2014-15andonly year-olds receivedoneapplicationof Only athirdofregisteredtwotofive- to around40%ofthoseregistered. three tofive-year-olds,thisfiguredrops they should.For and interventions only 65%arereceivingthesupport advice andtoothbrushingsuggeststhat (Table 6),thelatestISDdataondietary nought totwo-year-oldsregistered claims hasrisen,withonly48%of However, whilethetotalnumberof Source: ISD value from2011/12to2013/14 Table claimsand 9:Childsmileservice carriedoutby of Childsmileservices Table 9showsthenumberand value 28% oftheIoSpayments(Figure9). in2013/14represented interventions claims madeforChildsmile As previouslynoted,the352,489 2013/14 2012/13 2011/12 Year of claims Number 352,489 674,713 305,936 556,778 143,383 307,751

Value (£)

interventions. participate indeliveringChildsmile rise asmoredentalpractices of claimsandthevaluecontinuesto thatthenumber to 2014.Itisobserved from2011 caredentalservices primary found inAppendix2. later. questionnairecanbe Thesurvey re-contacted threeweeks the firstsurvey were followed,withnon-respondersto addresses. Two timelinesofcontact were contactedbyalternativeemail some GDPsworkinginthatarea absence ofrespondentsfromLothian, salaried PDSdentists.Becauseofthe nhs.net email.Thisincludedsome conducted ofGDPswhohadanactive was In thefirstinstanceasurvey Method clinics anddentalhospitalservices. providing routinecare,anduseofPDS anybarriersto Childsmile interventions, by aGDPincludingtheprovisionof provision ofroutinecaretochildren determine thenatureandscopeof wasto The aimoftheGDPsurvey Aim 6.1.1 GDP Survey Results in the survey may represent an Out of 1310 GDPs invited to participate interest in the topic, therefore the in the survey, 375 (28.6%) GDPs results might not fully reflect all responded to the survey. Of these, 40 GDPs’ responses. Table 10 shows (10.6%) were salaried GDPs working GDPs who have responded to the within the PDS. Given the response survey and their corresponding NHS rate, it is recognised that participation Board area. Current Service Provision

Table 10: Responding GDPs’ NHS Board area

NHS Board Number of Percentage of respondents total response Ayrshire & Arran 13 3.9 Borders 2 0.6 Dumfries & Galloway 12 3.6 Fife 18 5.4 Forth Valley 13 3.9 Grampian 56 16.7 Greater Glasgow & Clyde 85 25.4 Highland 39 11.6 Lanarkshire 55 16.4 Lothian 11 3.3 Orkney 4 1.2 Shetland 4 1.2 Tayside 15 4.5 Western Isles 5 1.5 Not Reported (NR) 3 0.9 Total 335 100.0

Preventive Treatments is notable that this differs from the childsmile data (Central The majority of GDPs who participated Evaluation and Research Team, 2015), in the survey indicated that they confirming that this may not be a provided preventive care including representative sample of GDPs but the interventions incorporated by instead reflects a more highly motivated Childsmile (Table 11). However it group (Section 6.1).

Table 11: Preventive treatments provided by GDPs

Preventive treatments Number of respondents Percentage of all respondents Dietary advice 320 95.5 Toothbrushing instruction 317 94.6 Fluoride varnish application 299 89.3 Fissure sealants 293 87.5 NHS Scotland

43 44 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report providing multipleextractions (65.7%), their childpatients(Table 12),when challenge theyencounteredwith that patientcooperationwasthemain providing treatmentGDPsindicated When askedaboutthechallengesto treatments tochildpatients Challenges orbarrierstoproviding Figure 8:RestorativetreatmentsprovidedbyGDPs common and‘stainlesssteelcrowns’ ionomer restorationswerethemost range ofrestorativetreatments.Glass provideda participated inthesurvey Figure 8showsthattheGDPswho Restorative Treatments “Parents don’t likethestainlesssteelcrownseventhoughoftenonlyoptionleft.” crowns astheydisliketheappearance.” “Parents canoccasionallybeachallengefortheplacementofstainlesssteel continues toheavilyaffectasmallnumberofchildren.” “Parents arereluctanttoacceptappearanceofstainlesssteelcrowns.Caries Number of respondents 100 150 200 250 300 350 50 0 restorations Amalgam restorations Composite Restorative Treatments Glass ionomer restorations crowns. parents didnotlikestainlesssteel crowns’. SomeGDPsreportedthat colloquially knownas‘stainlesssteel Preformed metalcrowns(PMCs)are restorative treatmentsundertaken. (Hall technique)weretheleastcommon (14.9%). (23.3%) andendodontictreatment provision ofstainlesssteelcrowns for tworestorativeprocedures;the Training wasalsocitedasa challenge fee wasabarriertothesetreatments. steel crowns(49.6%).Inaddition,SDR restorations (54.6%)andstainless endodontic treatment(60.3%), Stainless steel crowns/Hall technique Endodontic treatment Table 12: Challenges to providing the following treatments for child patients

Treatment SDR fee Time Training Staffing Patient cooperation Count % Count % Count % Count % Count % Preventive advice 150 44.8 134 40.0 28 8.4 34 10.1 75 22.4 Fluoride varnish 116 34.6 71 21.2 15 4.5 25 7.5 132 39.4 Current Service Provision Fissure sealants 111 33.1 76 22.7 7 2.1 17 5.1 161 48.1 Restorations 130 38.8 83 24.8 12 3.6 10 3.0 183 54.6 Stainless steel crowns 95 28.4 94 28.1 78 23.3 16 4.8 166 49.6 Endodontic treatment 157 46.9 116 34.6 50 14.9 17 5.1 202 60.3 Multiple extractions 143 42.7 103 30.7 17 5.1 20 6.0 220 65.7

Some GDPs believed that they were child patients. GDPs felt that SDR fees not remunerated appropriately for time would be adequate if the child patients spent on provision of dental services to were able to cooperate.

“Dental services for children have always been under funded and always will be. They are more time consuming and more difficult to treat but dentists are paid less than the adult fees.”

“Fee provided by the SDR is adequate if child patient is cooperative but not if more time is taken.”

“Restoration fees for a child are ridiculous. A seven-12 year old child takes much more time to carry out a routine restoration. An occlusal amalgam fee for what can be easily half an hour’s work is laughable, for the practice it does not even pay the nurse, let alone materials.”

“Treating children can be extremely challenging and stressful. It is an added insult when the fee does not cover the cost of the time involved. Effectively we do not get paid for doing some of these treatments.”

Referral to Public Dental Service thirds (68%) of GDPs also indicated that

they had referred child patients to their Over half (59%) of GDPs who local PDS. Some GDPs reported that participated in the survey indicated communication between PDS and GDS that they were aware of the treatment was poor, while others believed that offered by the PDS but 22.4% indicated they did not have a local paediatric PDS that they were not. More than two service. NHS Scotland

45 46 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report child patients toadentalhospital indicated thattheyhave referred Over twothirds(67.8%) ofGDPs Referral todentalhospitals Table 13:ReasonsforreferraltoPDS add uptomorethan100%.The the percentages showninTable 13 than onecondition,andtherefore A numberofreferralscitedmore GDPs referredchildrentothePDS. Table 13summarisesthereasons protocols forthePDS. that theywereawareoflocalreferral refer tothePDSwith39.1%indicating to that theyfounditstraightforward Over half(58.8%)ofGDPsindicated Vulnerable orLAAC Trauma Surgical care Degree ofdentalcomplexity High cariesrateormultiplecariousteeth Degree ofmedicalcomplexity Special needs Sedation Anxiety General anaesthesia Poor cooperation Referral category littleinformation.” “Referral pathwayisdifficult,very “Not surewhotoreferto.” locally.”“No service “We haveonlyavagueideaofwheretoreferandwhattreatmentisprovided.” dental procedureitself.Thismirrors of theanticipatedcomplexity than 30%makingareferralbecause and specialneeds(47.8%),withfewer anxiety (53.7%),sedation(51.6%) need fortreatmentunderGA(54%), as poorcooperation(56.4%),the child’s abilitytoaccepttreatmentsuch most commonreasonsrelatedtothe to hospital (Table 14). condition isthemainreason forreferral of GDPsindicatedthat severityof that theyhadnot.Nearly half(47%) or institutes,while14% indicated children. the challengesGDPsfoundintreating 35 35 10.4 52 59 101 102 160 173 51.6 180 53.7 181 189 responses Number of 10.4 15.5 17.6 30.1 30.4 47.8 54.0 56.4 total Percentage of “Our PDS has no specialist paediatric dentists.”

“If GA required then must refer to hospital, our PDS will not accept referral.”

“Provision of GA, I do not think our PDS offers this.”

“Unaware of other local options.” Current Service Provision

Table 14: Factors influencing GDPs’ decision to refer to a hospital rather than PDS

Factors Number of Percentage of responses total Severity of condition 158 47.2 Preference 55 16.4 Hospital proforma dictates referrals accepted 61 18.2

Some GDPs listed the absence of PDS to one of the dental hospitals, while service because of geography, lack of 30.4% indicated that they were not. specialists in the PDS and unavailability The most common reason for of GA in the PDS as other reasons for referral was for GA (44%), followed referral to hospital instead of the PDS. by dental complexity (36%) then Almost half (43.6%) of GDPs indicated poor cooperation (32%). Table 15 that they were aware of referral summarises the reasons for referral to protocols for children being referred dental hospitals.

Table 15: Reasons for referrals to dental hospital

Referral category Number of Percentage of responses total General anaesthesia 150 44.8 Degree of dental complexity 122 36.4 Poor cooperation 106 31.6

Trauma 98 29.3 Degree of medical complexity 91 27.2 Anxiety 91 27.2 Sedation 85 25.4 Special needs 76 22.7 High caries rate or multiple carious teeth 74 22.1 Surgical care 72 21.5 Vulnerable or LAAC 14 4.2 NHS Scotland

47 48 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report registered withtheGDC inAugust DCPs basedinScotlandwhowere Table 16summarisesthenumberof Figure 9:Thedentalteam arose asaresultofthefindings of anumbertheseprofessionals patient care(Figure9).Theemergence each withaspecificremitinrelationto recognised withinthedentalteam, dentist, therearesixgroupsofDCPs and adultpatients.Inadditiontothe care andtreatmentofbothchild professionals whoareintegraltothe DCPs areanexpandinggroupof 6.1.2 Dental CareProfessionals 2013b). GDC (GeneralDentalCouncil, all DCPshasbeenpublishedbythe specific skills.Thecompleteremitof of professionalseachpossessing population couldbemetbyavariety that theoralhealthneedsof ofdentalcare,suggesting delivery document encouragedflexibilityinthe Thisvisionary toDentistry’. Auxiliary ‘Education andTraining ofPersonnel of1993entitled the NuffieldInquiry registered inmorethanonecategory. 2015. Anumberofindividualsare Table 16: Scottish DCP workforce August 2015

DCP group Number of GDC registrants Dental nurses 5678 Dental technicians 510 Dental hygienists 412

Dental hygienist-therapists 195 Current Service Provision Dental therapists (singly qualified) 16 Orthodontic therapists 44 Clinical dental technicians 13

Dental hygiene and therapy without the need for a referral from a education dentist.

In Scotland, all dental institutions have Dental hygienist-therapists a remit for the education and training of dental hygienist-therapists with 49 In addition to undertaking the skills students graduating each year. Three of a dental hygienist, dually qualified year ordinary degrees in Oral Health individuals can also provide all direct Sciences are available in the University restorations in the primary and of Dundee, Glasgow Caledonian secondary dentition (adult teeth), University and the University of the and may extract primary teeth. They Highlands & Islands, while a four are also permitted to diagnose and year Honours degree is offered by the treatment plan within their scope of University of Edinburgh. practice without prescription and work under direct access arrangements with The following is a summary of the the public. clinical remit of dental hygienists, dental hygienist-therapists and dental Survey of dental hygienists and therapists who may be involved in the therapists treatment of children in all branches of the dental services. During January and February 2016 an

online survey of Scotland-based dental Dental hygienists hygienists and therapists was carried out to explore the range of clinical Dental hygienists are trained and treatment they provided for children educated specifically in periodontal within the GDS. A total of 214 out and preventive therapy. In addition of 451 completed the questionnaire, to screening for oral disease, they are representing a 47% response rate. able to undertake all aspects of non- Details of the survey can be found in surgical periodontal treatment and Appendix 3. preventive care for both the child and adult population. They are qualified It was apparent from the survey that to diagnose and develop a treatment the majority of dental hygienists and plan within their scope of practice and therapists provided treatment for are now able to see patients directly children, but the range of procedures NHS Scotland

49 50 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report full clinicalpotential. academic trainingarenotfulfillingtheir professionals withextensiveclinicaland the reasonswhythesehighly-skilled analysis willhopefullyidentifymorefully to befullyutilised.Inaddition,further allow hygienistsandhygienist-therapists policy changesmayneedtobemade However, structuralandhigh-level to undertakemorecomplexwork. dental teamwouldfreedentists’time increasing theskillmixwithin It isthereforerecommendedthat paediatric patientsintheGDS. for caredentistry provision ofprimary therapists areunder-utilisedinthe data thathygienistsandhygienist- (Appendix 3).Itisclearfromthesurvey of commentsmadebyrespondents practice areindicatedinthesample the reasonsforthislimitedclinical undertaken wasrestricted.Someof in Scotlandwasunclearattheoutset provision tochildrenwithinthePDS The leveloforalhealth/dentalservice Children 6.2.1 Government, 2014c). severe anxietyandphobia(Scottish compromised, LAAC,migrants, physical disabilities,medically needs, includinglearningdisabilities, reference tochildrenwithadditional caresettings,withspecific secondary including community, custodialand inavarietyofsettings, range ofservices Government in2014.Itprovidesawide The PDSremitwasdefinedbyScottish 6.2 carry outGA). carry availability ofspecialists,facilitiesto mix andinfrastructure(forexample, dependent ontheavailabilityofskill is variableacrossScotlandand provided the scopeofservice specific PDSclinics(Table 17).However PDS andchildrenareoftenreferredto withinthe paediatric dentalservices All NHSBoardswithinScotlandprovide andinterviews Results ofPDSsurvey Appendix 4. questionnaire canbefoundin within eachNHSBoard.Thesurvey provision determine thelevelofservice were carriedoutto face interviews, the PDS,andinsomecasesface-to- ofclinical directorsof 2015, asurvey between October2014andDecember of thisneedsassessment.Therefore, PDS Service Provisionfor PDS Service PDS Service Provision PDS Service Table 17: Number of PDS clinics providing care for children by NHS Board

NHS Board Are children referred If yes, please If so, how many to specific clinic/s specify specific clinic locations? locations? Ayrshire & Arran Yes GA & anxiety management 5 Borders Yes For assessment pre-sedation 6

or GA Current Service Provision Dumfries & Yes Secondary dental care clinics 2 Galloway in two main bases Fife Yes A central hub then dependent 8 on needs moved to closest possible clinic with skilled clinician (8 clinics) Forth Valley Yes 6 Grampian Yes Referrals are made centrally 10 then assigned to individual clinics Greater Glasgow Yes Determined by specific user 17 & Clyde need and location Highland Yes Depends what they are At least 14 sites referred for have inhalation sedation services Lanarkshire Yes Children with special care 10 needs for dental treatment are referred to the nearest community clinic Lothian Yes Edinburgh central. East, and 10 Mid Lothian one area; West Lothian as separate area Orkney Yes One clinician fronts the 2 Childsmile practice Shetland Yes To any of the PDS clinics 6 Tayside No No, because all clinics across

Tayside accept referrals Western Isles Yes 1

Patients are referred to PDS clinics by a and the availability of PDS clinics, range of professionals including GDPs, infrastructure and the available skill mix. general medical practitioners (GMPs), The PDS is often the main provider of hospital consultants and Childsmile dental care in the Island Boards, i.e. DHSWs. The referral rate is variable Shetland, Orkney and Western Isles, across Scotland (Table 18) and this is because of the limited provision of dependent on a number of factors, GDS. In some Boards the PDS has staff for example, GDPs’ awareness of PDS specifically responsible for the treatment services (Section 6.1.1), accessibility of children. NHS Scotland

51 52 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report Table 19:ApproximatereferralrateforGAprovision Table 18:Paediatricreferrals to PDSbyNHSBoard the NHSBoardsandreferralratesare Extractions underGAareofferedinall under GA Provision ofdentaltreatments Western Isles Tayside 35-40 Shetland 0-5 Orkney 0-5 Lothian 45-50 Lanarkshire 100 Highland 10-15 Greater Glasgow&Clyde Grampian Forth Valley Fife Dumfries &Galloway Borders 15-20 Ayrshire &Arran clinics NHS Board Western Isles Tayside population Shetland Orkney Lothian Lanarkshire Highland Greater Glasgow&Clyde Grampian 125 Forth Valley Fife Dumfries &Galloway Borders Ayrshire & NHS Board Arran 0-5 416 125 35-40 50-70 No 05-10 70-80 received inamonth Number ofGAreferrals 100-150 0-50 50-100 forthewhole dentistry care PDS providesprimary Currently noGDSinShetland, 0-50 150-200 50-100 0-50 600 50-100 50-100 0-50 0-50 received permonth Number ofreferrals in fourBoards(Appendix5). intravenous (IV)sedationisonlyoffered (IHS) isalsoofferedinallBoardsbut an alternativetoGA,inhalationsedation variable acrossScotland(Table 19).As

Ys Yes Yes Yes No No Yes Yes No No No No Yes example, prevention Post-GA follow-up,for 25% -30% 5% -10% 20% -25% Not Applicable 1% -5% 55% -60% 20% -25% 45% -50% 60-65% 30% 20% -25% 25% -30% 45% -50% Not Reported referrals referrals comparedtoall Percentage ofpaediatric

GA lists for dental extractions are In NHS Boards without a dental available in all Boards. The vast majority hospital or children’s hospital, ‘out-of- of these lists are provided by the PDS. Board’ referrals for children requiring However child patients are not always multidisciplinary care are made when admitted under the PDS. In some NHS required (Appendix 9). Boards children may be admitted under oral and maxillofacial surgery, and Workforce in the PDS for provision of therefore there might be some under- paediatric dental services Current Service Provision recording of PDS activity. Most NHS Boards also provide comprehensive Table 20 shows the composition of staff care including restorative care under providing paediatric dental services GA. Appendices 5, 6 and 7 give in the PDS. Some Boards have staff further details for the provision of both specifically for children, while the PDS comprehensive care and extraction-only staff in other NHS Boards provide dental lists within each Health Board area. treatment for adults and children. The majority of the staff working in the Treatment provision for children who PDS responsible for treating children require multidisciplinary care are dentists with an interest and some have obtained additional postgraduate Generally, multidisciplinary care is qualifications. Specialists in paediatric provided to child patients through dentistry are employed in Lothian, dental hospitals and other specialist Greater Glasgow & Clyde and Fife paediatric hospitals, for example, the NHS Boards (WTE 4.1). The presence Royal Hospital for Children. However, in of specialists in the PDS allows the some NHS Boards multidisciplinary care provision of specialist care for their is also provided through the PDS to a child patients in community settings. certain extent (Appendix 8). However in some NHS Boards specialists in paediatric dentistry have been recruited at senior dental officer (SDO) level rather than specialist level.

NHS Scotland

53 54 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report

Table 20: PDS workforce for provision of paediatric dental services by NHS Board

Health Board Staff Clinical Assistant Specialist SDO/Senior CDO/ Therapist Hygienist Specialist Additional With an specifically director clinical in paediatric salaried salaried (WTE) (WTE) in paediatric postgraduateinterest in responsible (WTE) director dentistry GDP GDP dentistryqualification paediatric for the (WTE) (WTE) (WTE) (WTE) (Head but not on dentistry treatment specialistcount) (Head of children list (Head count) count) Ayshire and Yes 1.3 1 1 1 3 Arran Borders No 20 Dumfriesand Yes 1 1 1 Galloway Fife Yes 1 8 2 1 2 3 5 Forth Valley Yes 1 1* Grampian Yes 0.4 1 Greater Yes 0.9 4.4 13.5 2.5 2 2* 16 26 Glasgow and Clyde Highland No 2 2 Lanarkshire No 10 Lothian Yes 2.2 4 3 1 10 Orkney No Shetland No 1 Tayside No 1 6 WesternIsles No 1 Total 4.1 7.7 27.5 5.5 4 10 22 84

* Staff with specialist qualifications but not employed as a specialist Numbers were accurate as of March 2016 6.2.2 PDS Retrospective Referral clinic from NHS Greater Glasgow & Audit Clyde (GG&C) participated in the four-week audit. Three of the six A one-month retrospective PDS referral NHS Boards who took part in the audit audit (Appendix 10) was undertaken did not employ a dentist at specialist across Scotland between January level. The referral rate was very varied and February 2015 to investigate the and ranged from 15 in the Borders

nature of referrals made to the PDS. to 115 in Fife. This was felt to be due Current Service Provision The collated data included the reason to the variation in population, service (condition) given for the referral, age provision and staff available in the and SIMD of patients being referred. Boards (Table 21). Of note, the data for GG&C were for the one specialist The PDS in Borders, Fife, Forth Valley, clinic only and not the entirety of the Highland, Tayside and one specialist PDS service.

Table 21: Referrals received during four week audit and availability of a specialist

PDS clinic Total number of Availability of a specialist referrals received during four week audit Borders 15 No Fife 115 Yes Forth Valley 66 No* Highland 53 No Greater Glasgow & Clyde 33 Yes specialist clinic based in Royal Alexandria Hospital (RAH) Tayside 69 Yes Total 351

* SDO is on the specialist register but is not employed as a specialist

Reason for referral of children to extraction under GA or sedation the PDS (52.7%) and severe childhood caries (42.2%), as shown in Table 22. A The most common reason for referral number of referrals cited more than of children to the PDS was for the one condition, and therefore the management of anxiety and phobia percentages shown in Table 22 add (61.5%) followed by treatment up to more than 100%. planning for children requiring NHS Scotland

55 56 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report the PDSin Fife, Tayside and Highland (Appendices 12-14),for example, there wereregionaldifferences condition (Appendix11). However, related toadisabilityor medical referral. Almosthalfof thesewere Many otherreasonsweregivenfor Table 22:Reasonforthereferral ofchildrentothePDS(collateddata) 19 18 17 16 resorption 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 Multidisciplinary care Multidisciplinary Non-vital orvitalbleachingtechniques Reason notspecified Severe toothtissueloss or teethundergoinginternalexternal management ofnon-vitalimmatureteeth Complex endodontictherapiesincluding Child protectionissues Complex dento-alveolartrauma enamel/dentine defects teeth withextensivetoothtissuelossor Direct/indirect compositerestorationsfor Disturbances oftootheruption Periodontal orsofttissueconditions/lesions Interceptive orthodontictreatment restorations including laboratory-made Advanced restorative/endodonticcare comprehensive dentalcareunderGA Treatment planningandprovisionof practitioner competence oftheprimary outwiththe Surgical interventions and structure Abnormalities oftoothmorphology, number Others includingmedicalconditions dentition extensive cariesinthemixed/permanent Severe earlychildhoodcariesorunstable/ extractions underGAorsedation Treatment planningforchildrenrequiring Anxiety orphobia Reason severe caries. received over60%of their referralsfor withinBorders PDS specialist service specialist clinicinGG&C andthenon- anxiety andphobia,whereas the received over60%ofreferralsfor

Number of received referrals 148 185 216 13 32 45 0 0 1 1 1 2 3 3 4 5 6 7 8

Percentage 12.8 42.2 52.7 61.5 3.7 9.1 0.3 0.3 0.3 0.6 0.9 0.9 1.1 1.4 1.7 2.3 0 0 2

Relationship between most prevalent Paediatric patients seen in the PDS condition and SIMD come from all SIMD quintiles, with more referrals overall from the most In common with other chronic deprived areas. There were regional diseases, this audit confirmed that differences, for example, the majority referrals received for anxiety or phobia, of child patients referred to Highland extraction under GA or sedation and and Borders PDS came from SIMD 4

dental decay were more prevalent in area, whereas child patients referred Current Service Provision areas of deprivation (Appendix 15). to Fife, Forth Valley and GG&C came from the most deprived SIMD 1 areas. Relationship between number of In contrast, for Tayside there was no referrals, Health Board and SIMD difference between the numbers of referrals received from SIMD 4 and Table 23 shows the relationship SIMD 1 areas. However, there were a between referral rate and SIMD. few referrals received from SIMD 5 area.

Table 23: PDS clinic and SIMD 2012 quintile cross tabulation

Health Board SIMD 2012 quintile Total 1 2 3 4 5 Borders 0 4 4 5 0 13 Fife 32 28 28 13 9 110 Forth Valley 22 16 11 9 4 62 Highland 6 13 12 17 2 50 Greater Glasgow & 11 7 4 4 6 32 Clyde(GG&C) specialist clinic (RAH) Tayside 18 12 11 18 2 61 Total 89 80 70 66 23 328 Percentage 27.2% 24.4% 21.4% 20% 7% 100%

Note: Postcode could not be matched/was not reported for 23 referrals

NHS Scotland

57 58 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report might bemoredifficulttoidentifyor may notyethavedevelopedorit three arelesscommonbecausedecay reasons. Referralspriortotheageof years old.Thiscouldbeforavarietyof those agedbetweenthreeandten that referralratesweregreaterfor old (Figure10).Itwasnoted,however, audit rangedfromagetwoto15years for managementofdentalcariesinthis The ageofchildrenreferredtothePDS Relationship betweenageandcaries Figure 10:ReferralsreceivedbythePDSforcariesage

Count 10 15 20 25 0 5 2 3 4 567 2 1011 3 8 9 12 13 14 15 Age GDS setting. manage treatmentwithintheroutine they aremorelikelytobeable permanent teethareatanagewhere Additionally, thosewithcariesinthe complications arelessfrequent. at astagewheresymptomsor will beclosetoexfoliationand/or teeth because mostoftheprimary appeared todiminishandthismaybe difficult. Referralsaftertheageoften has beenpossible,makingdiagnosis perhaps onlyalimitedexamination childhood cariesor unstable/extensive mixed/permanent Severe early caries inthe Yes dentition Relationship between age and the development of anxiety may be anxiety or phobia multifactorial and impacts on child wellbeing. There are some children Anxiety and phobia was the most who may not present to other commonly cited reason for referral to the PDS. A wide age range of services, but they will attend the children were referred to the PDS for dentist, so it is important that all anxiety or phobia (Figure 11). The dental professionals use the GIRFEC vast majority were between five and approach and are mindful of other Current Service Provision nine years of age. It is recognised that potential underlying reasons.

Figure 11: Referrals received by the PDS for anxiety or phobia by age

Anxitey/Phobia Yes 30

20 Count

10

0 0 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Age

Referral Triage Outcome available, or a dentist for an assessment. Very few children were returned to the In general, children referred to the GDS or referred onwards to the HDS PDS were seen by a specialist, where (Appendix 16). NHS Scotland

59 60 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report a structuredintroduction todentalcare acclimatised totreatment, andtherefore These childrenrequire timetobecome with dentaltreatmentachallenge. who areanxiousorfindcooperating management ofdentalcariesinchildren referrals madetotheHDSarefor Currently alargepercentage of • • • treatment • PDS • department includestheprovisionof: The remitofahospitalpaediatricdental until2014. service Dental Hospital(ADH)hadaconsultant acute children’s hospitals.Aberdeen withinthelocal also provideservices andstaff led hospitaldentalservices, Dental Hospital(GDH)haveconsultant- Dental Institute(EDI)andGlasgow Dental Hospital(DDH),Edinburgh four mainlocationsinScotland.Dundee aredeliveredin Hospital dentalservices 6.3 practitioners. postgraduate specialistsanddental training gradehospitalstaff, DCP undergraduatestudents, Teaching andtrainingofdental clinical networks Access tospecialistadvicethrough for medicallycompromisedchildren paediatric dentalservice A tertiary for childrenwhorequirespecialist Specialist paediatricdentalservices practitioners fromtheGDSand Paediatric dentaladviceforreferring Provision Service Dentistry Hospital Paediatric

children who require multidisciplinary children whorequiremultidisciplinary dental departmentistoensurethat The mainroleofahospitalpaediatric considered inthefirstinstance. colleagues orthePDSshouldbe referrals todentaltherapistorhygienist are themainreasonsforGDPreferral, Where cariesmanagementandanxiety and theseareavailablewithinthePDS. techniques andIHSareusefuladjuncts, 2014). Behaviourmanagement Intercollegiate GuidelinesNetwork, Network (SIGN)guidelines(Scottish with ScottishIntercollegiate Guidelines children atriskofcaries,inaccordance caresettingforall in theprimary appropriate teethshouldbeundertaken as fluoridevarnishandfissuresealantof is required.Preventivemeasuressuch from staffingfluctuations. to reflectavariationin capacityarising total patientattendances, whichwasfelt 2010-2014 therewas a 25%rangein and Dundee.InEdinburgh,between changes tothepatientflowinGlasgow year toyear, therewerenosignificant there weresmallfluctuationsfrom detailed inTables 24and 25.While four Scottishdentalhospitalsandare were obtainedfromthreeoutofthe attendances overafive-yearperiod Data fortotalandnewpatient 6.3.1 working incommunitysettings. in England,withsomeconsultants settings butthereisadifferentmodel consultants workmainlyinhospital In Scotland,paediatricdental shared carepathways. level ofdentalcaretheyrequirethrough other dentalspecialities,receivethe co-morbidities orrequiringinputfrom care, particularlychildrenwithmedical Hospital Activity Table 24: Total paediatric dental patient attendances

Dental hospital 2010 2011 2012 2013 2014 Glasgow Dental Hospital (GDH) 10,323 10,333 10,195 9,972 10,173 Edinburgh Dental Institute (EDI) 5,692 5,332 4,251 4,499 4,816 Dundee Dental Hospital (DDH) 4,497 5,078 4,989 4,826 4,626 Current Service Provision Source: Dental hospital paediatric departments

Table 25: New paediatric dental patient attendances

Dental hospital 2010 2011 2012 2013 2014 Glasgow Dental Hospital (GDH) 3,267 3,549 3,494 3,437 3,277 Edinburgh Dental Institute (EDI) 1935 2240 1869 2054 2252 Dundee Dental Hospital (DDH) 887 933 762 755 765

Source: Dental hospital paediatric departments

6.3.2 Hospital Retrospective paediatric dental departments. The Referral Audit data included the reason (condition) given for the referral, age and SIMD Retrospective referral audits were of patients being referred (Appendix undertaken in GDH, EDI and DDH for 17). A number of referrals cited more a period of four weeks or a calendar than one condition, and therefore the month to investigate the nature of percentages shown in Table 26 add up referrals made to hospital-based to more than 100%.

NHS Scotland

61 Table 26: Referrals received in the three centres over a month by condition

Condition Number of referrals received n (%) Total GDH EDI DDH Total number of referrals 887 440 315 132 Severe early childhood caries/extensive 499 262 (59.5) 175 (55.6) 62 (47.0) caries in mixed/permanent dentition Other (including medical conditions) 233 101 (23.0) 79 (25.1) 53 (40.2) Treatment planning for extractions 211 172 (39.1) 16 (5.1) 23 (17.4) under GA Anxiety or phobia 198 63 (14.3) 98 (31.1) 37 (28.0) Abnormalities of tooth morphology, 122 42 (9.5) 55 (17.5) 25 (18.9) number and structure Treatment planning and provision of 89 65 (14.8) 24 (7.6) 0 (0.0) comprehensive dental care under GA Periodontal or soft tissue conditions 42 16 (3.6) 16 (5.1) 10 (7.6) Complex dento-alveolar trauma 38 21 (4.8) 7 (22) 10 (7.6) Surgical interventions outwith the 24 13 (3.0) 9 (2.9) 2 (1.5) competence of the primary practitioner Oral Health and Dental Services for Children Needs Assessment Report Multidisciplinary care 19 19 (4.3) 0 (0.0) 0 (0.0) Complex endodontic therapies 17 13 (3.0) 2 (22.0) 2 (1.5) Disturbances of tooth eruption 12 3 (0.7) 3 (1.0) 6 (4.5) Advanced restorative/endodontic care 11 4 (0.9) 5 (1.6) 2 (1.5) including laboratory-made restorations Interceptive orthodontic treatment 8 4 (0.9) 2 (2.2) 2 (2.3) Child protection issues 8 3 (0.7) 3 (1.0) 2 (2.3) Direct/indirect composite restorations 5 2 (0.5) 2 (6.0) 1 (0.8) Severe tooth loss 4 2 (0.5) 1 (3.0) 1 (0.8) Non-vital or vital bleaching 3 (0.5) 1 (3.0) 0 (0.0)

Referral rate across the three centres as a whole was other. This includes patients with Child patients were referred to hospital medical conditions who were at high- departments by GDPs, GMPs, medical risk, either from dental disease or from consultants, PDS staff, and ‘others’. the treatment to manage oral disease, Almost 900 children were referred for example, oncological, cardiac, to the hospital services in the one- haematological conditions. month period (Table 26). In all three centres, the commonest reason for Across the three centres as a whole, the referral of the child patient was for the third most commonly referred patient management of severe caries (59.5%, group was patients requiring treatment 55.6% and 47% in Glasgow, Edinburgh planning for extractions under GA. and Dundee respectively). The second The estimated cost for providing

NHS Scotland most commonly referred patient group extractions under GA across the three 62 centres based on the referrals received compared to the cost of dental GA. (Table 27) is £151,898.90/month, or However, a number of sedation £1,670,887.90/year (Table 28), based sessions might be required for a on the cost per case shown in Section course of treatment, whereas all 4.6.1. It is recognised that the cost of treatment can usually be carried out sedation is considerably cheaper when under a single GA.

Table 27: Referrals received in the three centres over a month by condition for Current Service Provision extraction only GA

Condition Number of referrals received n (%) Total GDH EDI DDH Treatment planning for extractions 211 172 (39.1) 16 (5.1) 23 (17.4) under GA

Table 28: Cost of extraction only GA in the hospital setting as calculated by NICE (NICE 2010)

Time period Cost of dental GA Cost of sedation 1 month/4 weeks Number of referrals received 211 Number of referrals received 211 211 x £719.90 = £151,898.90 211 x £273.01 = £57,605.11

1 year/12 months Number of referrals received 211 Number of referrals received 211 211 x 12 = 2321 211 x 12 = 2321 2321 x £719.90 = £1,670,887.90 2321 x £273 = £633,656.21

Of interest, when compared to the Relation between referral rate, Health PDS data (Section 6.2) it was noted Board and SIMD that ‘patients requiring comprehensive dental treatment under GA’ was In general, the three dental hospitals a frequent reason for referral to serve their own population but accept

hospital services. This difference a small number of patients from other perhaps reflects the limited capacity NHS Board areas (Appendices 18, 19 for provision of comprehensive care and 20). There were a number of ‘out- within the PDS. However, in common of-Board’ referrals, particularly to GDH with the PDS data, anxiety or phobia (28%), which indicates there may was also a frequently cited reason for be an unmet need where there is no referring a child to the hospital-based availability of local specialists. departments. While it is recognised that there will also be a need for these The referral rate per 10,000 population departments to manage caries, it would within the Board areas of dental be appropriate to review the pathways hospitals ranged from 15 in Glasgow to for anxious children to ensure that, 17 in Edinburgh (Table 29). where appropriate local services exist within the PDS, their treatment needs

are met as close to home as possible. NHS Scotland 63 64 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report treatment ofcaries, planning to dentalhospitalsmainly forthe ‘Out-of-Board’ referrals weremade Board areas. communities withinthedifferentNHS not unexpectedgiventheprofileof most deprivedSIMDquintile.Thiswas the NHSBoardareawerefrom to GlasgowDentalHospitalfromwithin more thanhalfofthechildrenreferred referrals acrossallfiveSIMDquintiles, While thethreehospitalsreceived between referralrate,NHSBoardand Figure 12demonstratestherelationship Board area Table 29:Referralsreceivedby GDH,EDIandDDHfromwithintheNHS Clyde, LothianandTayside, groupedbySIMD2012quintile Figure 12:ReferralsreceivedwithintheNHSBoardareasofGreaterGlasgow& Lothian (EDI) Greater Glasgow&Clyde(GDH) Tayside (DDH) Count 100 120 140 160 180 200 20 40 60 80 0 1 Count

100 120 140 160 180 200 20 40 60 80 0 2 SIMD 2012Quintile 1 3 2 SIMD 2012Quintile

316 (72%) 282 (90%) area n(%) received withintheBoard 121 (92%) Number ofreferrals 4 3 Dundee respectively. SIMD forGlasgow, Edinburghand referred toGDHallcorresponded to that thetopfivetreatment conditions asexpected, SIMD. Itisobserved, dental hospitalswiththepatient conditions thatwerereferredto referral rateofthetopfivetreatment Figures 13,14,and15comparethe condition withSIMDquintile Relationship betweenreferralrateof care. multidisciplinary for extractionsunderGA,traumaand 5 4 Tayside Lothian Greater Glasgow&Clyde 5 15 17 population 10,000 16 Rate per Greater Glasgow&Clyde Tayside Lothian

the SIMD profile for deprived areas. Glasgow Dental Hospital come This relationship was not as strong for from the most deprived quintile. EDI and DDH except for caries referrals. It is also confirms the fact that This may relate to the fact that that caries is most prevalent in the majority of patients referred to deprived areas.

Figure 13: GDH referrals for top five conditions with SIMD quintile Current Service Provision

140 140 Severe early childhood caries/ Severe early childhood caries/ extensive caries in mixed/permanent extensive caries in mixed/permanent 120 dentition 120 dentition Other (which includes medical Other (which includes medical conditions) 100 conditions) 100 Treatment planning for extractions Treatment planning for extractions 80 under GA 80 under GA Anxiety or phobia

Count Anxiety or phobia

Count 60 60

Treatment planning and provision of 40 Treatment planning and provision of 40 comprehensive dental care under comprehensive dental care under GA GA 20 20

0 0 1 2 3 4 5 1 2 3 4 5

SIMD 2012 Quintile SIMD 2012 Quintile

Figure 14: EDI referrals for top five conditions with SIMD quintile

60 60 Severe early childhood caries/extensive cariesSevere in early mixed/permanent childhood caries/extensive dentition caries in mixed/permanent dentition 50 50 Other (which includes medical conditions) Other (which includes medical conditions)

40 40 Anxiety or phobia Anxiety or phobia

30 Abnormalities of tooth morphology Count 30 Abnormalities of tooth morphology Count

20 Treatment planning/treatment for children 20 underTreatment sedation planning/treatment for children under sedation 10 10

0 0 1 2 3 4 5 1 2 3 4 5

SIMD 2012 Quintile SIMD 2012 Quintile

NHS Scotland

65 66 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report departments byage.Thecommonest patients referredtopaediatricdental Figure 16showsthenumberof and age Relation betweenreferralrate Figure 16:Referralsreceivedbydentalhospitalsforallcategoriesage Figure 15:DDHreferralsfortopfiveconditionswithSIMDquintile

Count Count 10 15 20 25 10 20 30 40 50 60 70 0 5 0 Count 0 10 15 20 25 0 5 1 1 2 1 3 2 4 SIMD 2012Quintile 5 2 6 SIMD 2012Quintile 3 7 8 3 Age 9 4 10 five (10.8%and11.4%respectively), age ofreferralforEDIandDDHis accessing dentalcareatanearlierage. deprived areasofGlasgowmightnotbe This maybebecausechildpatientsfrom compared tosevenforGDH(14.3%). 11 11 4 12 5 13 14 5 15 under GA Treatment planningforextractions Anxiety orphobia Abnormalities oftoothmorphology conditions) Other (whichincludesmedical dentition extensive cariesinmixed/permanent Severe earlychildhoodcaries/ 16 under GA Treatment planningforextractions Anxiety orphobia Abnormalities oftoothmorphology conditions) Other (whichincludesmedical dentition extensive cariesinmixed/permanent Severe earlychildhoodcaries/ 17 18 19 DDH EDI GDH Relation between referral rate, age, delayed access to dental health services. and caries There is also the possibility that, because of complex social factors, these As shown in Figure 17, the most children may be absent from school frequently referred age group for severe when NDIP inspections are undertaken, caries to EDI and DDH was five, but was and therefore are not referred on to a six in GDH. Again, this might be due to dentist via that route. Current Service Provision

Figure 17: Referrals received by GDH, EDI and DDH for caries by age

60

GDH EDI 50 DDH

40

30 Count

20

10

0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Age

Consultation outcome by a consultant for an initial assessment. Very few children are immediately In general, children referred to sent back to the GDS or on to the PDS paediatric dental departments are seen without first receiving treatment.

NHS Scotland

67 68 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report *including vacancy (as of January 2016) *including vacancy(asofJanuary Table 30:Currenthospitalworkforce • • • • includes: paediatric dentaldepartments The currentworkforce inhospital 6.3.3 WTE ofconsultants andspecialists in (Table 20) andHDS(Table 30), thetotal and monitored.Overall, acrossthePDS resource should becarefullyscrutinised are small,andtheutilisation ofthis the numbersofstaffwithinHDS is13.1.AswiththePDS, dentistry consultants inhospitalpaediatric The totalWTEforspecialistsand 6.3.4 Total Hospital Dental Dundee Institute Dental Edinburgh Hospital Dental Glasgow consultants CCST (CertificateofCompletion Specialty registrars(StRs)andpost- Specialists Academic/teaching consultants NHS consultants

Current HospitalWorkforce

Consultants andSpecialists

WTE 2.9 2.4 7.3 *2

NHS Count Head AcademicSpecialty *2 *4 3 1.121.8 9 3.885.466.2 WTE 1.1 40.611.2 1.6 Head 2 31 (StR) registrarsofficersdentists

WTE Head

Seniorhouse (SHO) activities (SPA). Thisincluded CPD, allocated forsupporting professional of whichinitially2.5sessions were consists oftensessions perweek, consultant postonthe newcontract One WTENHSpaediatricdental 6.3.5 respectively). Scotland is17.2(PDS4.1andHDS13.1 Table 30. patient careresponsibilitiesarelistedin Current figuresforthosewithdirect • • • posts 4 Count Dental hygienistsandtherapists. senior houseofficers(SHOs) Pre-specialist coretrainees,formerly and specialitydentists(SAS) Staff grades,associatespecialists Specialist Training) development Head WTE 2 0.93 4 1 7 0.93

Consultant JobPlan SAS SpecialistsTherapists

WTE 2 2 Count Head 2 2

WTE Head

teaching and training, non-clinical 6.3.8 Pre-specialist Trainees administration etc. The remaining 7.5 sessions were allocated for direct clinical Core trainees (CTs) attend paediatric care (DCC) which included new patient dental consultants’ clinics and clinics, theatre, sedation, treatment, undertake some aspects of paediatric joint clinics and clinical administration. dental care as part of their core training. Some consultants are now on a contract These were previously known as SHOs

of 9:1 (DCC:SPA). Academic consultants at the time of workforce survey. Current Service Provision do provide some DCC sessions, but these tend to be fewer than 6.3.9 Dental Therapists NHS consultants because academic consultants have their teaching and A definition is given in Section 6.1.2. other academic commitments. No therapists were found to be working in the hospital paediatric 6.3.6 SAS Dentists dental departments at the time of the workforce survey. These middle grade staff work within a paediatric department to provide treatment usually following assessment and treatment planning by the consultant. They are considered valuable members of the team and can increase the capacity of the unit. They have undergone at least two years of speciality training and are able to work autonomously.

6.3.7 StRs and Post-CCST Development Posts

There are two grades of StRs: pre- and post-CCST. These trainees are GDC-registered dentists who are undergoing specialist training, either

to speciality level to gain access to the GDC specialist register in paediatric dentistry, or in the case of post-CCST registrars, specialist paediatric dentists undergoing further training in complex and multidisciplinary assessments and treatments to pass their Intercollegiate Speciality Fellowship Examination with a view to becoming NHS consultants or senior clinical academics in the hospital or university services. NHS Scotland

69 70 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report 7 interviewed preferredtobeseen interviewed withintheirlocality.the service Patients was proactiveindirectlycontacting had specialneedsandtheparent/carer made insomecaseswherethechild Additionally, self-referralhadbeen or medicalconsultantmidwife. referred bytheirownGDP, dental Participants reportedthattheywere extractions. for restorations,fissuresealantsand root canaltreatment,tongue-tie,and hypodontia, enamelhypomineralisation, such asthemanagementoftrauma, dental diagnosisandtreatmentneed phobia or, secondly, thenatureoftheir learning difficulties,anxietyand as autisticspectrumdisorder, complex challenges toacceptingtreatment,such and/or relating tomedicalhistory a numberofreasons:firstly, reasons for referred tothespecialistservice by aparentorcarerandhadbeen to 16years.Theywereaccompanied The patients’agesrangedfromnought clinics participatedintheinterviews. from fourspecialistpaediatricPDS A totalof22patientsandtheirparents Patients’ profile can befoundinAppendix21. ensure relevantareaswerecoveredand A patientquestionnairewasusedto PDS specialistpaediatricdentalclinics. sample ofpatients/parentsattending the perceptions ofarepresentative 2014 andAugust2015toinvestigate were conductedbetweenDecember Structured face-to-faceinterviews 7.1 Patient Perceptions inPDSandHDS oftheSpecialistServices Interviews Paediatric Patient Public DentalService

local PDSspecialistservice. GDPs appearedtobeunawareofthe hospital andsomereportedthat locally ratherthantravellingtoadental hospital service to the PDS. hospital service as theyhadbeenreferredonfromthe reported thattheyhadwaitedlonger, initially referredtoadentalhospital four weeks.Somepatientswhowere waiting timeforanappointmentwas Theaverage the PDSspecialistservice. that thepatientswereseenquicklyin It wasperceived fromtheinterviews treatment Waiting timeanddurationof the city.” ordeal togothroughahospitalin because thatwouldhavebeenabig appointment indentalhospital, we didn’t havetowaitforan washereand that thisservice “And iflocaldentistswereaware speaking directlytothedentist.” managed togetanappointmentby whose sonwasattendinghere,andI out aboutitmyselfthroughafriend the dentalhospital……….Ifound “The dentistreferredusthroughto us becausewestayin X.” because itwasmoreconvenient for Glasgow, andtheyreferredushere first wenttothedentalhospitalin “It tookquiteawhilebecausewe weeks.” “I thinkitwasabouttwoorthree “It wasmaybeaboutamonthorso.” Information, communication and Quality of service and support awareness of risks Specialist care for children in the PDS In general, patients reported that they was highly valued and was considered were well informed about the treatment an essential service by the participants options and treatment procedures. In interviewed. They understood that addition, it was perceived from the the service delivered was at specialist interviews that patients were aware level and appreciated the fact that they of the risks of treatment options and could access the service locally. Patients felt that they have made an informed valued the consistency of seeing the decision. same specialist and reported that the staff were very approachable, friendly, considerate and helpful. Patients valued “Yeah, they explained it as well. They the time taken by the specialist to see need to give him gas and air as well so them and did not feel rushed. Parents they explained all that, they explained praised the skills of the specialist in everything to him. They’ve been really calming children and felt that they were good with him.” well supported. Patient Perceptions of the Specialist Services in PDS and HDS Patient Perceptions “If it had to go any further then obviously he would need anaesthetic “I think it’s an extremely important and stuff, they explained the risks of service because if it wasn’t for the likes that. But I think what they’ve done will of this service my son, and especially hopefully do the job.” my daughter here, wouldn’t have anywhere to attend regularly. Because “The risks, I think it was just with she needs that continuity, the same getting put to sleep. Obviously the risks people that she sees on a regular basis. that always come with that. But when I And dentists in practice, don’t have weighed up the pain that he’d been in the time to do that with her. And this with the teeth there was no questions specialist centre is really good for the asked, they have to get it done.” likes of them. And it’s well worth it.”

“I just felt from the moment we came “Oh yeah. I just knew that local in that day, he was only five years old anaesthetic and sedation wouldn’t - it when he had to get the teeth taken

just wouldn’t have been an option, out, he was very nervous, I was really and they were going to try... As in all nervous, so was his dad. The staff cases, because don’t want a child to in here seemed to calm me down have a general anaesthetic... I mean, because I was upset, they seemed I’ve seen children and that experience to calm him down, make him feel at wasn’t nice for any of us, but after ease before going under. And as soon xx had been in the room just a few as he woke up the aftercare was also minutes, he kind of accepted that ‘No, brilliant. I felt they couldn’t have done a local’s not going to work here, it any better.” needs to be...’ And because he needed quite a little bit of work doing and they “The staff are very, very friendly, very wanted to have a look at a few more welcoming. They’re happy to deal things than what they might have, they with the kids, fantastic with kids. And said, ‘No, general would be better” couldn’t ask for better.” NHS Scotland

71 72 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report service forcontinuingcare.Ingeneral, service needs andweretherefore accessingthe medical conditionsand additional paediatric dentalclinics hadlong-term that somepatientstreatedinthePDS It wasperceived fromtheinterviews Benefits anticipated wait longertobeseen. was goodbutbusyandtheyhadto and reportedthatthehospitalservice tothehospitalservice specialist service Some patientspreferredthePDS is overcrowded.” hospital ingeneral.Theunit dentist isexpectedforyourkid.It’s appointment, youneverknowwhat the queues,andthendental an hourminimumbecauseof you waitalways.Imean,ahalf but “Xx hospitalisagreatservice it’s abetterservice.” or tenminutessomething.Here youhaveto waitfiveminutes service an hourtohour. Whileherethe Sometimes youhavetowaithalf always busyandyouhavetowait. is goodbut “Hospital service is, andnobodyhasevercomplained.” they knowthatthat’s justthewayhe obviously accommodatehim,but appreciate... Theycan’t always is atacertaintimethenthestaff he justdoesn’t. Ifhisappointment ------’s bigproblemiswaiting,and feel rushed,youdon’t feel...Because take thatintoaccount.You don’t knows thatthereareotherissuesand everyone’s approachableandfriendly, And “No, I’mhappywitheverything. and dentalhealthbenefits. patients wereanticipatingfunctional one forher.” wasn’t theonethatwasmajor a slightelementofpain,butpain partly practical.AsIsay, therewas think thebenefitispartlycosmetic, opposed tojustbrokenstumps.SoI now thatshehasfrontteethas and thingsisobviouslymucheasier begin with,andcertainlychewing “I knowhermouthwasquitesoreto I feelclean.Itfeelsclean.” thing thatwouldstopanything. than anything.Sothisisthefirst “It’s morepreventative,Ithink,rather well, butthat’s takenintoaccount.” You knowthatwe’veotherneedsas can bedoneunderGAifnecessary. here, andnotinmylocaldentists.It be done,thenIknowitcandone arise, andifanythingshouldneedto can dealwithanyproblemsasthey close eyekeptonhim.Sothatthey “Just thathe’s goingtobegettinga his life,greatpronunciation.” lateronin him withhisvocabulary “Just forthefactthatitcanalsohelp do needtocomeout.” teeth. Orevenkeepthemuntilthey “Really justtosavethebacktwo because he’s hadalotoftrouble.” “Pain reliefwasmymainconcern 7.2 Dental Hospital and emergency patients were seen Paediatric Patient immediately. Interviews “It wasn’t a long wait.” Structured face-to-face interviews were conducted between 5 June and “It was weeks, not too long. I 25 September 2015to investigate wouldn’t say more than six weeks.” the perceptions of a representative sample of patients attending the “I would say about ten weeks, hospital paediatric dental departments. maybe.” A questionnaire was used to ensure relevant areas were covered and can be found in Appendix 22. Some parents reported that, although their children were in pain, they were Patients’ profile not prioritised. In general, parents reported that they did not mind waiting In total, 43 patients from three dental if the child was not in pain.

hospitals participated in the interviews. of the Specialist Services in PDS and HDS Patient Perceptions Patients’ ages ranged from nought to 16 years and most patients were “We waited six or seven months, it’s accompanied by a parent. been quite a wait. I phoned and they In similarity with the patients couldn’t get her anything sooner. So interviewed within the PDS specialist she’s been in constant pain for the clinics (Section 7.1) the reasons cited last two weeks.” for the referral to the hospital service included those related to a medical “If it wasn’t urgent then I wouldn’t condition and/or ability to accept have bothered, we can be patient. treatment such as autistic spectrum But just because there was a bit of disorder, complex learning difficulties, pain involved.” anxiety, phobia and medical conditions, or the management of a variety of dental conditions such as trauma, In some hospitals, patients reported that hypodontia and extraction under GA. they experienced delays arising from Patients interviewed reported that communication and or administration they were referred by either a GDP or problems. medical consultant.

Waiting time and duration of “We got a phone call to come treatment up on the Monday, but then we got a letter to say to come up the It was perceived from the interviews following Tuesday. There was a bit of that across the three hospitals, patients communication breakdown, really.” were not waiting long to be seen by a consultant. However, it was noted “It was a mix-up with the records, that the average waiting time for a and the appointment came outwith consultant appointment was between one of my other kids’ names and two to eight months, although trauma date of birth on it.” NHS Scotland

73 74 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report term medicalconditions. however thismightbe becauseoflong- in thehospitaloveralong timeperiod, that themajorityofpatientswereseen It wasapparentfromtheinterviews losing theirclinicalrecords. difficulttime asaresultofstaff a very Some patientsreportedthattheyhad sorted out.” departments. ButeventuallyIgotit then Igotreferredtofivedifferent then thelossofcasenotes,and you waitforanappointment,and getting herreferred.Bythetime “It’s justthegeneralbeginning, and thentheylosthisrecords.” problems, hehadoneinitialvisit, “It wasquitedifficult. We didhave them.” of communicationswithboth both ofthem,there’s abreakdown hospital saidshedidn’t. SoIthink that shesentthereferrals,and “I think…well,thedentistsaid consultant yet.” So wehaven’t actuallymetthe letters andthingscamethrough. “But itwasabitmixeduptheway now.” until thisweek.Notgreatup appointment.’ Anditwasputoff told ‘no,you’venotbeengivenan them toconfirmthetimeIwas for lastweek.AndwhenIphoned given arearrangedappointment was onthephoneIactually “And whenIphonedup,while consent. Someparentsofchildpatients presented tothemwhileobtaining relating totherisksofGAthatwas were unabletorecalltheinformation In somedentalhospitals,parents/carers Awareness ofrisks from mostotherareasofdentistry. different the riskbenefitratioisvery realistic optionotherthanGA.Therefore are alsodentallyanxious,thereisno referred withpainandinfectionwho However, formanyofthepatients any risks. they havenotbeenmadeawareof who haveundergoneGAreportedthat “It mustbefiveyears.” am turningfourteeninJuly.” since Iwasquiteyoung,maybesix. “I’ve beeninthedentalhospital sincehewasthreemonths.” service “We havebeeninthehospital sixteen now, yeah.” “About eightyears,becausehe’s don’t explain theriskstoyou.” coming andgoing.Because they “Well, no risks.That’s mekindof R: Nothing.Nothing.” something aboutGA? “I: didtheygiveyoualeafletor R: Nope.” explained anyrisks? “I: You hadtwoGAsandnobody saying anything….” honestly can’t remembersomebody an anaesthetic.You know yourself.I information. You know, sayinglike “No. Reallymorethepaperwork, However, some patients reported that “I think they should be able to they had to wait longer for treatment explain things a wee bit more to on the day of appointment than you regarding general anaesthetic, originally scheduled and were not and even give you a leaflet on it informed of any delays. explaining the dos and don’ts. Other than that, the service is excellent.” “What I’m not happy with is Information and communication first time we came we waited an hour from when we arrived. Our In general, patients felt they were appointment was at eleven, got in well informed. Patients reported that twelve. The second time we came the treatment options and treatment we waited for fifty minutes. Which I procedures were explained to them understand - it’s a trauma clinic, but and it was perceived that patients nobody came out to tell us what was felt involved when they were given going on.” information about their treatment. “The quality is good. My only gripe

“Yeah. They explained everything is that our appointment is ten past of the Specialist Services in PDS and HDS Patient Perceptions quite clear.” nine and it’s now quarter to ten. And quite often they’re late. Especially “Xx has to be put under general considering you’re the first in the anaesthetic, so it’s the day ward. morning. But other than that it’s So from start to finish everything’s been good.” explained and again they try to accommodate him because of his “They’ve been really good and really needs, and the whole staff were all helpful but sometimes we have to very understanding.” wait a bit longer.”

“Up to now he has explained “Some people have maybe not everything well.” been as good at managing to communicate with you as others.” “Yes, because we had a couple of options so they explained it.” Quality of service and support “They’re giving us choices and we’ve been going through. We’ve In general, the hospital paediatric been quite conservative to start with dental service was highly rated by the because we don’t really want to go patients interviewed. Patients praised offering veneers but we didn’t want the staff and consultants for the quality to go down that route until she’s a of treatment the department was little bit older, or see how the other providing. Patients felt that consultants treatments would work better.” and staff were very considerate and helpful. Parents appreciated that the “Yeah, they told you both ways, consultants knew how to treat anxious whether he wanted to be awake for children and children with additional the procedure or not. And he made the decision himself. So they gave us needs and reported that the consultants all the options, yeah.” made them and their children feel

relaxed and supported. NHS Scotland

75 76 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report allocated. notice andadifferentconsultantwas appointments werechangedatashort It wasalsoreportedthatthepatient therefore therewasnoconsistency. not seeingthesameconsultantand was reportedthatthepatientswere It complained aboutthepoorservice. However, patientsinsomehospitals this hospital.” old, sowe’vebeenherenineyearsto here, likenowhe’s nearlynineyears a goodexperiencehere.I’vebeen “Ten. I’llgiveten,becauseIhave that understands.” now, butit’s goodtohaveadentist he’s clever. He’s juststartingtospeak like they’reretarded,andhe’s not, your childisnon-verbal,treatthem nothing aboutautism,particularlyif A lotofprofessionalswhoknow how totalkthemappropriately. interact withyourchildandknow autistic children.Theyknowhowto dentist actuallyhasaninsightinto good. Andit’s goodtoknowthatthe “I can’t faultit.It’s beenreally, really time.” because shewasquiteworriedatthe Especially,everything. formymum, comfortable andsupported “They makemefeelquite more traumatisedthanthechild.” Because, theparentissometimes possibly can to make it not traumatic. they “They absolutelydoeverything maybe asixorseven.Butcertainly go wrongandthenitcanbecome just takesformaybeonethingto breeze, it’s tenoutoften.Butit everybody’s inplacethenit’s a “If everybody’s familiarand colour.” weeks agobecauseitwasn’t theright afew self-conscious. Shewascrying think, oneofthosethings.She’s abit quite traumaticforher, butit’s just,I needed tobelengthened.Ithasbeen cover neededtobechangedandit that ifitdidfalloutagain,the said thatshe’dputonthenotes we werehere,thedentistwe’dseen rebuilt threetimes.Sothelasttime it felloutafewtimessince.It’s been “Yes, they’verebuilthertooth.But understand.” maybe understaffing thatIdon’t don’t havethe staffhere.Soit’s And theysaynobecause they can’t gettheseappointments. to fightconstantlyhave….AndI on aFridayafternoon,andIhave because hisschooldoesahalfday appointment onaFridayafternoon biggest complaintiswewouldlikean works fulltime,soit’s difficult.My person. Iworkfulltime,myhusband becauseIdon’teverything knowthe consulting me.Anditjustchanges consultant he’s under, without “They keeponchangingwhat maybe anothersixyears.” fourteen now, we’retalkingabout treatment isgoingtotake…he’s R: Iwouldlikeconsistency. Buthis I: Differentpeople? people. “R: No,weconstantlyseedifferent importanttochildren.” very the wholefamiliaritythingisvery, Some patients reported that they would Benefits anticipated prefer to be treated at a local clinic rather than travelling long distances. It was obvious from the interviews Parents of special needs children felt that patients treated in the paediatric that their children would cope better if dental department were anticipating treated at the school rather than being functional benefit, dental health benefit referred to hospital. and social benefit, for example, able to see dentists regularly without phobia.

“The only thing is, we live in Ayrshire and it’s got its own dentist so…it’d “He’s become a bit more tolerant of have been more convenient for us to me brushing his teeth, because he go to our own.” doesn’t understand the concept of brushing teeth. So through time, and “I would say to try and maintain obviously the guidance. the importance of the needs of the children with special needs. Years “To get rid of all the decay the ago when he was young, the dentist daughter has in her teeth and to get

used to visit the school, and in their them all treated.” of the Specialist Services in PDS and HDS Patient Perceptions own surroundings with special needs schools. They would visit the school “Well, obviously she’s not going to and do the dental examinations there have infected teeth there, and long- in conjunction with the child going term care for her mouth.” to a dentist or coming to children’s hospital. So there will be some “To ensure that her teeth are parents that will be happy to do that, operating properly. She’ll have a to go to hospital and persevere with healthy life.” their child, but I think there’s a lot of parents that won’t be able to cope. “The dentist here has worked with They’ll have one bad experience and autistic children before, and he’s got that will stop, and that is detrimental quite good techniques at getting to their child’s oral health. So if them calm and to cooperate. So they’re not seeing somebody at it gives us the reassurance that school, not going to a local dentist, between the two dentists his teeth and they’re not accessing a hospital are being looked at.”

dentist I think that’s bad.” “Her benefits are both going to be her appearance, and she’s going to be able to chew properly, because with the gaps she wouldn’t have functioned properly and her jaw wouldn’t have been in line. So it’s a bit of both.” NHS Scotland

77 78 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report 8 Workforce Perceptions: PDSSpecialistsandHDSConsultants soft tissuelesions suchasulcers extractions underGA, IHS, MIH, were managementof caries, trauma, carried outbythePDS specialists Common treatmentsthat were referrals aremadeforcontinuingcare. islimited, access toGDPservices reported that,insomeBoardswhere that comeacrosschildren.Itwasalso social workandotherprofessionals NDIP, Childsmile DHSWs,healthvisitors, a numberofsources includingGDPs, Children werereferredtothePDSfrom conditions. of somedescriptionorcomplexmedical anxious, orwhohaveadditionalneeds that theyacceptchildrenwhoaretoo settings. Somespecialistsreported to receivecareingeneralpractice time educationwhoarenotsuitable birth untileighteenyearsofageinfull criteria. Theyacceptchildrenfrom Scotland didnothavespecificreferral across that PDSspecialistservices It wasapparentfromtheinterviews Referral criteria and canbefoundinAppendix23. to ensurerelevantareaswerecovered specialists guide wasusedtointerview acrossScotland.Atopic interviewed Seven specialistsbasedinthePDSwere of specialistsinpaediatricdentistry. perceptions ofarepresentativesample 2015toinvestigatethe February conducted betweenJuly2014and were Semi-structured interviews 8.1 receive theirtreatmentwithaGDP.” pretty muchanychildthatcan’t “I wouldsayourcriteria,weaccept Perceptions PDS Specialists’ significant ‘grosscaries’. that theytreatedteenagerswith lists. Insomeareas,specialistsreported there isabigincreaseinMIHandGA among theirpatientsbutreportedthat there wasareductionindentalcaries Specialists acrossScotlandreportedthat Changes inprevalence offered insomeNHSBoards. hypodontia. IVsedationwasalso and swellings,impactedteeth not needto betreatedinadental Some specialistsfeltthat childrendid in thetransitionstage. management planfor children whoare thatmostNHSBoardshavea observed Itwas to adultspecialcareservices. they are18andthentransferred needs oftenremainwiththePDSuntil of treatmentbutchildrenwithcomplex be sentbacktotheirGDPafteracourse Children withnospecificdisabilitymay also providedinsomeNHSBoards. under IHSandGA,IVsedationis Most PDSclinicsprovidetreatment typically betreatedwithintheGDS. patients inthecommunitywhocannot The PDSprovidesdentalcareforchild model provision/service Service children thatfindtheirwayinto and thosearethe sedation service up. ItmightbebecauseIrunanIV I wouldn’t liketosaythat’s going “I seeteenagerswithreallybadcaries. picked upasMIH.” for cariesfromGDPsbuthavebeen for MIH,butjustreferredinprobably started butnotnecessarilyreferredin “I’ve seenquitealotofMIHsinceI service.” hospital or children’s hospital setting if the treatment does not involve “I had a child this morning where the multidisplinary care or the need for child has certainly got needs but the treatment under GA. It was argued that mum has got probably more needs. specialist expertise should be available And we will bend over backwards to locally as much as possible to prevent make sure the child is seen.” patients having to travel long distances or wait longer for treatment. It was “We’re seeing a group of children also argued that if a specialist was who are very deprived.” based locally and was able to provide sedation, there would be less chance of patients being referred for GA. This was Workforce/skill set/workforce model viewed as more cost effective for the service and more beneficial to patients. Specialists’ views about the workforce available in the PDS were variable. Some reported that they needed more “… if you’ve got a specialist working specialists while others reported that in the PDS clinic, and you’re set up they had an adequate number of for sedation, your conversion to specialists. They agreed that specialists general anaesthetic for treatment should be based in the PDS with one or of PDS Specialists and HDS Consultants Perceptions Workforce is lower than if you see all those two regular sessions in a dental hospital. patients in a hospital setting.” Specialists felt that by doing a session or more in hospital they would be able to develop further and also provide Specialists viewed the provision of an appropriate clinical network with dental care in the local community consultant colleagues. setting to be good practice and patient-centred. They reported that clinics based in the community can “You’re going to need more often liaise more directly with medical specialists, not based in dental practitioners, health visitors and social hospitals, because that’s only work colleagues, especially if they share Dundee, Glasgow, Edinburgh, the same premises. It was observed that Aberdeen. There are huge areas in specialists were very aware of the socio- between, there’s lots of population. economic, demographic and working So I think we’re going to need a profile of the population of patients much more localised specialist service they manage. but it must have backup of access to general anaesthesia because there are times we can’t do stuff without that.” “I think the difficulty is you do have a concentration of specialists and “I think it is important for people consultants in hospital settings, and that are PDS-based to have hospital while I think that’s a good idea to experience and vice-versa.” have centres of excellence, I’m not sure that that’s always the best place for that level.” It was reported that the majority of staff who work in the PDS are dentists with an interest in treating children but the presence of specialists enables the PDS NHS Scotland

79 80 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report improve the delivery of careinthe improve the delivery and otherspecialistswould significantly with consultantsinpaediatric dentistry The specialistsreported thatnetworking challenging behaviourorspecialneeds. the skillsettomanagechildrenwith children, andsomeGDPsmaynothave totreat the timewhichisnecessary are notremuneratedappropriatelyfor treating childrenbecausetheyfeel did notalwayshaveanincentivefor administrative. ItwasfeltthatGDPs and support,bothclinical because oftheabsenceinfrastructure they wereprovidingwaslimited Some specialistsfeltthattheservice care, guidanceandsupport. because thereisaccesstospecialist to delivercomplextreatmentlocally early years.” sympathetically, ifyoulike,inthe to achildifthey’renottreated “You candoalotofdamage for thetimewhichisnecessary.” they’re remuneratedappropriately wellbecauseIdon’tdentistry think general practitionerstodopaediatric think there’s agreatincentivefor here, buthandonheartIjustdon’t I’m maybespeakingoutofturn think youcouldexpecthugely… is fundedatsuchalevelthatIdon’t GDS regulationsingeneralpractice “I thinktreatingchildrenunderthe get ontheHighStreet.” who needabitmorethantheycan committed toworkingwithpeople andthey’reallkeen everything workforce, theyalldoabitof “We’re fine. We’ve gotagood community. that theywereontheirowninthe thatthespecialistsfelt the interviews community. Itwasperceived from not enoughspecialists. community butthisisbecausethereare to specialistswhocanworkinthe there aremoreconsultantscompared It wasreportedthatinsomeareas limited funding. qualifications. Thiswasfelttobedue PDS arenotpromoteddespitehaving was alsoperceived thatsomestaffin delivering careatspecialistlevel.It example, SDO)reportedthattheyare appointed atnon-specialistgrade(for Some specialistswhohavebeen up withthem.Ialsoknowthere’s know we’resupposedtobejoining perhaps what’s goingtohappen.I the PDS,whichIunderstandis hospital setupwereincludedwithin specialists/consultants withinthe be strengthenedgreatlyifthe “I dothinkthatthePDSwould more onyourown.” If you’reincommunityabit because it’s amoresolidstructure. specialists dolikethehospitalsetting because consultantsparticularlyand “I thinkit’s amind-setthing, But thereisakindofthemandus…” should beallpartofthesameteam. in thesamepartofworld,we essentially forthesamepatientgroup because ifwe’redoingthesamejob But itmakesanawfullotofsense, a bitofresistancetothatidea. “I think we’re top-heavy with “I will retire in less than three years’ consultants. I think you’ll find there time, but I hope that there’s enough are more consultants than we have people been trained who want to specialists. And that’s a top-heavy stay as specialists and not go on pyramid, isn’t it?” to two year, further training to be consultants. The other barrier I think in Scotland is you’re training people Some specialists, close to retirement, who aren’t necessarily Scottish and reported that they might not be who may not settle in Scotland long- replaced appropriately as they felt the term.” number of dentists in specialty training was inadequate. However, others felt “What I would like to see is maybe they were training enough numbers. what they call in England a special There was also a worry among some interest or a particular interest where established specialists that, after training you’re not a specialist but you’re able to a specialist level, many younger to cope with kids that maybe general specialists seem to continue to post- dentists aren’t.” CCST/consultant training which may lead to an inadequate number of of PDS Specialists and HDS Consultants Perceptions Workforce specialists available to fill PDS posts in Gaps/improvements the future. 1. PDS referral criteria should be It was suggested that dentists ‘with a developed nationally and special interest’ might bridge the gap standardised as much as possible so between dental officer/general dental that there is more consistency in practitioner and specialist. Postgraduate how child patients are accepted and qualifications and/or training in treated across all NHS Boards. paediatric dentistry, GA or sedation and managing children with special needs should be made available to PDS “I think to have a national standard dentists so that they can gain additional rather than just a “well, in Lothian skills and experience. we do it this way and in Lanarkshire we do it this way, and in Greater Glasgow it gets done this way.” I “We are struggling because it won’t think that’s not helpful.” just be me that is due to retire, there must be a cohort of us who “There would have to be local got onto the specialist list without variation to address local needs and

formal specialist training. It was taking into account the availability of created in 99, and a lot of people a dental hospital.” got grandfathered on. And they’re due to retire, and we haven’t got the equivalent cohort.” NHS Scotland

81 82 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report 3. 2. different fromworkinginahospital.” other managementthings?It’s quite links. Howdoesthatfeedinwith follow-up. You’ve gottomakethe to realiseyou’vegotdoallthe to makethedecisions,you’vegot the buckstopshere,you’vegot points, butsomeoftheissuesthat environment. Someofthegood when you’renotinadentalhospital they realisesomeoftheissues shadowing foraweekortwo,so registrars comingout,maybe “I thinkweneedmorespecialty be providedforthem.” and that’s wherethetreatmentcould go totheschoolwhereclinicsare the hospital.Thespecialistsshould children fromtheschoolsgoingto those clinicsratherthanhavingthe be workinginthespecialschools think thereisaneedforspecialiststo that arewithinthespecialschools.I opportunities wehaveistheclinics “I thinkoneofthemissed

Specialty registrarsshouldspend Specialists couldtakemore their experience. some timeinthePDStobroaden should beused. available intheschoolsetting,they their dentalcare.Ifclinicsare ‘mainstream’ schoolstocoordinate additional supportwithin needs schoolsanddepartmentsof responsibility forchildreninspecial

4. 5. strengthened greatlyifthespecialist/ “I dothinkthatthePDSwouldbe need to.” so Icankindoflinkinwiththemif know theconsultantsthatarethere worked inbothenvironmentssoI I’m probablyquiteluckybecauseI’ve maybe havemoreoverlapwiththem. consultant comesoutandyou you werelinkedtoahospital, clinical networkwheremaybeif have itasamuchmoremanaged “I thinkitwouldbequiteniceto was includedwithinthePDS.” consultant withinthehospitalsetup

The currentGP17/SDRsystemmay secondary care. secondary and and hygienistsbasedinprimary and non-specialists,therapists to includeconsultants,specialists Local MCNsshouldbeestablished the SDR. be potentialtousespecialcodesin conditions. However, there may palate orsignificantmedical with hypodontia,cleftlipand clinicsforchildren in multidisplinary It alsomaynotreflectanywork molars withintwoyearsoferuption. of teethotherthanpermanent permanent molars,fissuresealants stainless steelcrownsonfirst hypoplastic teeth,bleaching, restoration ofmalformedor PDS, includingcomposite carried outbythespecialistin not fullycapturetheprocedures

“It’d be nice not to need to use 8.2 Hospital Consultants’ the GP17 paperwork and terms of Perceptions the dental remuneration. It’s of no material gain to us. And it’s very Semi-structured interviews were time consuming. But to say that conducted between August 2014 and we’ve to work to the terms of dental September 2015 to investigate the remuneration is actually so out of perceptions of a representative sample date. We’re not using amalgams in of consultants in paediatric dentistry. the same way. It doesn’t cope with Eleven consultants/honorary consultants bleaching, it doesn’t cope with a lot based in three dental hospitals of things that we do. And it won’t participated in the interviews and the let you do stainless steel crowns on topic guide used to ensure relevant sixes. It doesn’t let you fissure seal an areas were covered is in Appendix 24. E, and that might actually be the best thing for that tooth. We do it, but Referral criteria there’s no way of showing our work out. And you just think it’s pointless Consultants’ views on referral criteria because they’re not even collecting were variable, with some consultants

accurate information.” reporting that they have specific referral of PDS Specialists and HDS Consultants Perceptions Workforce criteria, while others do not. Some consultants stated that they would like 6. In some Boards, where the PDS to tighten their referral criteria, while activity in hospital is not recorded others stated that they would accept appropriately, arrangements should inappropriate cases/routine cases or be made to record activity to reflect cases that could be treated in local work carried out by the PDS. PDS for their undergraduate students. On the whole, it was perceived that consultants felt that there should be an “What’s bizarre is on the general agreement on how much routine care dental service recording that my should be accepted within a hospital activity is recorded for assessing a service. In some areas, new referral child, looking at the radiograph, and criteria were being developed to reflect for treatment plan, but the work I do the integration of the PDS with the when the child’s asleep under GA is hospital service. not counted. We’re chasing that up at the moment because it kept being labeled under oral surgery. And I “We do not have referral criteria, kept objecting that this was wrong. but that said, we may, depending

Because it’s not under maxillofacial or on what transpires at the actual new oral surgery, it’s under, as far as I’m patient consultation, advise they go concerned, paediatric dentistry.” back to their GDP for the treatment or attend a student clinic or whatever rather than necessarily get specialist- type treatment.” NHS Scotland

83 84 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report be treatedinthePDS. care orcomplextreatment,theyshould patient didnotneedmultidisciplinary Some consultantbelievedthat,ifthe dental departmentsacceptpatients. in Scotlandthewaypaediatric consistency acrossdentalhospitals at nationallevelsothatthereis should bedevelopedandagreed It wasalsostatedthatreferralcriteria should beabletoprovide it.” then potentiallyaPDS practitioner “And ifitisn’t ofacomplexnature different HealthBoards.” takes referralsfromanumberof across, becausethedentalhospital Not justwithinthisHealthBoardbut part ofanagreedandacceptedplan. be happytodothataslongit’s our referralcriteria.Ithinkwewould probably tightenupsignificantlyon “I thinkwhatweneedtodois than theyshould.” because theyendupwaitinglonger care, sometimesaredisadvantaged paediatric dentistry, multidisciplinary more urgentlyneedhospital-level keep taking,maybepatientswho level ofpatientwe’regoingto to decidehowmanyofthatbasic to accept,andhowwe’regoing referrals wearegoingtocontinue management teamastowhat the consultantbodyandour “We needanagreementbetween the studentclinic.” then triagethemandseeon may notbenecessary, butwewill specialist oraconsultanttosee,it “They maybeinappropriatefora consultants acceptthesecasesinthe child patients.Itwasreportedthat for thevolumeoftimetheyspendon GDPs werenotsufficientlyremunerated were referredinlargenumbersbecause there wasaperception thatthesecases management ofdentalcaries.Generally, with routinetreatmentandthe management, difficultyincooperating basiclevelofcare,anxiety for avery from GDPssometimestendedtobe complex, whilethereferralsreceived and medicalconsultantstendedtobe The referralsreceivedfromthePDS consultants andspecialistnurses. referrals fromGDPs,thePDS,medical Consultants reportedthattheyreceived Referral patterns not usedwidelybyGDPs. spread outgeographicallyandtherefore wasnot that theyfeltthePDSservice interest ofthechild.Consultantsstated out ofpocket.” mean they’recontinuously financially a standardofcarethat isn’t goingto economic modelforthem toprovide because ofthelackaproper by generaldentalpractitioners still notbeacceptedfortreatment “I thinkprobablychildrenwould them toprovideatreatment.” to makeiteconomicallyviablefor they’re notsufficientlyremunerated practitioners sendtheminbecause and myfeelingisthatgeneraldental time-consuming patientstotreat, in largenumbersbecausetheyare their dentalcaries.Thesegetreferred treatment, andthemanagementof difficulty incooperatingwithroutine care, foranxietymanagement, referred fromGDPsareforroutine “A lotofthepatientsthatwere Consultants reported that they “We sometimes write back to the were seeing an increase in MIH and general dental practitioner and say gingival hyperplasia cases. While the “this patient is not appropriate for prevalence of MIH is known to be the hospital, please send them to increasing, they also speculated that, your local PDS.” And they’ll write in the past, the teeth damaged by back again and say I don’t know who the hypomineralisation process were that is, which I find astonishing.” extracted because of caries and so MIH was not diagnosed. Therefore, due to the decrease in caries levels, they are Consultants felt that consultant- now seeing more MIH. led paediatric dental departments should accept referrals for cleft lip and palate, trauma including complex “There seems to be an awful lot of trauma, complex hypodontia, severe MIH. It wasn’t a million years ago behavioural problems, congenital that I was a dental student, but we abnormalities and complex cases didn’t even get taught about it. I’m requiring multidisciplinary dental and/ sure it was there because you can see or medical care such as cases requiring it in some older people, but every an input from orthodontics, restorative single one of my new patient clinics of PDS Specialists and HDS Consultants Perceptions Workforce dentistry, oral surgery, oral medicine, has at least three MIH patients. It just haematology, cardiology or oncology seems really prevalent.” on an ongoing basis. The less complex cases should be managed within “I see increasing number of children the PDS. Further details of proposed with gingival hyperplasia. I think national referral criteria are given in overall the demand and expectation Appendix 1. that we should be doing more for these children.” Prevalence/demand “We’ve seen an increase in Consultants reported that currently what I would call molar incisor they do not see demand for private hypomineralisation, particularly specialist paediatric practices in with poor quality first permanent Scotland, in contrast to England where molars. Whether that is actually a some specialists are engaged in private genuine increase in the prevalence services. of this, or the fact that the caries rate is decreasing and therefore we’re seeing it for what it is, and not just “There isn’t that kind of demand. as very advanced caries, I’m not sure. I know in England there are a few But there is an increasing prevalence people now who are working as across Europe, and I would say that independent contractors or private our department is measuring that.” specialists. I know people from London and Leeds, but it’s not happening in Scotland.” Some consultants reported they have not noticed any change in prevalence of caries. In some areas consultants reported that they are noticing

reductions in GA lists, while others NHS Scotland

85 86 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report in treatingchildren. PDS byadentistwith a specialinterest hospital couldbemanaged withinthe anxious childrenwho were referredto Consultants feltthatthemajorityof model provision/service Service extra GAlists. they werebeingaskedtoundertake reported thattherewasanincreaseand extractions.” in referralforgeneralanaesthetic “There hasbeenadefinitereduction some change.” caries risk.Soyes,therehasbeen same, though,andthat’s thehigh type ofpatientreferredremainsthe of sessionsthatarecarriedout.The “We’ve actuallyreducedthenumber service.” a continuedhighdemandforthat quite high.Sothereseemstobe appear toberunningjustnoware paediatric assessmentclinicsthat decreasing, becausethenumberof the figures,butinmyheadit’s not Idon’tfor theGAservice. have “We appeartohaveahighdemand I’m seeing.” change inthetypesofpatientthat personally perceive theretobemuch slow.seem tobevery Sono,Idon’t but inGlasgowparticularlyitdoes that intimethingswillimprove And obviouslywecontinuetohope minimaleffect. have hadavery Glasgow forwhomallthesechanges There arepocketsinandaround “We stillgetlotsandofcaries. “I guessit’s prettymuchthesame.” clinics andrearrangeappointments. easier forpatientstotravelPDS Consultants reportedthatitwasoften care. patient requiredmultidisciplinary treated intheirlocalPDSunlessthe consultants thatpatientsshouldbe There wasagreementamong sustainable ifsomeonelefttheservice. up theirskillsandwouldbemore specialists andconsultantstokeep that thismodelofnetworkwouldhelp be possible.Someconsultantsargued consultant orspecialistsupportshould but thatanetworkapproachwith specialist cannotbelocaltoeveryone, geographical issues,aconsultantor was acknowledgedthat,becauseof PDS settingswouldbebeneficial.It establishment ofaclinicalnetworkin Some consultantsfeltthatthe hospital. Ithinkahospitalcanbe flow thanitisthroughdental PDS clinicsisoftenamuchbetter “I thinktheflowofpatientsthrough with specialinteresttypemodel.” referred…you know, likethedentist of theanxiouschildrenwhoare dentist canprobablymanage90% “A welltrainedpublicdentalsalaried home andin atimelyfashion.” appropriate levelofcare closeto ground sothatchildren canreceive “Better networksinthe middle flow muchbetterinPDS.” to getthehospital.Itjustseems change appointments,howeasyitis patients, forhowpatientsmanageto worked inthatit’s muchharderfor found thatinallofthehospitalsI I’ve administration oftheservice. much moreboggeddowninits Overall, consultants agreed that service “Create a network. For somewhere provision should be patient-centred like Tayside, Grampian, Highlands, where a patient could access care close where you’ve got huge geographic to home so as to minimise disruption to issues to deal with, you couldn’t have the child’s routine. a consultant or specialist local to everyone, but you could have a more 18 week waiting time referral to networked approach……..I know treatment (18 week RTT) guarantees Grampian has got a real problem right now in terms of they’ve lost The consultants’ view about the 18 their staff.” week waiting time was variable. Some consultants reported that they are meeting the guarantee and that there Others felt that the PDS and hospital were no problems. service should work closely as an entity. This would require agreement in terms of clinical management and “We’re working to the waiting time responsibility for treatment plans guarantee.” amongst other things. In some Boards, integration between the PDS and dental of PDS Specialists and HDS Consultants Perceptions Workforce hospital has already started. Consultants However, others reported that they in some areas felt that the model of were under pressure because of the consultants based primarily in PDS, as in 18 week RTT, which in turn was areas of England and Wales, should be causing detriment to other areas. It considered. was reported that the waiting time target was met for the assessment appointment (12 week target) and “The ideal model is that PDS and the the patient is taken off the waiting hospital work very closely together list as soon as treatment started (18 as an entity. But that requires week target). However, patients could agreement on terms of clinical then wait much longer for follow-up management and responsibility appointments and may not complete for treatment plans and various treatment in a timely fashion. In other things that I think is always some hospitals, treatment sessions potentially a point of conflict.” were reported to have been cancelled

on a regular basis to accommodate “And also it’s about maintaining additional new patient assessment relationships. It’s not good never appointments. However, management meeting… there’s a huge value of did not appear to be concerned face-to-face time, working together.” about this. “It’s about linking the services together for children.” “It’s also because there’s a lot of pressure on that waiting list, “I don’t believe that a consultant there’s very little leeway in terms of has to be hospital based. I think leaving any space if you have any the model south of the border has emergencies or whatever.” worked very well.” NHS Scotland

87 88 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report and IVsedation. 18 weekRTTisnotbeingmetforIHS In someareas,consultantsreportedthat number of months.” intravenous sedation, equally a of months.Ifthey’relooking for sedation, it’s probablyanumber “If they’relookingfor inhalation eighteen weektargetonthat.” sure thatwe’renotmeetingour “For inhalationsedationI’mpretty the firstappointmentandforGA.” “The onlypressurethatwehaveare appointment.” about waitinglisttimesforthefirst treatment. They’reonlyconcerned They don’t careaboutfollow-up importance tothemanagers. “Well, ofcourse,that’s ofno guarantee.” which doesn’t haveawaitinglist guarantee overatypeoftreatment treatment whichhasawaitinglist and it’s prioritisingonetypeof one typeoftreatmentoveranother “So whatit’s doingisprioritising longer togettreatmentdone.” you canseepatientsarewaiting cancelled isatreatmentsession.So patient clinicbutwhatwillget what won’t getcancelledisanew and notbeseenwithinthetime, patient clinicsarestartingtobreach “So whathappensisifyournew detriment ofotherareas….” those areas.Whetherthat’s tothe because ithasdrivenfinancein actually beneficial,tothepopulation, “I thinkoverallhaving18weekRTTis treated byspecialistsinthePDS. while somecomplexcasescouldbe PDS bya‘dentistwithaninterest’, some childrencouldbetreatedinthe Consultants reportedthattheyfelt PDS specialist inthePDS. hospital whocouldbetreatedbya that theyweretreatingpatientsin local PDS.Someconsultantsreported departments couldbedeliveredinthe providedby hospitalpaediatric services It wasreportedthatsomeofthe are goodwithchildrenandwhojust “We justwantgooddentistswho service.” in thePDSratherthanhospital providing regularcare.Iseethem in lookingafterchildrenand team (therapist),whoareinterested a gooddentist,orpartofdental don’t needaspecialist.They “95% ofchildreninthiscountry setting.” could treatthemincommunitytype community-based specialistwho patients thatiftherewasa “I thinkIpotentiallyamtreating community service.” there wasstaff,specialistinthe if delivered bythecommunityservice delivered herecouldbebetter thatare “A lotoftheservices without therazzmatazz.” want todotheregularcare,maybe However, it was acknowledged by Consultants felt that networking consultants that the PDS service does with the local PDS seems to be a not always have adequate staffing way forward and recently some levels, skill mix and facilities to deliver PDS specialists have been involved services. Some consultants reported in hospital GA assessment services, that they felt the PDS is not making the which has reduced the burden on the best use of the staff and their skills for, hospitals, as the specialists have taken example, some specialists employed as these patients to their clinics in the PDS. SDOs, rather than specialists.

“Since the Public Dental Service staff “I think that if you had a better have been much more involved in staffed specialist-led service in the our assessment service for general salary service you wouldn’t need as anaesthesia they are taking quite a many of them here and you could lot of these patients back with them do some of the more complex stuff to their health centre and providing here.” restorative care for them locally.”

“We have a very supportive PDS service. However, I think they also In some areas, the local PDS was of PDS Specialists and HDS Consultants Perceptions Workforce need additional resources.” delivering continuing care for patients with special needs and to patients “I think there’s definitely overlap and where access to GDP services was there’s ways we could manage the limited or absent. It was reported that pathways better, more efficiently, delivering routine continuing care by where you probably would end up the PDS is not looked upon favourably seeing a lot more children in the PDS by their management, even where there and reduce the waiting times in the was limited access to GDP services. hospital dental services. But it has to be managed properly and there However, it was suggested that the PDS needs to be resources put in place.” should continue to deliver continuing care for patients in remote and rural “I think they’re over-utilising some areas where the access to a GDP was staff for the grade that they’re being limited. paid for at the moment. So I think

the Health Board is getting a really good deal out of them, but it’s not “There’s a lot of tension, I think actually fair to those individuals. But the management team here would even at that, they could be doing a like general dental practitioners lot more. They’ve got the capability to actually be providing a higher to do a lot more if they would be level of interventional care for their given the rein to do that.” patients rather than referring them to PDS. They don’t want PDS to deliver continuing care; they don’t want them to do that because they say they don’t have capacity in the public dental service to take on all these additional patients.” NHS Scotland

89 90 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report 1. Workforce treatment.” all theslow-turnaround gapsin care inatimelyfashion ratherthan system andbackoutinto primary get patientsefficientlythroughthe enormous differencetoourability itwouldmakean delivering services, career gradestaffinwhowere “If wehadoneorandahalf children.” dentists withextraknowledgeabout of viewthatwedon’t haveenough “We’re strugglingfromthepoint appointments anymore.” “There arenostaffgrade career gradestaffappointed.” itwouldbe tohavemiddle service patients efficientlythroughour additional helptomanageour area nowwherewefeltneeded “So ifweweretotargetasingle

Middle gradestaff: the efficiencyofdepartment. grade staffwouldgreatlyincrease felt thattheappointmentofmiddle reported inSection7.2.Itwas duration oftreatmentwhichwas about waitingtimesandthe explanation forpatientperceptions sessions. Thismightprovideone patients goingthroughtreatment cover andaddstothedelayin impact onprovidingemergency provision.Thishasan for service depend upontraininggradestaff of middlegradestaff,they middle gradestaff.Intheabsence would bemuchbetteriftheyhad inefficientand provision wasvery Consultants agreedthatservice

2.

is theonlywaytoputit.In “We’re shortstaffed,Ithink, very breaching.” clinic therebecausethewaitinglistis do anextraclinichereor from managementtoaskifIcan workload istheconstantmessages “The thingInoticeaboutmy job.” been high.It’s ahighpressurised “The workloadishigh,italwayshas doing alotmorethansheshould.” now. Sotheconsultant wedohaveis “We’re shortofaconsultantjust pretty stretched.” to goabroad……That’s it.Soweare specialist attheendofsummer consultant. We lostour NHS time memberofstaffastheNHS NHS side,weonlyhaveafull

time guarantees. extra clinicaldutiestomeetwaiting they wereoftenaskedtoundertake under stress.Theynotedthatin small andtheywerestretched reported thatstaffnumberswere Consultants acrossScotland Consultant workforce/workload: left werenotreplaced. staff memberswhohadretiredor gradually reducedovertheyearsas departmenthad paediatric dentistry the treatingcapacityof inadequate staffnumbersandthat felt pressuredbecauseof It wasalsoreportedtheconsultants

service provision in the remaining “I certainly know that we don’t have NHS Boards is inadequate. the workforce to treat that we used However, consultants in Dundee to have. So it may feel as though we reported that they are short staffed have higher demand because we as they have had only one full-time don’t have any associate specialists consultant, and a specialist recently now on our team, we don’t have any resigned. staff grades. We have two specialty registrars and we have one higher specialty registrar, but she’s doing a “I think you need to be very careful PhD. And they’re also reducing the with what the workforce appears number of core trainees that we get. to be, because there’s a difference So our capacity to treat, I guess due between numbers and the people to the resources having been reduced you have. But if you look at that as over the years, has reduced.” actual whole time equivalent it’s actually much smaller than that. And then if you look at whole time Consultants also reported that they equivalent of what they provide for love their job but it was stressful the NHS… and when you look at as they are constantly trying to time allied to the NHS, it’s probably of PDS Specialists and HDS Consultants Perceptions Workforce accommodate patients. They do not about four sessions.” want children waiting longer than they are required to. As a result, “If you look at the Health Board they work extra evenings and distribution it’s relatively well administration time is often weighted towards Glasgow, reduced. Edinburgh and Dundee. And that is fairly weighted for the population, but in the Borders, Ayrshire & Arran, “It’s always squeezing patients in, it’s Western Isles, Orkney Isles, Shetland, always being asked to do extra, it’s Grampian, Highland, we have no always running into your admin time, specialists at all. So the hospital it’s always working extra evenings. provision in there is completely It’s also knowing that children are inadequate.” waiting longer than they should do.”

“I actually really love my job and I It was reported that the academic love treating anxious kids. I love it all. members of staff are often But it does make it stressful.” asked to do extra sessions, which has an impact on teaching sessions. Academic consultants felt that the Consultants reported that the actual hospital management do not have whole time equivalent of the an understanding of an academic workforce is smaller than the head consultant’s role. count and the number of sessions of direct patient care is again smaller. Some consultants believed that the hospital service provision in Glasgow, Edinburgh and Dundee is adequate, whereas the hospital NHS Scotland

91 92 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report 3. into orthodontics.” not plannedout.They’re goingoff there’s notthiscareerpathway, it’s perception withpaediatricsthat “I thinkthat’s becausethere’s this carethattheyshouldhave.” primary we’re notgivingthempositionsin “We’re nottrainingenough.And trainees inScotlandattheminute.” “We don’t haveanypost-CCST, NHS doing.” over whatanacademicuniversityis understanding inNHSmanagement question wouldbethereisalackof “So mymaincommenttoyour an NHSduty, whichiswrong.” lecturing andteachingjobstocover asking academicstafftogiveuptheir NHS staffaren’t here.Andsothey’re academic memberstocoverwhen “The NHSreliestooheavilyonits

(Section 6.4.1) for example,aSDOwithinthePDS employed atnon-specialistlevel, some specialistshavebeen programme. Itwasreportedthat on completionoftheirtraining employment asaspecialist not successfulinfinding because someofthetraineeswere opting forpaediatricdentistry believed thatstudentswerenot interest inthespecialty. Consultants due tolackoffundingand were nottrainingenoughspecialists Consultants reportedthatthey Training

1. Gaps/improvements

consultants inScotlandneedtotake “I thinkit’s somethingthatthe trauma.” of dentiststoknowwhenrefer careandtheinability in primary managed reallybadlyistrauma “The onethingthatIdothinkis five.” outwith MondaytoFriday, nineto dental traumaout-of-hours. Anything dental trauma,andthe provisionfor found particularlyismanagement of “I thinkoneoftheissuesthatI’ve for aspecialistorconsultant.” that shouldbereferredinpromptly get themtoknowthatisonething way getaneducationtodentistsor to dealwithdentaltrauma,insome on boardandactuallymakeaplan

Dental trauma be madeavailabletodentists. and referralofdentaltraumashould that coursesonthemanagement care waspoor. Itwassuggested referral ofdentaltraumainprimary NHS Boards,themanagementand Consultants believedthat,insome Scotland. patients shouldbedevelopedacross accessible carepathwayfortrauma consultants agreedthatan and treatdentaltrauma.Generally, a specialinterestcouldassess while othersfeltthatdentistswith should betreatedbyaspecialist stated bysomethatdentaltrauma hours wasnotadequate.It of dentaltraumaduringout-of- also reportedthatthemanagement In someNHSBoards,consultants

3. Childsmile DHSWs “I think trauma needs a specialist.” Childsmile DHSWs can support “Dentists with special interest can patients at high-risk of dental handle trauma.” disease, encouraging the whole family to attend a local practice “I think there ought to be a readily regularly (Section 4.5.1). It was accessible care pathway for trauma reported that while some patients.” consultants were trying to liaise with DHSWs to support children with welfare concerns, they did not 2. Remuneration/capitation fees for have the same relationship as health children’s dentistry visitors did with DHSWs and therefore were unable to refer at risk Consultants across Scotland felt that children to a DHSW. Some remuneration for carrying consultants felt that Childsmile out children’s dentistry in GDS is DHSWs should liaise with the inadequate and the SDR is hospital service to target children outdated. It was reported that who were at risk of decay and to there was felt to be no incentive deliver primary prevention. of PDS Specialists and HDS Consultants Perceptions Workforce for general dentists to treat children because of low remuneration and the time taken to manage a child “There’s not the same tie-in that can be significantly more. It was we could approach Childsmile and suggested that dentists treating say can we join in to your health children should be appropriately support workers .… Every time we remunerated. discharge somebody who’s had multiple teeth extracted for dental caries, theoretically they and their “Payment to general dental siblings are the ones that are at risk. practitioners for treating children has These children should be given to to be changed. It has to be because it the DHSW to make sure that they doesn’t work. It only works for them are registered with a practice and if a child has a very low treatment support the family. And we don’t need and is a cooperative child.” have that.”

“Biggest victories for children’s “I do a lot of child protection dentistry would be if we could make work, we call them comprehensive the argument that these items of oral assessment, part of the remuneration or the capitation fee, comprehensive medical assessments which is what they get for children, for children with welfare concerns, needs to properly reflect the amount and what I would really like to do of time it takes.” with that, is to get dental health support workers linked in with these families.” NHS Scotland

93 94 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report 4. every week. It’severy impossible.” quantify them,well,they’re different sheet ofpaper. Andtheyasked usto an officialreferralpathway ona because theydon’t comethrough these contactswithusasimportant to-face. Themanagementdoesn’t log referral, itwillbedirectcontact,face- and thenhopefullyifthere’s anew constantly seethekidsonward and or threesessionsaweektotry people goinguptothewardstwo slips throughthenet.We have always becaseswheresomebody of childrenwithcancer. Andthere’ll “There’s alwayscases.There’s alot presence.” not thatonsitedentalpaediatric particularly incentreswherethere’s not doneaswellitcouldbe, condition…. Butweknowthatit’s chemotherapy toassesstheirdental be assessedpriortostarting that childrenwithcancershould “Guideline documentstates then nothinghappened.” dental healthsupportworkers…. about twoyearsagotogetlinkswith appointments. We triedprobably concerns andnotgettingtakento that someofthemareoralhealth have welfareconcernsandweknow “These arefamiliesthatweknow

assessment beforechemotherapy. children havenothadtheirdental facilitator onsite.Thusseveral colleagues unlesstherewasadental for dentalassessmentbymedical children werenotalwaysreferred conditions. Itwasreportedthe cancer andotherhigh-riskmedical dental assessmentofchildrenwith expressed concernregardingthe Consultants acrossScotland other high-riskpatients Dental assessmentforoncologyand

wards. tell usaboutthepatient.” well, wedon’t knowitiftheydon’t we have.We areexpectedtobetold, we’re told.Butthatisasystem don’t knowwhotheyareunless physically referthem,becausewe involved intheirtreatmenttoactually that requiresthemedicalperson dental department.Now, obviously they’re actuallyreferredtothe patients, whenthey’rediagnosed all ourmedicallycompromised “We haveasystemwherebyfor I haveseveredoubtsthat theywill advice wewanttothat familybut of decay. We can giveallthedental poor andhe’s alreadygothighlevels his socialcircumstances arepretty from school,he’s gotapolicerecord, talked about.He’s beenexcluded He’s inthatreallyhigh-riskgroup we that hedoesn’t developanabscess. fingers forfourmonthsandhope or we’regoingtobecrossingour organise somethingreallydifficult we’re noweithergoingtohave time todothedentalassessment, different placesandnobodytookthe care wassuchthathewenttothree immune system.Butbecausehis life threateningbecausehe’s gotno he getsanabscessit’s potentially is notgoodnewsatallbecauseif which forachildonchemotherapy decay, andfairly significantdecay, his mouthandtherewasobvious “We werehavingachat,lookedin liaising witheachother. Consultants notcommunicating or services dental assessmentasaresultof chemotherapy sessionswithouta dentinal decayhadbeenthrough In someareas,patientswith they assessduringtheirvisitstothe quantify thenumbersofpatients referral made,theywereunableto felt that,sincetherewasnoofficial

change. And the chance of him “I created an information sheet for developing an abscess is pretty high. the parents so that they knew all So that’s the sort of case that’s really about what mucositis was and what worrying.” the role of the paediatric dentist is in the care of children with oncology. “I’ve got a child who is on the And it’s very frustrating when you go waiting list at present and should up to the ward and the leaflets aren’t have had a general anaesthetic for there. They’re not out.” their teeth, and in the waiting list entry it said ‘treatment no longer “There are cases that I see where required as the child has finished you just cannot understand why the chemotherapy’. But the only reason dental treatment has not been done. the child finished chemotherapy is I’m sure if you looked at them case because they were about to have a by case there would be reasons for bone marrow transplant.” each of them, but at the same time I do find myself chasing things up a lot of the time.” It was reported that various initiatives in an attempt to improve Consultants suggested that the the rate of dental assessment had of PDS Specialists and HDS Consultants Perceptions Workforce been undertaken by paediatric dental assessment for high-risk dental departments, for example, patients should be supported, audits, establishing referral evaluated and reported nationally. paperwork for medical colleagues, contributing to core trainee induction and the development of “I would not have confidence patient information leaflets. that we see every child that has However it was felt that there had cancer, because I don’t think the been no major improvement in pathway is reliable enough yet, and referral rates. it’s because we have not had the resources to work on it. If you’re doing a new patient clinic where “We’ve done various initiatives, you’re constantly running an hour joint initiatives, we now have the over, every new patient clinic, you core trainees, every single rotation do not have the time to then spend in oncology having a dental going and working on… basically,

presentation, so it’s part of their a lot of the consultants here use all induction. We created paperwork their SPA time doing clinical related for the doctors to send us referrals administration.” routinely on assessment. We did various audits which showed if we put loads and loads of effort in on an ongoing basis that they had a better uptake of referrals to us. We also have worked quite hard to make sure there’s core trainees screening on the ward. However, it appears that no matter how much we have been doing, dental care is not seen as a priority until it’s a problem. It’s very difficult.” NHS Scotland

95 96 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report risk conditions. morbidity ofchildpatientswithhigh- played animportantroleinreducing asanessentialonewhich the service patient groups.Consultantsdescribed tohigh-risk routinely providedservices that thepaediatricdentaldepartment It wasapparentfromtheinterviews department services Importance ofthepaediatricdental the interviews. for. Intotal,five consultants tookpartin ashadbeen initiallyhoped interviews outasmany it wasnotpossibletocarry Royal HospitalforChildreninGlasgow, fromYorkhilltransfer ofservices tothe participation, butbecauseofthe Several attemptsweremadetogain Appendix 25. The questionnaireisin the interviews. hospitals wereinvitedtotakepartin Edinburgh andGlasgowchildren’s provision. Consultantsfromthe paediatric dentaldepartmentservice haematology, cardiologyaboutthe specialitiessuchasoncology,tertiary of medicalconsultantswithinthe 2016 toinvestigatetheperceptions 2015andMarchbetween February wereconducted Structured interviews 9.1 Stakeholders’andFacilitators’Perceptions9 HospitalService Departments) Haematology Cardiology and (Oncology,Interviews Stakeholder Hospital Service

could notbeofferedinthecommunity. which described asaspecialisedservice wasalso surgical procedure.Theservice and managingchildrenpriortoany to preventdentalinfectionbytreating paediatric dentaldepartments’rolewas dental infectionwasgenerallyhigh.The oral hygieneandthereforetheriskof high-risk conditionsoftenhadpoor It wasreportedthatchildrenwith appalling dentalhygiene.” children, quiteafewofthemhave are fromthemouth,soespecially endocarditis andthingslikethat a lotofthemareproblemswith “It isimportantmainlybecause bleeding disorderpatients.” patients andriskofbleedingforthe the riskofinfectionforoncology becauseof “It isimportantservice our long-termresults.” preoperatively, thenthatimproves their teethareasgoodpossible dental hygiene,ifwemakesurethat our morbidity. Ifwehavegood “It’s importantbecauseitreduces change.” change, it’s notreallygoingto specialised andthatcan’t really in thecommunity, ithastobe “Patients can’t gettheirtreatment are good.” keenthattheirteeth tend tobevery of ourinfectioncomesfrom.Sowe teeth. AndasIsaythat’s wherealot treats andtheytendtohavepoor they givethemlotsofsweetsand they’ve gottobenicethemso got heartdisease,theirmothersthink hygiene. Andplusbecausethey’ve of ourpatientstohavepoordental “There isaterrifictendencyforlot It was reported that the nature of their Referral pathway and patient medical condition meant that child assessment patients could not wait long for their dental treatment and had to be treated It was apparent from the interviews immediately. Therefore, the paediatric that some departments were actively dental service had to be flexible and developing referral pathways, whereas accommodate child patients at short others did not have a referral procedure notice when required. in place. Child patients were mainly referred verbally to the paediatric dental service and in some cases for, example, “It is really important because oncology, child patients were put on these patients cannot get dental their clinic list by the paediatric dental treatments outside so it’s important consultant or dental nurse during the that it’s timely if they have an urgent medical ward round and/or medical problem. If they have a semi elective team meeting. problem you don’t want them to wait longer than they would wait in

the community to have something “At one point there was a dental Hospital Service Stakeholders and Facilitators’ Perceptions done or that causes frustrations for referral form that we had. I think families.” xx helped to arrange for that. But certainly, personally, and the rest “Given how problematic dental care of the staff grades who work in is in the west of Scotland it’s really day care, we tended to pick up the important that we have prompt phone and ask. It’s so much easier access to dental services. It’s an just to pick up the phone and ask.” important part of the service.” “I don’t think there’s a written down pathway, but what happens is that xx Some consultants reported that comes to our Thursday morning sit- their departments employed dental down ward round, and she will note hygienists to monitor the oral hygiene down any new patients that there of their child patients. are, and any patients where there might be any concerns from a dental point of view, and gets patients “Really just because dental health into the system that way. And then

is so poor in the west of Scotland, equally we can pick up the phone and one of the most frequent and make a referral if we need to.” reasons to have to treat a patient with a bleeding disorder with factor “We’re involved with it in terms of products, which are quite expensive, our oncology type patients who is to facilitate dental treatment. So might have problems with their there’s a drive to try and improve teeth, who could then be at risk their dental health and because all of of infection. And we know how to them, even if we tell them to go to access it for them to be seen by the their local dentist, don’t necessarily dental nurse who comes along.” go, so, we have a dental hygienist that helps us screen out early problems.” NHS Scotland

97 98 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report morbidity. in somecases,thiscouldresult or nationally. Itwasrecognisedthat not monitoredorrecordedlocally offered dentalassessmentasthisis some childpatientsmightnotbe urgent medicalcare.Inothercases, assessment becauseoftheneedfor might occasionallydelaythedental example, theoncologydepartment, dental assessmentwhileothers,for Some departmentsroutinelyoffered treatment established.” weeks orsomethinguntilwegetthe to takeabackseatforcoupleof the dentalsideofthingsmayhave occasions whenchildrenpresentand what happens.Thereareobviously at thetimeofpresentationisoften starting. Sogoingtoseethedentist sites ofinfectionpriortoanythat want todealwithanypotential giving kidschemotherapyandyou assessment becauseobviouslywe’re should getdoneisadental one oftheup-frontthingsthat “When newpatientsarediagnosed, time.” their dentalassessmentsatthesame a one-stopshop,basically. Theyget assessment atthesametime.Soit’s and theyaresentonfordental us andbythenursepractitioners And allthepatientsareseenby week,effectively.do aclinicevery colleagues, there’s fourofus,sowe preoperative andmythreesurgical prior tosurgery. Soallmyclinicsare are referredfordentalassessment clinicwedothepatients “Every accommodated withoutdelay. offered wastimelyandpatientswere and itwasreportedthattheservice was describedasagoodservice In generalthepaediatricdentalservice provision Service work there.” Portal. Idon’t knowwhythedentists write inthenotebitatsideof the dentistswriteinPortal,andthey highlighting thedentalreview. Often, I thinkweprobablydoneedawayof problem. Idon’t thinkso.But,yeah, but Idon’t knowthatitisabig “I’m notsayingit’s neverhappened, service.” good concerned wegetavery “At themomentasfar aswe’re forwardly.” straight- seems tomeworkvery have tendedtodoallthatandit nurses doallthat,nursepractitioners We havetofilloutforms,but the well. settled in,itseemstoworkvery atall.It’sproblem withtheservice isgood.Ihaveno “I thinktheservice dental worksortedout.” theyneed to havetheir surgery they’re goingtohavetheirheart appropriately, andtheyaccept,if “They seemtogetonwithit treatment wegetitdoneontime.” Certainly ifsomeoneneedsurgent But, yeah,Ithinkbyandlarge. more settlednowthantheywere. previously. Ithink thingsareabit There havebeensomestaffingissues “I thinkthingsarefairlytimely. However, some patient groups, for example, those with bleeding disorders, “I think it’s probably fair to say that sometimes have to wait longer for when we were in the old hospital treatment. with whatever the setup was there, you could have somebody who came to day care for review “With bleeding disorder patients I who had developed some sort of think it’s probably a bit more difficult dental problem that was kind of because they have to just be on the important they were seen, and waiting list like anybody else. And the dental department were very it can be difficult to coordinate it accommodating at seeing patients because, maybe a day that’s picked there and then. It’s a bit more by the dental service, we then have difficult to get in touch with them a very busy day in day case and we now that we’re here. I’ve certainly can’t really accommodate it. And found that quite difficult. Where often the families are a bit difficult as we were before there were a variety well. So dates that suit us might not of treatment rooms, they were just down the stairs from us, you could

suit the families, and then we have to Hospital Service Stakeholders and Facilitators’ Perceptions start all over again. I think there are nip down and have a quick word probably more delays in that side of with somebody. That doesn’t happen the service.” here to the same extent. It isn’t as easy.”

Gaps and improvements “I don’t know if anybody comes from the ward, you’d need to double 1. The oncology department in check in the ward, because I’m Glasgow reported that access to generally based in the day care unit. the paediatric dental department So what’s happened since we’ve had been difficult after moving into moved over here I’m not exactly the new hospital. In one instance, sure. You used to be aware that a child patient was not somebody was going to the ward accommodated as expected. It was because they would come into day also not clear if the dental care as well. I haven’t been aware of consultants on duty were visiting somebody coming into day care.” the day care unit after the ward

roundup. It was suggested that “The other week there was a kid the appointment of a facilitator came up who had a particularly sore or link person would greatly benefit mouth, and we couldn’t get hold of the service as it would address the any of the consultants on the day communication problem. that she came up. And one of the junior dentists came to see her, and arranged for her to come back on the Friday which wasn’t the best.” NHS Scotland

99 100 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report 3. 2. used to.” comes fromtheirmouth thanwe more patientswithendocarditis that because wecertainlyseem tosee endocarditis actuallyisn’t increasing, to lookatitandmakesurethat guideline, yes.Somebodyneeds “I thinkweneedanupdated where theygotthisguidelinefrom.” die ofendocarditis.Idon’t quiteget of anaphylaxisbutI’veseenplenty is fatal.I’veneverseenapatientdie population. Theriskofendocarditis population butnotinourpatient That mightbetrueinthegeneral that’s trueinourpatientpopulation. endocarditis, whereasIdon’t think anaphylaxis isgreaterthantheriskof because theyfeelthattheriskof “The guidelinesaredesigned understand.” is thereforallpatientsthatweboth I thinkjusthavingsomethingthat suitable treatmentplanforthem.So or theyshouldbeabletoaccessa probably haveatreatmentplan treatment plan,whereasweshould dentist fromclinicsaskingfora to…. Igetalotoflettersfromthe record, ratherthanthemhaving plan thatbecomespartofthedental way ofusproducingatreatment We perhapsneedamorestreamlined perhaps notthemostefficientway. writing letterstoeachotherthat’s “We sometimeswastealotoftime

Dental guidelinesrelatingto Generic treatmentplansshouldbe should beconsideredforanupdate. treating childrenwithendocarditits in atimelymannerwithoutdelay. groups sothatthepatientistreated developed fordifferentpatient

1. Gaps andimprovements questionnaire isinAppendix26. and Edinburghchildren’s hospitals.The inGlasgow paediatric dentalservices who facilitatethehospital-based representative sampleofanaesthetists to investigatetheperceptions ofa 2015andJuly between January wereconducted Structured interviews 9.2 admission. patients.” the daythananyother groupof more dentalpatientscancelled on cancellation ontheday. Thereare “I thinkthebigproblem is inefficient.” which makestheservice number, ofcancellationsontheday, number, orcertainlyagreater of thedaywhichresultsinahuge behavioural problemsinadvance or potentiallypsychological out potentialmedicalproblems doesn’t giveadequatetimetosort “On thedayofadmission,andthat

It wasreportedthatthecancellation very highinGlasgow and very not undercomprehensivecarewas rate forGApatientswhowere undertaken onthedayof Currently pre-GAassessmentis before thedayofadmission. the samedayaseachotheror assessment shouldbeofferedon that dentalassessmentandpre-GA admission itwasrecommended cancellation onthedayof Therefore, inordertoreduce were oftenunfitforanaesthetic. Edinburgh becausethechildren Interviews Anesthetist Facilitators:

3. It was recommended that children “There is high rate of cancellations with special needs should be because they’re inappropriately fit for managed on a separate list so a general anaesthetic on the day of that professionals can concentrate treatment.” on managing this group of children effectively and reduce delays. It “There is a high rate of cancellations was acknowledged that this may because of patients not turning up have resource implications. for surgery. There’s a lot of that but also patients unwell, or occasionally because you run out of time.” “To have a specific list to manage the children who have particular “The waiting list manager knows that behavioural and learning difficulties, the dental patients are the biggest rather than they get managed in the group of cancellations on the day, same way as all the other patients, but I’ve no idea what they’re doing so they’re expected to turn up to a about it.” very busy day case ward, very noisy,

which a lot of these children don’t Hospital Service Stakeholders and Facilitators’ Perceptions like. And in an ideal world you’d 2. Parents/carers of child patients manage these children separately, undergoing extraction under GA you could manage them in a quiet should be made aware of the risks part of the hospital, and they of GA. would have adequate workup and preparation. But there’s clearly a resource implication. That would be “The other thing that is a defect the one thing I would like to change. noted from the dental quality The list I had at the end of last week, improvement audit is the lack of busy list, the ward was absolutely information given to patients about going like a fair with thirty patients anaesthesia. And that’s because they going through that day, and then don’t have time to get given any trying to manage two patients, one information because there is no pre- who had been properly worked up GA assessment in advance. So, all with challenging behaviour, and then patients should be given information the second one with challenging prior to general anaesthetic. And behaviour. And that was very

there is some, but it’s not the type of difficult to manage that within that information that we would give from environment.” the medical pre-assessment point of view” “Maybe having more resource to be able to dedicate more time to these children with difficulties, special needs, to try and improve their experience.” NHS Scotland

101 102 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report fees. Dental statistics–NHS treatment and Division.(2014). Information Services DOI(6), CD010856. of SystematicReviews,(6):CD010856. of dentalcaries. Water fluoridationfortheprevention Welch, V., &Glenny, A. M. (2015). J. E.,Macey, R.,Alam,Tugwell, P., V., Walsh, T., O’Malley, L.,Clarkson, Iheozor-Ejiofor, Z.,Worthington, H. (3).pdf practice%20september%202013%20 documents/scope%20of%20 org/dentalprofessionals/standards/ 2016, from Scope ofpractice. General DentalCouncil.(2013b). direct-access.aspx dentalprofessionals/standards/pages/ 2016, from Direct Access. General DentalCouncil.(2013a). Data. (2015). Central EvaluationandResearch Team. Department ofHealth. health strategyforEngland. Department ofHealth.(1994). Society ofPaediatricDentistry. paediatric dentistry (2009). British SocietyofPaediatricDentistry. e0136211. programme. toothbrushing a nationalnursery child oralhealth:Costanalysisof Macpherson, L.M.(2015).Improving D. I.,Ball,G.E.,McIntosh,& Anopa, Y., McMahon,A.D.,Conway, 10 References Edinburgh:ISDScotland. Glasgow, University ofGlasgow. Childsmile NationalHeadline Consultants andspecialistsin http://www.gdc-uk. http://www.gdc-uk.org/ RetrievedJuly25, PloS One,10 The CochraneDatabase RetrievedJuly25, . London:British (8), London: An oral Scotland. 2011/12-2015/16p. data, Childhood admissionssummary Division.(2016). Information Services Edinburgh: ISDScotland. in acutehospitalsforchildrenunder18. Number ofdischargesbymainprocedure Division.(2015c). Information Services Scotland. participation 2015. Dental Statistics–NHSregistrationand Division.(2015b). Information Services ISD Scotland. statistics Scotland2014/15. Child health27-30monthreview Division.(2015a). Information Services Statistics PublicationforScotland. 2013 births, deathsandmarriagesforScotland Annual reportoftheregistrargeneral National RecordsScotland.(2014). 110. Community DentalHealth,31 using BASCDcriteria. sectional surveys England in2011-2012:Reportsofcross- old childreninScotland,Wales and (2014). Thecariesexperienceof5-year- C. M.,Neville,J.S.,&Pitts,N.B. Monaghan, N.,Davies,G.M.,Jones, Suppl 1 society, healthylives. Marmot, M.,&Bell,R.(2012).Fair (No.159).Edinburgh:National , S4-10. Edinburgh:ISD Edinburgh: ISD Public Health,126 Edinburgh: (2), 105-

National Records Scotland. (2015). Office for National Statistics. Mid-2015 population estimates Scotland (2012). Country profiles:Key and corrected population estimates for statistics - Scotland, August 2012. mid-2012, mid-2013 and mid-2014. Retrieved May 9, 2016, from http:// References Retrieved May 9, 2016, from http:// webarchive.nationalarchives.gov. www.nrscotland.gov.uk/statistics-and- uk/20160105160709/http://www.ons. data/statistics/statistics-by-theme/ gov.uk/ons/rel/regional-trends/region- population/population-estimates/mid- and-country-profiles/key-statistics-and- year-population-estimates/mid-2015- profiles---august-2012/key-statistics--- and-corrected-mid-2012-to-mid-2014/ scotland--august-2012.html mid-2012-mid-2013-and-mid-2014- corrected-tables Petersen, P. E. (2008). World Health Organization global policy for National Dental Inspection Programme. improvement of oral health--World (2015). National Dental Inspection Health Assembly 2007. International Programme (NDIP) 2015. Edinburgh: Dental Journal, 58(3), 115-121. ISD Scotland. Save the Children. (2014). Policybriefing: National Dental Inspection Programme. Scotland - A fair start for every child. (2016). National Dental Inspection Scotland; Save the Children. Programme (NDIP) 2016. Edinburgh: ISD Scotland. Scientific Advisory Committee on Nutrition (SACN). (2015). National Institute for Health and Carbohydrates and health. London: The Clinical Excellence. (2010). Sedation in Stationary Office(TSO). children and young people, costing report implementing NICE guidance. Retrieved Scottish Government. (2007). Getting it May 9, 2016, from www.nice.org.uk/ right for every child (GIRFEC). Retrieved guidance/CG112 May 10, 2016, from http://www.gov. scot/Topics/People/Young-People/ NHS Health Scotland. (2011). Childsmile gettingitright incorporation into the statement of dental remuneration. Retrieved May 9, 2016, Scottish Government. (2009). from http://www.child-smile.org.uk/ Valuing young people: Principles and uploads/documents/16793-ChildsmileD connections to support young people entalRemunerationBooklet.pdf achieve their potential. Retrieved May 10, 2016, from http://www.gov.scot/ North of Scotland Planning Group. Publications/2009/04/21153700/0 (2014). Paediatric dentistry in the north of Scotland. Scottish Government. (2011). Protection of Vulnerable Groups (Scotland) Act Nuffield Foundation. (1993). In Ralph 2007. Retrieved May 10, 2016, Hancock (Ed.), Education and training of from http://www.legislation.gov.uk/ personnel auxiliary to dentistry. London: asp/2007/14/contents The Nuffield Foundation. NHS Scotland NHS

103 104 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report Effectiveness Programme. Dundee: ScottishDental Clinical management ofdentalcariesinchildren. Programme. (2010). Scottish DentalClinicalEffectiveness scotlands%20oral%20health%20pla.pdf health-plan/supporting_documents/ scotland.gov.uk/dentistry-division/oral- October 30,2016,from Scotland’s oralhealthplan Scottish Government.(2016b). Government. FRAMEWORK]. Edinburgh:Scottish measures (Dentistry) Boards (Ed.), Scottish Government.(2016a).InNHS Edinburgh: ScottishGovernment. Scotland –pre-birthtopre-school. Universal healthvisitingpathwayin Scottish Government.(2015b). People/Equality/Equalities/DataGrid/Age from Age. Summary: Scottish Government.(2015a). Government. PCS (DD)2013/5).Edinburgh:Scottish contract ofemployment (PDS)model public dentalservice Scottish Government.(2014c). indicator/dental About/Performance/scotPerforms/ 10, 2016,from children’s dentalhealth. Scottish Government.(2014b). contents/enacted www.legislation.gov.uk/asp/2014/8/ Retrieved May10,2016,from and Young People(Scotland)Act2014. Scottish Government.(2014a). http://www.gov.scot/Topics/ Outcomes & performance Outcomes &performance RetrievedMay9,2016, http://www.gov.scot/

[OUTCOME Prevention and (Circular No. RetrievedMay https://consult. . Retrieved http:// Scottish Children Improve

pdf http://www.sign.ac.uk/pdf/SIGN138. 16,2017,from Retrieved January SIGN; 2014.(SIGNGuidelineno.138). to preventcariesinchildren. Network. (2014). Scottish Intercollegiate Guidelines 175 foundation. dentistry. AsubmissiontotheNuffield to and trainingofpersonnelauxiliary Smith, N.J.(1993).Theeducation Rural College. Rural PolicyCentre,SRUC,Scotland’s Rural Scotlandinfocus2014. Thomson, S.andWoolvin, M.(2014). Carson, D.,Heggie,R.,McCracken, Skerratt, S.,Atterton,J.,Brodie,E., (2001st ed.) Handbook ofPublicHealthPractice Wright, J.(Ed.). (2001). of MedicalSciences. public by2040. (2016). The AcademyofMedicalSciences. reviews epidemiologically basedneedsassessment Health careneedsassessment:The Stevens, A.,&Raftery, J.(1997). Commission. Social MobilityandChildPoverty Great Britain 2014: Socialmobilityandchildpovertyin Commission. (2014). Social Mobility&ChildPoverty (6), 193-195. . Oxford:RadcliffeMedicalPress. Improving thehealthof (AnnualReport).London: British DentalJournal, London:TheAcademy Dental interventions Dental interventions State oftheNation Oxford Edinburgh: Edinburgh:

11 Appendices

Appendix 1: Proposed toothpaste usage instruction/ prescription, scaling and national referral criteria prophylaxis This referral guidance is based on the Appendices • Detection, diagnosis and clinical potential complexity of procedures. staging of dental caries (extent of However it is recognised that care caries i.e. enamel only or enamel should be holistic and child-centred, and dentine) and that even simple procedures can be complex and demanding for children • Behaviour and pain management with additional needs, significant techniques including use of topical anxiety or medical complications. and local anaesthetics for children Ideally children should be able to move and acclimatisation for mild to freely between care settings and care moderate anxiety providers, according to their needs, so that as much high quality care as • Restorative care – adhesive possible is delivered close to home, (composite/compomer) and with the least disruption to the family amalgam restorations where unit. The most important factors in required (primary teeth, single determining where care should be surface only), preformed metal delivered are the skills and experience crowns (PMCs) for multi-surface of the relevant local dental team. It restorations in primary teeth is also acknowledged that there is a continuum of care and there may be • Endodontic treatment of closed some overlap between what is provided apex permanent teeth by each of the teams. • Exodontia of primary and 1. Primary care and enhanced care permanent teeth, including orthodontic extractions and A) General dental practice and non- removal of erupted supernumaries specialists in the Public Dental Service (PDS) – dentists in teams, • Single tooth partial dentures working with hygienist-therapists, (transitional) and removable space hygienists, extended duties dental maintainers nurses (EDDNs) and the Childsmile team: • Interceptive orthodontic treatment with a removable appliance • Routine assessment of healthy cooperative children, including • Emergency treatment and pain clinical and radiographic management for simple dental examination, assessment of caries trauma and dental infection risk, preventive advice in accordance with SDCEP guidelines • Advice on common soft tissue conditions such as recurrent

• Preventive care including topical aphthae and primary herpes fluoride, application of fissure sealants, diet analysis and advice, • Advice on early tooth tissue loss toothbrushing instruction,

NHS Scotland NHS

105 106 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report • mucocoeles. • • • • • PDS: B) • • general dentalteams cannot beaccommodated bythe difficulties, Asperger’s etcwho additional needsorlearning Management ofchildrenwith for example,gingivitis,epulidesand common gingivalconditions, Advice andmanagementof indirect restorationswhererequired loss includingprovisionofdirect/ moderate progressivetoothtissue Management andadviceon undergoing resorption those withincompleteapicesor endodontic treatmentincluding multiple anteriorteethrequiring Management ofpatientswith been unsuccessful carehas programme inprimary where astandardpreventive mixed andpermanentdentition of unstableprogressivecariesinthe Assessment andmanagement severe earlychildhoodcaries Assessment andmanagementof withinthe Specialist-led services during anyperiodsofsharedcare. maintenance ofregularreview outwith theabovescope,and requiring diagnosisortreatment (HDS)ofchildren dental service (PDSorhospital appropriate service Timely onwardreferraltothemost appropriate skillsandtraining indicated, andwherethereare conscious sedation,where Provision ofanytheaboveunder

• • • techniques • teeth • anaesthesia • care. • • • • • removal ofroots/uneruptedteeth suchas Surgical interventions permanent molars Preformed metalcrownson and hypomineralistion/hypoplasia Microabrasion forenamelopacities Vital andnon-vitalbleaching Endodontic treatmentofprimary methodsforlocal delivery sedation anduseofelectronic techniques, provisionofinhalation Enhanced behaviouralmanagement review duringanyperiodsofshared and themaintenanceofregular treatment outwiththeabovescope, of childrenrequiringdiagnosisor Timely onwardreferraltotheHDS under GA children forcomprehensivecare Treatment planningforhealthy anaesthesia (GA) requiring extractionsundergeneral Treatment planningforpatients joint dysfunction children withtemporo-mandibular Assessment andtreatmentof with appropriateappliances Interceptive orthodontictreatment and simplesofttissueprocedures

2. Consultant-led services including laboratory-made onlays, crowns and adhesive bridges • Assessment and treatment of

complex dental or craniofacial • Endodontic treatment requiring Appendices conditions requiring a thermoplastic obturation or use multidisciplinary input to treatment of microscopes, placement of MTA planning and care provision such as (mineral trioxide aggregate), dens cleft lip and palate, moderate to in dente teeth severe hypodontia cases and children with complex syndromes • Management of abnormalities such as DiGeorge and Treacher of tooth eruption sequence or tooth Collins morphology

• Assessment and management of • Assessment and provision of dental children with significant medical co- care for neonates morbidity (ASA 2 or more), who require input from other hospital- • Treatment of children with based teams such as haematology significant tongue-tie interfering or cardiology in order to meet their with feeding or speech dental health needs • Provision of sedation services, • Assessment and management of especially intravenous sedation as soft tissue disease/disorders such an alternative to general as granulomas, cysts, intractable anaesthetic. oral ulceration etc All children should be returned to the • Assessment and monitoring of the primary care provider at the completion dental health of hospital inpatients, of episodes of treatment at the earliest including the provision of urgent opportunity. In cases where long- dental treatment prior to significant term shared care is required, a clear medical interventions i.e. cardiac understanding of each individual surgery, bone marrow ablation, service input is essential. In addition, chemotherapy; management of links to preventive programmes such mucositis as Childsmile should also be made and maintained. • Treatment planning and provision of comprehensive care under GA Glossary of terms including restorative, endodontic and surgical treatment on patients Adhesive (composite/compomer): with co-morbidity, in conjunction Sticky fillings with other medical teams Amalgam restorations: Metal/silver fillings • Provision of restorative care for developmental conditions such as Amelogenesis: An inherited

amelogenesis, complex dento- malformation of tooth enamel alveolar trauma such as complicated Aphthae: Mouth ulcers crown fractures, crown/root fractures, intrusion injuries etc, Asperger’s: Social and communication difficulties

Scotland NHS

107 108 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report reduce the need fortreatmentlater on Orthodontic treatment startedearlyto Interceptive orthodontic treatment: formed ordevelopedtooth enamel Hypomineralisation/hypoplasia: swelling Granulomas: Gingivitis: Exodontia: Epulides: treatment Endodontic treatment: folds inward outer surface A conditionfoundinteethwherethe Dens indente(toothwithinatooth): deformities andlearningdifficulties genetic disorderwhichcancausefacial DiGeorge syndrome: and supportingbone Dento-alveolar trauma: Crown: and skull and/or sizeofthestructuresface Craniofacial conditions: treatment andsurgery including fillings,extractions,preventive care requiredtorestoredentalhealth, Comprehensive care: patient condition orillnesshappensinthesame Co-morbidity: significant side-effects with potentmedicineswhichoftenhave Chemotherapy: adjacent teeth tooth orteethwhichiscementedonto Bridge: transplant marrow cellsbeforeabone used togetridofanindividual’s bone Bone marrowablation: Areplacementformissing A capcoveringanentiretooth A swellingonthegum Inflammedgums Extractions Soft tissuegrowthor Wheremorethanone Treatment ofcancers Provisionofall A complex Rootcanal Atechnique Injury toteeth Injury Abnormal shape Poorly Preformed metalcrowns(PMCs): Neonates: mouth membranes, thesoftliningof Mucositis: soft tissueofthemouth Mucocoele: end ofrootcanals cement-like materialusedtosealthe MTA (mineraltrioxideaggregate): discoloration fromtheteeth used toremovestainingand Microabrasion: bony sockets Intrusion injuries: which donothealorresolve Intractable oralulceration: way which isspreadinginan uncontrolled Unstable progressivecaries: disorder causingcraniofacialdeformities Treacher Collinssyndrome: plasticised material of fillingarootcanalwithwarm Thermoplastic obturation: clicking fromthejawjoints Pain, restrictedmovementand/or Temporo-mandibular jointdysfunction: Supernumaries: bone gum-line, attachingthetoothto Root: bridges Restorative care: Radiographic examination: causes ulcers herpes: Primary baby teeth Stainless steelcaps,usuallyusedfor The partofatoothbelowthe Inflammationofmucous New bornbabies Acollectionofsalivainthe Apolishingtechnique Extra teeth A viralinfectionwhich Fillings,crownsand Teeth pushedinto Aprocess Mouthulcers AnX-ray Decay A congenital A Appendix 2: GDP survey questionnaire

1. Please indicate the Health Board you practise in Appendices o Ayrshire & Arran o Highland o Borders o Lanarkshire o Dumfries & Galloway o Lothian o Fife o Orkney o Forth Valley o Shetland o Grampian o Tayside o Greater Glasgow & Clyde o Western Isles 2. What preventive treatment do you routinely provide under NHS regulations for your child patients? o Dietary advice o Toothbrushing instruction o Fluoride varnish application o Fissure sealants 3. What restorative treatment do you routinely provide under NHS regulations for your child patients? o Amalgam restorations o Composite restorations o Glass ionomer restorations o Stainless steel crowns/Hall technique o Endodontic treatment 4. Are there any challenges to you providing the following treatments for your child patients? Please tick all boxes that apply

SDR fee Time Training Staffing Patient cooperation Yes No Yes No Yes No Yes No Yes No Preventive advice o o o o o o o o o o Fluoride varnish o o o o o o o o o o Fissure sealants o o o o o o o o o o Restorations o o o o o o o o o o Stainless steel o o o o o o o o o o crowns Endodontic o o o o o o o o o o treatment Multiple o o o o o o o o o o extractions

Other Additional comments

NHS Scotland NHS

109 110 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report Please specify………………………………………………………...... o o o o 11. o o o o o cariousteeth o o o 10. If youanswerednowillbetakentoquestion12. o institutes? 9. o o o o o cariousteeth o o o 8. o 7. (if youanswerednowillbetakentoquestion10) doesnotexist If no,whynot?e.g.paediatricservice o 6. o 5. Preference Severityofcondition Specialneeds Degreeofmedicalcomplexity Surgicalcare Trauma Degreeofdentalcomplexity Highcariesrate/multiple Sedation Generalanaesthesia Yes Specialneeds Degreeofmedicalcomplexity Surgicalcare Trauma Degreeofdentalcomplexity Highcariesrate/multiple Sedation Generalanaesthesia Easy Yes Yes Other Hospitalproformadictates referralsaccepted than PDS? What factorsinfluenceyourdecisiontorefer toahospitalrather If yes,pleaselistreasonsforreferral Have youreferredchildpatientstooneofthedentalhospitalsor Please listreasonsforreferraltoPDS If yes,howeasydoyoufindittoreferPDS? Have youreferredpaediatricpatientstoyourlocalPublicDentalService? (previously knownasthecommunity/salarieddentalservice)? offers Do youknowwhattreatmentsyourlocalPublicDentalService

o o o o No Neithereasynordifficult No No ………………………...... Please specify……………………… ………………………...... Please specify……………………… o o o o o o o o accommodatedchildren accommodatedchildren Other Vulnerable/looked afterand Anxiety Poorcooperation Other Vulnerable/looked afterand Anxiety Poorcooperation o Difficult

12. Does your area have referral protocols for children being referred to

Yes No Don’t know Appendices PDS o o o Dental hospital o o o

13. Would you be willing to participate in a short interview? o Yes o No

NHS Scotland NHS

111 112 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report potential befullyrecognised. in thechildpopulation,shouldtheir prevention andtreatmentofdisease a furtherpositiveimpactonthe see adentistinitially. Thiscouldmake and withoutthepatienthavingto scope ofpracticewithoutprescription and therapiststoworktheirfull (GDC) madeitpossibleforhygienists 2013 bytheGeneralDentalCouncil The introductionofDirectAccessin skills areunderusedinthissetting. there isevidencetosuggestthattheir shouldbe significantalthough dentistry care their contributiontoprimary and adultpopulation.Consequently, forboththechild of routinedentistry qualified toprovideapproximately70% degree inOralHealthSciencesandare undertake eitherathreeorfouryear students graduatingeachyear. They of dentalhygienist-therapistswith49 a remitfortheeducationandtraining All dentalinstitutionsinScotlandhave 1. Introduction dental care. the futuredirectionofpaediatric of baselinedatawhichwouldinform that itcouldcontributetothecollection Scotland. Itwasundertakeninthehope (GDS)in the generaldentalservice dental hygienistsandtherapistsin the clinicaltreatmentofchildrenby wasinstigatedtoexplore This survey the generaldentalservice by dentalhygienistsandtherapistsin ofpaediatricdentalcare The delivery survey hygienists andtherapist Appendix 3:Dental subjects completedthequestionnaire, did notworkintheGDS.Atotalof219 a smallnumberofnon-respondents for thesurvey, althoughitislikelythat It wasestimatedthat456wereeligible 3. Results questionnaire). the survey only (seeSection4ofthisAppendixfor or HDS,toconfineresultstheGDS excluding thosewhoworkedinthePDS each individualwasemployed, email determinedtoestablishwhere therapists. Aninitialpre-notification Scotland-based dentalhygienistsand wasconductedamongst online survey 2016,an andFebruary During January 2. Methods singly qualifiedtherapists(seeFigure1). hygienist-therapists, and2%(n=4)were 41% (n=88)wereduallyqualifieddental were singlyqualifieddentalhygienists, Of therespondents(214),58%(n=124) Qualifications 47% responserate. response of214451representsa they didnotworkintheGDS.The although fiveofthesereportedthat Figure 1: Qualifications of the respondents

70% Appendices 60%

50%

40%

30% Percentage 20%

10%

0% Singly qualified dental hygienists Dually qualified dental hygienist- Singly qualified therapists therapists Qualification

Nature of employment were 50/50 private and NHS, 33% were mainly or all NHS, 14% Thirty nine percent of hygienists worked in both the GDS and PDS, and therapists stated they worked in 8% were employed in the hospital completely private or mostly private service and 2% in the corporate practices, 26% reported practices sector (Figure 2).

Figure 2: Respondents’ place of employment

45% 40% 35% 30% 25% 20%

Percentage 15% 10% 5% 0% Completely 50/50 Private and Mainly or all NHS GDS and PDS Hospital service Corporate sector private or mostly NHS private practices

Place of employment

NHS Scotland NHS

113 114 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report children: hygienists andtherapistsdidnottreat a selectionofcommentsastowhy said theydidnot.Thefollowingare their practicealthough36individuals reported thattheytreatedchildrenin The majority(80%)ofrespondents Treatment ofpaediatricpatients dentist • • • • • • • • Not bychoice.Iworkasaprivate Never referred I presumeit’s duetocosts.Seeing I donotgetreferredthem.One I canonlytreatchildrenona Hygienist appointmentsare Dentist doesnotpasspatientsto rarelyreferred Children arevery hygienist. Childrenseen byNHS seen anychildrenfor…. treat perioproblems.Havenot and periodiseasebutnowonly as trainedonpreventionofcaries for dentist.Iamsodisappointed hygienist isnotcosteffective children andpayingadental children’s dentist practice hasadedicated most,four peryear at thevery private basis,unfortunately. Isee, rarelyseechildren private sovery as doesn’t havetopayme a lottovocationaltraineedentist, are properlytrained”andpasses me. She“doesn’t thinktherapists them inhospitals to meinpracticeandIneversee

remaining 54%statingthesetreatments of preventivetreatments,withthe therapist carriedoutthemajority reported thatadentalhygienistor Forty sixpercent oftherespondents treatment Preventive care/restorative therapists. singly andduallyqualifiedhygienistsor the typesoftreatmentprovidedby of practice.Figure3demonstrates opportunity toworktheirfullscope that theywerenotbeinggiventhe felt thattheywereunder-utilisedin apparent thatmanyoftherespondents open-ended commentsreceiveditwas using theHalltechnique.From teeth,pulpotomies, orPMCs primary amalgam and preventive restorations on outlownumbers ofcomposite, carrying revealed thattherapistswere The survey or therapists Treatment providedbyhygienists dentists. while 62%stateditwascarriedoutby that thiswasdeliveredbyatherapist, regard torestorativecare,36%reported were undertakenbyadentist.With • out • • They donotgeneratemoneyfor Rarely referredthem.We havea Not referredanybyemployers the practice. do anyworkneededtobecarried Childsmile nurseandthedentists

Figure 3: Percentage of hygienists and therapists routinely providing certain treatments for child patients (blue bars=all respondents n=219; red bars=dually qualified hygienists and therapists only (n=90))

Appendices

0 10 20 30 40 50 60 70 80 90 100 OHI

Fissure sealant applica;on

Scale and polish

Dietary advice

Fluoride varnish applica;on

Acclima;sa;on

Infiltra;on analgesia

Caries risk assessment

Radiographs

Referral for treatment • Not required, normally charted Of the respondents, 30% said there for fillings as too extensive for were procedures which were not preventive resin restoration referred to them even though they were within their scope of practice. The • Patient compliance and time following are a selection of comments restraints as to why some treatments were not referred to hygienists and therapists: • Probably because it takes time out my book & dentist doesn’t • Dentist’s referral is more targeted get fee for it at restoring a cavity instead of alternative treatments such as • No assistance

PMCs. Dentists unaware of the scope of practice of a therapist • Dentist prefers to do himself NHS Scotland NHS

115 116 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report this. • in • • • • • • dentist • • • • • • have anurse].Haveoffered practice moremoney doing scalingstomakethe Both terribleexcuses the cavitywaspriortofilling. knowing whattheconditionof say itistodowithcontroland contracts work.Sometimesthey constraints -duetohowtheir treatments duetofinancial often statetheydon’t referthese preventive treatmentthemselves quieter bookssoundertake children. Thedentistshave all NHSworkcarriedoutby hardly seeanynow for referringchildrentomeso carried outbydentists extractiontreatment conservation composites. Allprivate teeth restoring primary myself asIworkwithoutanurse way thatIcandothis.Treatment isnotlaidoutina my surgery In generalpracticethedentists few busyand seevery I amvery I seepatientsonprivatebasisso Done bydentist Don’t thinkthedentistsgetafee Most parentsoptforprivate Dentist doesn’t seethepointof I don’t havealightforcuringand Childsmile dentistand nursedo The dentistclaimsacclimatisation Dentists prefer[asinitiallydidn’t The dentistswouldratherIwas Money/easy treatment the dentist’s surgery

care, someofwhicharedetailedbelow: barriers toprovidingpaediatricdental A totalof43%declaredtherewere Barriers totreatment • • • • • • • access…. • Books arefullforapproximately Time....Within a15minapptit’s Tim Gaining consentfrom a parent, Financial! Childrenhave topaya Cooperation ofchildislargest Commercial viability.... nofee The finalbarriermaybethat Childsmile astheywouldnotget Dentists willnotreferpatientsfor three-four monthsahead. instruction (OHI)inthattime polish anddooralhealth difficult todisclose/scaleand than prevention spent ontreatingproblemsrather acclimatisation. Too muchtime some childrenatte private feetoseethehygienist no treatmentcanbeclaimed bring childreninforvisitswhen barrier asit’s notcosteffectiveto acclimatisation canbringona enough time/visitsfor barrier. Sometimesnothaving subject only focus moredirectlyonthis separate appointmentIcould separately. IfIcould have appointment, andnotgiven has tobegivenduringtreatment given forthis...whichmeansOHI security sincetheadventofdirect dentists areconcernedaboutjob any paymentsifIcarrieditout e e.g.timeinpracticefor nd alone

• GDP principals don’t allow it due • Parents need to pay private fee to loss of cost for children to see hygienist Appendices • High failed to attend (FTA) rates • Poor referral/inadequately in NHS practices. Compliance worded, teeth not charted etc. from parents. Dentist’s No nurse can be a juggling act knowledge of hygienist/therapist making moisture control very remit difficult

• In most of my practices time is • Sadly in practice the financial so booked up with hygiene that it implications of using the is quicker for the child to be hygienist’s time is more weighted booked in with the dentist. In one to paying adults. It is more cost of my practices it’s not so much effective to treat adults rather of an issue as there is another than OHI, dietary advice for hygienist children. I think the children are missing out. Cost and time are • Little time for acclimatisation as I the two main barriers. Also the need to meet daily financial claiming system in no way targets. Parents often want all recognises any of our work, no treatment carried out in one-two codes for OHI unless three visits visits which can be difficult when are undertaken, no code for scale child is afraid/uncooperative/ and polish for kids. This would needs a lot of treatment. Parents make a big difference if the work do not seem to realise we do can be claimed for in kids

• NHS fees • Prescriptions for fluoride toothpaste and varnish as per • NHS list number SDCEP. Time in mixed practice/ NHS - no fee for prevention • Not being able to prescribe treatment on the NHS e.g. • Preventive/OHI care is difficult to needing a local anaesthetic (LA) quantify so not always supported prescription or having to go back by admin managers to the dentist if they have missed something which can mean having to send the patient away if the dentist is not in

• Parents are often in a rush or frightened of dental treatment and this is relayed to the child

• Parents aren’t keen on a lot of Scottish Dental Clinical Effectiveness Programme (SDCEP) recommended treatments i.e. PMCs and amalgam restorations NHS Scotland NHS

117 118 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report 4. list numbertoundertakedirectaccess therapists respectivelyfeltthathavinga Thirty and45%ofhygienists Requirement forNHSlistnumbers 9.a 9. B. 8. 7.a 7. 6. 5. 4. 3. o2.a 2. 1.a o 1. A. Questionnaire used for dental hygienists and therapists survey Questionnaire usedfordentalhygienistsandtherapistssurvey o o o o o o o o IF NO:Whynot?...... Do youcurrentlyseechildpatients? TREATMENT YOUPROVIDEFOR CHILDREN you workin?...... IF YOUWORKINGENERALDENTAL PRACTICE:Howmanypracticesdo If youselectedOther, pleasespecify:...... (Community)Service practice/PublicDental Do youworkin practice ortheNHS)? Do youcurrentlyworkingeneraldentalpractice(eitherprivate How manysessionsperweekdoyounormallywork?...... Which institutiondidyouqualifyfrom?...... In whichyeardidyouqualify?...... If youselectedYes, pleasespecify...... Do youhaveanyadditionalqualifications? If youselectedOther, pleasespecify...... Are youqualifiedasa: ABOUT YOU Dentalhygienist Yes MainlyNHSpractice/all 50/50private&NHSpractice Mainlyprivatepractice Allprivatepractice Yes Yes Duallyqualifieddentalhygienist-therapist

o No

population. for childrenandmanyothersinthe theywereabletoprovide on theservice in theNHSwouldhaveapositiveeffect o o o Other Corporatebody/company Dentalhospital/school o o o o

o No Other Dentaltherapist Singlyqualified No Other

10. Who undertakes the majority of preventive care for children in your practice? o A hygienist or therapist o A dentist Appendices o Other 10.a If you selected Other, please specify:...... 11. Who undertakes the majority of restorative care for children in your practice? o A hygienist or therapist o A dentist o Other 11.a If you selected Other, please specify:...... 12. Approximately how many children do you see in an average month?...... 13. Approximately what percentage of the child patients you see are referred to you for treatment?...... 14. Which of these treatments do you routinely provide for your child patients? (select all that apply) o Caries risk assessment o Preventive resin restorations on o Acclimatisation primary teeth o OHI o Preventive resin restorations on o Scale and polish secondary teeth o Fluoride varnish application o Single surface restorations on o Fissure sealant application primary teeth o Dietary advice o Single surface restorations on o Inferior dental blocks secondary teeth o Radiographs o Multi-surface restorations on primary teeth o Pulpotomies o Multi-surface restorations on o Extraction of primary teeth secondary teeth o Infiltration analgesia o Amalgam restorations on primary teeth o Preformed metal crowns o Amalgam restorations on secondary teeth o Preformed metal crowns o Composite restorations on primary teeth using the Hall technique o Composite restorations on secondary teeth 15. Are you qualified in inhalation sedation? o Yes o No 15.a IF YES: Do you undertake inhalation sedation for your child patients? o Yes o No 16. Are there any treatments which you are qualified to undertake that you choose not to provide for children? o Yes o No 16.a If you selected Yes, please specify:...... NHS Scotland NHS

119 120 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report 23. COMMENTS 22. 21.b.i 21.b 21.a 21. C 20.a 20. 19.a o o scheduled? 19. 18.a.i o 18.a o o 18. 17.a.i 17.a 17. 16.a.i o o o o o o o o o this survey...... Please addanyfurther commentsyoumayhaveontheissuescovered in Finally, likethisonlineor by post? doyouprefertorespondsurveys IF YESOROTHER:Inwhatway?...... you areabletoprovideforchildren? an effectontheservice Do youthinkthatworkingonadirectpatient accessbasiswouldhave IF YESOROTHER:Inwhatway?...... youareabletoprovideforchildren? the service Do youthinkthathavinganNHSlistnumberwouldhaveeffecton TREATMENT YOUPROVIDEFORCHILDREN IF YES,pleasespecify...... for children? Do youfindthereareanyparticularbarriersinprovidingoralhealthcare IF DEPENDSONTREATMENT OROTHER:Pleasespecify...... On average,forhowlongareappointmentsyourchildpatients which treatments:...... IF THENURSE’SPRESENCEDEPENDSONTREATMENT: Pleasestate you treatadults Is adentalnursepresentmoreoftenwhenyoutreatchildrenthan When youtreatchildpatientsdohaveadentalnursepresent? Why arethesetreatmentsnotreferredtoyou?...... If youselectedYes, pleasespecify:...... undertake? (i.e.treatmentsyouarequalifiedtodobutnotgivendo) Are thereanytreatmentsforchildrenthatarenotreferredtoyou Why doyouchoosenottoprovidethesetreatments?...... Other Yes always Yes online Yes -anegativeeffect Yes -amixedeffect Yes -apositiveeffect Yes -anegativeeffect Yes -amixedeffect Yes -apositiveeffect Yes Other 15minutes Yes -moreoften o Yes usually o o bypost 30minutes o No-it’s thesame

o Dependsontreatment o o o o o Other Noeffect Other Noeffect nopreference o Depends on treatment on Depends o o o No No No-lessoften o No

Appendix 4: Clinical directors of PDS - Survey questionnaire

Health Board Details Appendices 1. Please indicate your Health Board Ayrshire & Arran Highland Borders Lanarkshire Dumfries & Galloway Lothian Fife Orkney Forth Valley Shetland Grampian Tayside Greater Glasgow & Clyde Western Isles Paediatric Dental Referral and Treatment Details 2. Are children referred to specific clinic/s or locations? Yes No If yes, please specify 3. If so, how many specific clinic locations? 1 6 2 7 3 8 4 9 5 10 If more than 10, please specify 4. Approximately how many paediatric referrals do you receive in a month? 0-50 250-300 50-100 300-350 100-150 350-400 150-200 400-450 200-250 450-500 If more than 500, please specify 5. Approximately what percent of referrals do you receive for children compared to all referrals? 1% - 5% 25% - 30% 5% - 10% 35% - 40% 10% - 15% 40% - 45% 15% - 20% 45% - 50% 20% - 25% 55% - 60% If more than 60%, please specify Workforce Details

Does your service have staff specifically responsible for the treatment of children? Yes No NHS Scotland NHS

121 122 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report If yes,pleasedetail Yes 15. 45-50 25-30 40-45 20-25 35-40 15-20 10-15 5-10 0-5 14. Other (pleasespecify) Medical paediatrics Paediatric dentistry Oral &maxillofacialsurgery Public DentalService 13. If yes,pleasespecify Yes 12. If yes,pleasespecify Yes 11. Other (pleasespecify) Children’s hospital District Generalhospital 10. Yes 9. General AnaesthesiaProvision With aninterestinpaediatricdentistry Additional postgraduatequalificationbutnotonspecialistlist Specialist inpaediatricdentistry 8. Hygienist Therapist CDO/salaried GDP SDO/senior salariedGDP Specialist inpaediatricdentistry Assistant clinicaldirector Clinical director 7. Do youhavepost-GA followupe.g.preventionclinics? Approximately howmanyGAreferralsdo youreceiveinamonth? Under whichclinicianarepatientsadmitted? If yes,isthisaseparatelist? Do youprovidecomprehensivecareincludingrestorativeunderGA? If yes,pleasespecifythelocation Do youoffer“extractionsonly”underGA? an interestorwithadditionalqualifications Please specifythenumberofstaffonpaediatricspecialistlistorwith If yes,pleaseindicatethewholetimeequivalent(WTE)

No If morethan50,pleasespecify 30-35 No No No

16. Do you offer an alternative to GA e.g. inhalation sedation? Yes No If yes, please detail Appendices Treatment for children who require multidisplinary care 17. Do you provide dental support and treatment for child patients undergoing tertiary medical treatment in other specialities e.g. oncology, haematology etc? Yes No If yes, please detail 18. Is this medical treatment outwith Board area e.g. tertiary service for oncology? Yes No If yes, please detail 19. Do you provide dental support and treatment for children who have completed their medical treatment? Yes No 20. If yes, do you receive support from hospital paediatric dental service? Yes No If yes, please detail 21. Do you make out-of-Health Board area referrals for children requiring dental treatment? Yes No If yes, please detail approximate numbers/ to where and any comments 22. Do you have a defined protocol/pathway for multidisciplinary care for children? Yes No If yes, please detail Help with SDNAP report 23. Would you be willing to help us by allowing us to carry out patient interviews in one of your clinics? Yes No Other, please specify 24. Would you be willing to help us with data collection for the SDNAP report? Yes No 25. If yes, please select all that apply Referral audit GA audit Additional Information or comments NHS Scotland NHS

123 124 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report Appendix 5:ReferralrateforGAprovisionandofalternativesto outreach programme, Galloway Dumfries & Fife Western Lanarkshire required Tayside Highland clinic Orkney Arran Ayrshire & Childsmile management caries Borders Forth required management Grampian currently afterwards. provided routinely Shetland Clyde Glasgow & Greater over appropriate Lothian Health Board Valley Isles 05-10 0-5 Yes Yes 35-40 10-15 No 0-5 Yes Yes Yes 15-20 35-40 No and anxiety treatment need Yes depending on assessed then 125 referralsare 0-5 416 45-50 in amonth? do youreceive GA referrals how many Approximately pre- circa 70 GA, wereceive one canrequest assessment, no than 50for We receivemore month About 100per month 70-80 per management or anxiety referred forGA generally and are This isvariable specify 50, please If morethan

No No No Yes Yes Yes No Yes No Yes clinics? prevention follow upe.g. post GA Do youhave

therapy school, care include special pathways -can adolescents Variable care programme RECUR research Involved in follow up assessment & Promotion at Oral Health OHSW referral toa generates a for pain,sepsis, referred forGA child every workers and health support from ouroral We haveinput GDS inShetland There isnot routine careis with ourPDS,so are allregistered Our GApatients to GAe.g. detail If yes,please

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes sedation? inhalation an alternative Do youoffer

IV in sedation, and Gaseous IV andIHS and sedationas management Behaviour sedation atone Inhalation four sites appropriate at IHS if older children offered for led) isalso IV (anaesthetic- anxiety which modeof made asto and decision pre-assessed All patients IHS sites IHS atmultiple 12 yearsand in Edinburghif and IVsedation offered IHSif All patients detail If yes,please

Appendices Other (please specify) Yes Medical paediatrics

Paediatric dentistry Yes

Under which clinician are patients admitted?

Yes Yes Yes Oral & maxillofacial Surgery Yes Yes

Yes Public Dental Service Yes Yes Yes

patients

Other (please specify) Lists are protected GA day case dental For special Yes If yes, is this a separate list? No Yes Yes No Yes Yes No No Yes No Yes Yes No Yes Yes No Yes Yes Only for special needs patients

patients secondary care Other (please specify) Delivered by Basic restorative care, generally only in dentition, no advanced care such as crown and For appropriate patients - not Only for special

GA? Yes Do you provide comprehensive care including restorative care under Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Isles Valley Health Board Lothian Greater Glasgow & Clyde staff Shetland Grampian Forth paediatric Borders permanent endodontics/ bridge & Arran Ayrshire needs including children Orkney Highland Tayside routine Lanarkshire care Western Fife Dumfries & Galloway Appendix 6: Provision of comprehensive care including restorative under GA Scotland NHS

125 126 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report Appendix 7:ExtractiononlyGAprovisionbyNHSBoard Dumfries &Galloway Fife Western Isles Lanarkshire Tayside Highland Orkney Ayrshire &Arran Borders Forth Valley Hospital Grampian Shetland Greater Glasgow&Clyde Lothian Health Board Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes No week Three sessions/ Yes Yes Yes Yes only” underGA? “extractions Do youoffer Yes Yes Yes Yes Yes hospital District General If yes,pleasespecifythelocation Yes Yes hospital Children’s

Two sites grounds ofDGH Special unitin Two hospitals St. John’s specify) Other (please

dental Appendices

services If yes, please detail Cleft services, If needed Our special care PDS senior works within district general rare we have Very cases but when we do the clinician treatment with the treating hospital, if that hospital has a service then they will guide us on the care On a temporary basis through a visiting consultant until July For small numbers of cardiac hospital coordinates paediatric 2014 patients

If yes, do you receive Yes Yes No Yes Yes No Yes No Yes No No

support from hospital paediatric dental service? Yes

Do you provide completed their medical treatment? Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes dental support and treatment for children who have No Yes If yes, please detail of Scotland West Always off Island Usually in Glasgow In Lothian or Dundee Is this medical treatment outwith board area e.g. tertiary service for oncology? No EDI Yes Yes No No Yes No Yes Yes Yes Yes Yes No No

consultant paediatricians Oncology clinic support

If yes, please detail EDI RHC Because tertiary level paeds is not available in our Health Board Referral to PDS as and when required Rarely approached to do so Ad hoc Poorly developed Small numbers only Specialist paediatric dentist sees Occasional, via

Do you provide dental support and treatment for child patients undergoing tertiary medical treatment in other specialities e.g. haematology etc? No Yes No Yes Yes No Yes Yes Yes Yes No Yes Yes

Isles Health Board oncology, Lothian Greater Glasgow & Clyde Shetland Grampian Forth Valley Borders & Arran Ayrshire Orkney Highland Yes Tayside Lanarkshire Western Fife Dumfries & Galloway Appendix 8: Treatment for children who require multidisciplinary care Appendix 8: Treatment Scotland NHS

127 128 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report Appendix 9:‘Out-of-Board’referralsbyNHSBoard Dumfries &Galloway Fife Western Isles Lanarkshire Hospital Tayside Highland Orkney Ayrshire &Arran appropriate Borders Forth Valley Grampian Shetland Clyde Greater Glasgow& Lothian No Health Board dental treatment? children requiring area referralsfor of-Health Board Do youmakeout- Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes No comments numbers/ towhereandany If yes,pleasedetailapproximate Occasional, viaYorkhill guidelines foraDGH Rare onlyifoutwithanaesthetic for dentalextractionsunderGA are referredtoYorkhill Hospital Children underthreeyearsofage to Yorkhill orSickChildren’s hospital. Lessthanonceayear, to attendaspecialistpaediatric Very occasionally, ifachildneeds Glasgow/Edinburgh Less thanfivetoDundee/ further afieldareusuallytertiary visiting consultants.Anyreferrals consultants andwehavesome In ourGrampiannetworkof specialist opinionortreatmentis Very occasionallywhena Varies butaboutcasespermonth One ortwoperyear to Grampian cases/patients, theyarereferred orthodontic and multidisciplinary maxillofacial For multidisciplinary

care forchildren? multidisciplinary pathway for defined protocol/ Do youhavea No DNA Yes No No No No No No No Yes no No No No

detail please If yes, who child referred

Appendix 10: PDS referral audit form

Referral Letter Information

Patient details Appendices

Date of Birth Date

Patient Postcode

Referred by GDP GMP Consultant specialty (specify)...... Other (specify)......

Does this patient have a history of? (Please tick all that apply)

Severe early childhood caries or unstable/extensive caries in the mixed/permanent dentition Abnormalities of tooth morphology, number and structure Advanced restorative care including laboratory-made restorations Complex endodontic therapies including management of non-vital immature teeth or teeth undergoing internal or external resorption Direct/indirect composite restorations for teeth with extensive tooth tissue loss or enamel/dentine defects Surgical interventions outwith the competence of the primary practitioner Treatment planning for children requiring extractions under GA and sedation Treatment planning and provision of comprehensive dental care under GA Severe tooth tissue loss Complex dento-alveolar trauma Disturbances of tooth eruption Non-vital or vital bleaching techniques Periodontal or soft tissue conditions/lesions Interceptive orthodontic treatment Anxiety or phobia Multidisciplinary care Child protection issues

Other (specify)...... Reason not specified

Reason for Referral (Please tick one box)

Advice only Treatment only Advice and treatment Second opinion Other (specify)...... Reason not specified

Was a treatment area clearly specified by the referrer? Yes No

If yes, please specify......

Referral Triage Result

Referred to the hospital service Accepted to be assessed for GA or sedation

Accepted to see a PDS specialist Sent back to GDP to re-refer to GA service Accepted to see PDS dentist Sent back to GDS to re-refer with further information NHS Scotland NHS

129 130 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report Appendix 12:Referralsreceivedforanxietyorphobia Appendix 11:Othercategories Fife Borders Total 45 Special needs Simple dentaltrauma,earlycaries RA forfissuresealants Pulpotomy/Hall crown Poor oralhygiene Pain 1 Orthodontic extractions Not underGA Medical conditions Large numberofteethtobeextractedandpatientsage GDP notconfidentintreatingpaediatricpatientswithearly caries Autism 7 ADHD, nocooperationfortreatment Abscess, cyst Registration request received Other Forth PDS clinic Highland 3253 Tayside 4569 Valley 2666 Total 216351 RAH 1433 received foranxiety Number ofreferrals or phobia 93 6 referrals received Total numberof 115 15

Number referrals Percentage 60.4% 80.9% 42.4% 61.5% 65.2% 39.4% 40% 6 2 1 1 1 5 1 4 2 1 2 2 9

Appendix 13: Referrals received for treatment planning for children requiring extractions under GA or sedation

PDS clinic Number of referrals Total number of referrals Percentage Appendices received for treatment received planning for children requiring extractions under GA or sedation Borders 10 15 66.7% Fife 76 115 66.1% Forth Valley 32 66 48.5% Highland 34 53 64.2% RAH 5 33 15.2% Tayside 28 69 40.6% Total 185 351 52.7%

Appendix 14: Referrals received for severe early childhood caries

PDS clinic Number of referrals Total number of referrals Percentage received for severe early received childhood caries Borders 10 15 66.7% Fife 49 115 42.6% Forth Valley 26 66 39.4% Highland 20 53 37.7% RAH 22 33 66.7% Tayside 21 69 30.4% Total 148 351 42.2%

NHS Scotland NHS

131 Appendix 15: Cross tabulation SIMD 2012 quintile and three most prevalent conditions in the PDS

SIMD 2012 Anxiety or phobia Treatment planning Severe early childhood quintile for children requiring caries extractions under GA caries or unstable/ extensive caries in the mixed/permanent dentition Count Count Count 1 55 43 42 2 50 43 39 3 39 41 22 4 39 34 24 5 15 13 11 Total 198 174 138

*Note: Postcode could not be matched/was not reported for 23 referrals

Oral Health and Dental Services for Children Needs Assessment Report Appendix 16: Referral triage result

PDS *NR Accepted to Accepted to Accepted to Referred to Sent back Sent back Total clinic be assessed see a PDS see a PDS the hospital to GDS to to GDS to for GA or dentist specialist service re-refer to re-refer with sedation GA service further information Borders 1 9 3 0 2 0 0 15 Fife 0 95 7 13 0 0 0 115 Forth Valley 0 19 33 11 0 1 2 66 Highland 0 36 17 0 0 0 0 53 RAH 4 10 15 4 0 0 0 33 Tayside 2 35 7 25 0 0 0 69 Total 7 204 82 53 2 1 2 351

*NR: Not Reported NHS Scotland

132 Appendix 17: Hospital audit form

Referral Letter Information

Patient details Appendices

Date of Birth Date

Patient Postcode

Referred by GDP GMP Consultant specialty (specify)...... Other (specify)......

Does this patient have a history of? (Please tick all that apply)

Severe early childhood caries or unstable/extensive caries in the mixed/permanent dentition Abnormalities of tooth morphology, number and structure Advanced restorative/endodontic care including laboratory-made restorations Complex endodontic therapies including management of non-vital immature teeth or teeth undergoing internal or external resorption Direct/indirect composite restorations for teeth with extensive tooth tissue loss or enamel/dentine defects Surgical interventions outwith the competence of the primary practitioner Treatment planning for children requiring extractions under GA Treatment planning and provision of comprehensive dental care under GA Severe tooth tissue loss Complex dento-alveolar trauma Disturbances of tooth eruption Non-vital or vital bleaching techniques Periodontal or soft tissue conditions/lesions Interceptive orthodontic treatment Anxiety or phobia Multidisciplinary care Child protection issues

Other (specify)......

Reason for Referral (Please tick one box)

Advice only Treatment only Advice and treatment Second opinion Other (specify)......

Was a treatment area clearly specified by the referrer? Yes No

If yes, please specify......

Referral Triage Result

Accepted to see a consultant Accepted to be treated under GA Sent to CDS Sent back to GDS

NHS Scotland NHS

133 134 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report Appendix 20:Referralsreceived byDDH *NR postcodenotreported Appendix 19:ReferralsreceivedbyEDI *NR postcodenotreported Appendix 18:ReferralsreceivedbyGDH Total 132 Fife 11 Tayside 121 received Health Board Total 315 *NR 16 Dumfries &Galloway Forth Valley Fife 7 Borders 7 Lothian received Health Board Total 440 *NR 69 Fife 1 Forth Valley Ayrshire &Arran Highland 7 Lanarkshire 39 Greater Glasgow&Clyde received Health Board Number ofreferrals 1 2 282 Number ofreferrals 4 4 316 Number ofreferrals 100.0 8.3 91.7 Percentage 100.0 5.1 0.3 0.6 2.2 2.2 89.5 Percentage 100.0 15.7 0.2 0.9 0.9 1.6 8.9 71.8 Percentage

Appendix 21: Patient questionnaire - PDS

1. What kind of treatment is your child undergoing and for what condition? Appendices 2. What are the reasons for this treatment?

3. Who referred your child to this service?

4. Were you and your child actively involved in deciding the appropriate dental treatment (were your opinions asked and were they valued)?

5. Did you provide written consent for undergoing IV, GA or other intervention?

6. Do you feel you or your child was given adequate information about the treatment options e.g. leaflet?

7. Did you understand the options given to you?

8. Were you or your child made aware of any risks?

9. Does/do the staff make you and your child feel safe, comfortable and supported?

10. Do you know who to ask for help if you have any questions? Are the staff approachable and knowledgeable?

11. From being referred, how long did you and your child have to wait before starting treatment?

12. What do you or your child think the benefits of the treatment are/will be?

• Pain relief

• Improvement in health of your teeth and gums

• Appearance: Feeling better about the way you look and feel

• Self esteem: Feeling more confident.

13. What is your/your child’s view about the staff providing the treatment?

14. Has your child ever felt discriminated due to race, distance from home, disability etc?

15. If your child received treatment was this successful (was there improvement)?

16. How would you rate the quality of the service your child received? Please expand.

17. Is there anything else you or your child would like to comment on? NHS Scotland NHS

135 136 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report 16. improvement)? 15. 14. etc? 13. 12. • • • 11. 10. attendance? 9. 8. 7. 6. 5. 4. 3. 2. 1. Appendix 22:Patientquestionnaire-Hospital How would you rate the quality of the service yourchildreceived? How wouldyouratethequalityofservice If yourchildreceivedoperativetreatmentwas thissuccessful(wasthere Did theconsultantconsideryourchild’s opinionswhileplanningtheirtreatment? Has yourchildeverfeltdiscriminatedduetorace,distancefromhome,disability What isyourchild’s viewaboutthestaffprovidingtreatment? What doyouoryourchildthinkthebenefitsoftreatmentare/willbe? Was yourchild’s treatmentpainful? How wereyourchild’s appointments?Diditaffectyourchild’s school How longhasyourchildbeenundertreatment?(Duration) How longdidyourchildwaittostarttreatment? Were youoryourchildmadeawareofanyrisks? Were youoryourchildinformedaboutdifferenttreatmentoptions? Was yourorchild’s consentobtained? Who referredyourchildtothisservice? What arereasonsforthistreatment? What kindoftreatmentisyourchildundergoing?(Type) Improvement inhealthofyourteethandgums. Self esteem:Feelingmoreconfident Appearance: Feelingbetteraboutthewayyoulookandfeel

Appendix 23: Topic guide for semi-structured interview: PDS

1. Which group of patients are accepted for treatment in PDS? Appendices

2. What are the most common treatment conditions that you are likely to treat?

3. Approximately how many referrals do you receive each month? Of these, what percentage of these are for advice and how many for treatment? (Specific service providers only)

4. Approximately how many inappropriate referrals do you receive each month?

• Inappropriate for PDS

• Inadequate information.

5. Do you see demand changing for specialists in paediatric service in the community/primary care setting?

6. Is a there a demand for specific treatment/s in the Public Dental Service setting?

7. What is the level of complexity of these treatments and why?

8. In the last one month how many patients did you treat? How many of them required Public Dental Service?

9. Are there any conditions which seem to be increasing in the referral base?

10. What are your views about the present workforce available for Public Dental Service?

11. Is your workload increasing/changing? If so, why?

12. Are there any gaps in the service? (IV sedation)

13. What arrangements are in place for children who are moving into adulthood?

14. How do you manage children who are in transitional stage?

15. How do you think the PDS can be improved?

NHS Scotland NHS

137 138 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report 20. 19. 18. planning 17. 16. 15. 14. 13. 12. service? 11. base? 10. 9. 8. 7. 6. service? 5. • • 4. 3. 2. 1. Consultants Appendix 24:Topic guideforsemi-structuredinterview: service viaPDS? service whichisconsultant-led, istherealsoaspecialist-ledGA If youhaveGAservice forchildren? GA services What impacthasyour HealthBoard’s requirement tomeet18weekRTThadon Are yourequiredtomeet18weekRTTor9 week assessmenttotreatment? Have you/yourgroupbeeninvitedtoprovide inputintonationalmanpower priorities? the overallservice Do youhaveautonomytodecidehowandwhere yourpatientsaretreatedand canbeimproved? How doyouthinkthehospitalpaediatricservice Are thereanydevelopmentsrequired? Are thereanygapsintheservice? Is yourworkloadchanging?Ifso,why? What areyourviewsaboutthepresentworkforce availableforhospitalpaediatric Are thereanyconditionswhichseemtobechanginginprevalencethereferral of themrequiredhospitalpaediatricservice? In thelastonemonthhowmanypatientsdidyoutreat?Howmany/percentage hospital-based treatment,community-basedtreatmentandGDP? What treatments/conditions/circumstances doyouconsider appropriate for available withagreatercapacity? whereavailable,orifalready inalocalPDS-basedspecialistservice better served thatcouldbe Are youtreatingpatientswithinthehospitalconsultantservice Is thereademandforspecifictreatment/sinthehospitalsettings Do youseeachangeinthevolumeofdemandforspecialistpaediatrichospital Approximately howmanyinappropriatereferralsdoyoureceiveeachmonth? or bygradeofstaffprovidingtreatment,pleaseprovidefurtherinformation. If thewaitingtimevariesdependentupontreatmenttypeormethodofdelivery How longisthewaitfortreatmentwhenaplanhasbeendevised? How longisyourwaitingtimeforaconsultantopinion/patientassessment? Inadequate information. Inappropriate forhospitaltreatment

Appendix 25: Hospital service stakeholder interview questionnaire

1. How often do you use the paediatric dental service? Appendices

2. Why do you use the service?

3. How important is this service to you and why?

4. How do you communicate with this service?

5. Do you receive the required treatment on time or is there a waiting list?

6. If there are delays what problems does this cause?

7. What are your views about the workforce available for this service?

8. What are the gaps in the service? Are there patients of yours who cannot be accommodated?

9. How do you think this service can be improved?

Appendix 26: Facilitators: Anaesthetist interview questionnaire

1. How often do you provide service for this service?

2. Are there problems specific to supporting the paediatric dental service?

3. How do you think this service can be improved?

NHS Scotland NHS

139 140 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report GIRFEC GG&C GDS GDP GDC GDH GA ft/d FTA EYC EDI EDDN DNA DMF/dmf DHSW DGH DDH DCP CSDS CPD CHSP CDS BSPD BME ASD ASA ADHD ADH 12

3

Abbreviations

mft x100

Decayed, MissingandFilledTeeth British SocietyofPaediatricDentistry Dental HealthSupportWorker Child HealthSystemsProgramme Greater Glasgow&Clyde Extended DutiesDentalNurse Dental CareProfessional nowknown Community andSalariedDentalServices, Attention DeficitHyperactivityDisorder Getting it Right for Every Child Getting itRightforEvery Dundee DentalHospital Continuing ProfessionalDevelopment Autistic SpectrumDisorder General DentalServices Early Years Collaborative Community DentalService Black andMinorityEthniccommunities General DentalPractitioner Glasgow DentalHospital General DentalCouncil General Anaesthesia Edinburgh DentalInstitute Did NotAttend District GeneralHospital Aberdeen DentalHospital filled teeth,multipliedby100 divided bynumberofobviouslydecayed,missing and treated restoratively;expressedasnumberoffilledteeth as PDS Failed toAttend American SocietyofAnesthesiologists Proportion ofobviousdecayexperiencethathasbeen

GP17 Form used for recording primary care dentistry GMP General Medical Practitioner HDS Hospital Dental Service Abbreviations HNA Health Needs Assessment ICD International Classification of Diseases IHS Inhalation Sedation IJB Integral Joint Board IoS Item of Service ISD Information Services Division IV sedation Intravenous Sedation LA Local Anaesthetic LAAC Looked After and Accommodated Children MCN Managed Clinical Network MIDAS Management Information & Dental Accounting System MIH Molar Incisor Hypomineralisation NDIP National Dental Inspection Programme NHS National Health Service NoS North of Scotland NR Not Reported NRS National Records Scotland OHI Oral Health Instruction ONS Office for National Statistics PDS Public Dental Service PMC Preformed Metal Crown CCST Certificate of Completion of Specialist Training RAH Royal Alexandra Hospital RTT Referral to Treatment SAS Staff Grades, Associate Specialists and Speciality Dentists SCIM10 Scottish Caries Inequality Metric SDCEP Scottish Dental Clinical Effectiveness Programme SDNAP Scottish Dental Needs Assessment Programme NHS Scotland NHS

141 142 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report WTE WHO StR SNS SMR01 data SIMD SHO Programme SHBDEP SDR SDO

Scottish MorbidityRecord-GeneralAcuteInpatientand Scottish HealthBoards’DentalEpidemiological Support NeedsSystem Specialty Registrar Scottish IndexofMultipleDeprivation Senior HouseOfficer Statement ofDentalRemuneration World HealthOrganisation Senior DentalOfficer Whole Time Equivalent Day Casedata

13 Glossary of terms

Care Index [(ft/d3mft)x100]: Proportion of obvious decay experience that has been treated restoratively; expressed as number of filled teeth divided by number of obviously decayed, missing and filled teeth, multiplied by 100.

Childsmile: National oral health improvement programme for children in Scotland. Glossary of terms of Glossary Deciduous teeth: Another term for primary teeth or ‘baby’ teeth.

Dental caries: A multifactorial, dynamic disease, caused by the action of plaque bacteria and fermentable carbohydrate on susceptible tooth surfaces over time.

Dental care professionals (DCP): This term refers to the wider dental team and is made up of dental hygienists, therapists, nurses, orthodontic therapists, technicians and clinical dental technicians.

Dental sealants/fissure sealants:Placing sealants involves the application of a clear resin over the biting surfaces of teeth to prevent decay and to protect the teeth, especially in children.

Dental trauma: Tooth loss or damage caused by physical injury.

Dentine: The main constituent of the teeth, composed of 60% calcium hydroxyapatite, which is covered by enamel.

DMFT/dmft: An indication of the experience of decay measured by counting the decayed, missing or filled teeth (dmft). DMFT refers to the decay in the secondary dentition (adult teeth), dmft refers to the levels of decay in the primary dentition.

The subscript 3 indicates more advanced decay into dentine (D3mft, d3mft). Enamel: The hard, white shiny surface of the crown, composed of 95% calcium hydroxyapatite.

Erosion: Loss of surface of tooth due to chemical dissolution of teeth.

Exfoliation: Falling out of the baby teeth.

Fluoride: A chemical compound that helps to prevent dental caries.

Fluoride varnish: Topical application of a fluoride gel or liquid that prevents decay.

General anaesthesia (GA): A state of controlled unconsciousness. During a general anaesthetic, medications are used to send a patient to sleep, so they are unaware of surgery and do not move or feel pain while it is carried out.

Hall technique: Is a novel method of managing carious primary molars by cementing preformed metal crowns, also known as stainless steel crowns, over them without local anaesthesia, caries removal or tooth preparation of any kind.

Hypodontia: The condition in which the patient has missing teeth as a result of the failure of those teeth to develop. There can be different levels of severity. NHS Scotland NHS

143 144 NHS Scotland Oral Health and Dental Services for Children Needs Assessment Report tooth decay, attheoptimalconcentrationofonepartpermillion(1ppm). Water fluoridation: and asanaidtocreatingindividualplanforachild. eventsandconcerns to reachtheirpotential.Theyareusedrecordobservations, forachildoryoungperson Included. Allofthesewellbeingindicatorsarenecessary wellbeing: Safe,Healthy, Achieving,Nurtured,Active,Respected,Responsible,and SHANARRI Wheel: Oral cancer: (upper) andmandibular(lower)arch Occlusion: of diseasesaffectingthemouth,jaws,faceandneck Maxillofacial surgery: resulting inenameldefectsfirstpermanentmolarsandincisors. Molar incisorhypomineralisation(MIH): of twelveinhumans,withthreeoneachsidetheupperandlowerjaws. Molar tooth: intravenous (IV)sedationisaneffectiveandsafetreatment. about havingdentaltreatmentoraprocedurewhichmaycausediscomfort, IV sedation: sedation isalsoknownas‘happyair’. nosepiece. Thishelpsthechildtofeelrelaxedandaccepttreatment.Inhalation consciousness. Itisamixtureofnitrousoxideandoxygenbreathedthrough Inhalation sedation(IHS): four onbottom). Incisor teeth: The relationship of the teeth in a closed position in both the maxillary The relationshipoftheteethinaclosedpositionbothmaxillary A sedative is injected directly into a vein. For people who are nervous Asedativeisinjecteddirectlyintoavein.Forpeoplewhoarenervous A tooth having a broad biting surface adaptedforgrinding,beingone Atoothhavingabroadbitingsurface Malignant tumourofthemouth The eightteethinthefrontandcentreofmouth(fourontop The acronymSHANARRIisformedfromtheeightindicatorsof Additionoffluoridetoapopulation’s drinkingwatertoreduce Surgicalspecialtyconcernedwiththediagnosisandtreatment A lightformofsedationwherethereisnoloss Acommondevelopmentalcondition NHS Scotland