REPORT ON ORTHODONTICS FOR THE SUB COMMITTEE OF THE JOINT OIREACHTAS COMMITTEE ON HEALTH AND CHILDREN
BY SENATOR MARY HENRY, MD
11 APRIL 2005
Amongst many who gave me information I would like to thank Tom Mooney of the Department of Health and Children, Bernard McCartan of the Dublin Dental Hospital and School,, Professor Millet of Cork Dental School and Deputy Fiona O’Malley for their help. Thanks also to Tara Wharton and Mary Bradfield for supplying me with all the necessary documentation and to Lynda Edwards for her unending patience in typing the report several times.
Orthodontics is a relatively new branch of dentistry. The first Consultant Orthodontist to the Dental Health Service in Ireland for public patients was appointed in 1985.
Prior to this Orthodontists were all in private practice. There are more than eighty Orthodontists in Ireland. Of the fifteen who are in the public service all, or nearly all, have private practices as well.
There has always been a serious shortage of Orthodontists available to deal with public patients, not only in Ireland but internationally, too.
In Ireland some public patients are referred to private practitioners for treatment. Some other public patients when they are unable to receive treatment under the public system attend private practitioners at considerable expense to themselves.
The demand for treatment is affected by several factors. Patients are referred to orthodontists by school dentists, other dentists or health care workers. Some refer larger numbers than others and parental pressure is described as being important by some primary practitioners. In general guidelines for orthodontic treatment are as follows;-
Category A - the most severe cases e.g. cleft palate and lip (this is less than 1% of cases referred).
Category B - cases with a functional handicap e.g. marked distortion between the upper and lower jaws - approximately 6%
Category C - non-handicapped but having a need for treatment - approximately 16% of those referred but later reduced to 9% as more realistically achievable.
Under some guidelines up to 50% of 12 year olds could need treatment. This would mean 25,000 to 30,000 children would require treatment each year at the current birthrate of 50 to 60 thousand births per annum. Those eligible under the state schemes would be about a third of this number.
It would be better if the Index of Orthodontic Treatment Need Code (IOTN) was adapted as soon as possible. The I.O.T.N. grades cases from 1 to 5, with 5 being the most severe and urgently in need of treatment. This might also make it easier for the same severity index to be applied all over the country.
During 2001 the Joint Committee on Health and Children reviewed the Report on Orthodontic Services (Moran Report) and heard submissions from interested parties who came before the committee.
A Report on the Orthodontic Service in Ireland was produced in February 2002. This report made recommendations and the progress made on these recommendations are reviewed herewith. Appendix A is a copy of the recommendations.
There does not appear to have been any resolution to the problems between some Regional Orthodontists, three in all, and the Department of Health and Children and the Dental Council. The Regional Orthodontists not only supply treatment to patients but act as excellent trainers for the Dental schools. All but these three co-operate with the training programmes. A Committee as recommended by the report was set up but the representative of the three orthodontists in dispute attended once only.
(2) ORTHODONTIC SERVICE STRATEGY
There does not appear to be a definitive action plan but 5 million euro were advanced to the former Health Boards under the National Treatment Purchase Plan (NTPP) for provision of orthodontic treatment. The spending of this money was not directed by the Central Office of the NTPP but left to the discretion of the Health Boards.
(3) Progress has been made on the establishment of a de facto Health Information and Quality Authority. The Board, Chairman and staff are in place and functioning the legislation has been brought forward by Ministerial Order on 11th of March 2005.
(4) & (5) GUIDELINES FOR PRIORITISING SERVICE
(4) & (5) - no changes in guidelines have been made.
Progress is being made on upgrading the teaching of orthodontics at primary degree level.
(7) The Dublin Dental Hospital and School facilities have been totally upgraded and there is plenty of room to cater for trainees. A professor of Orthodontics was appointed and to take up his post at the beginning of April. Unfortunately at the last moment he withdrew. One of the Senior Lecturers resigned about the same time to go into private practice. There are still sufficient numbers of consultants to supervise training but the posts of Professor and Senior Lecturer should be filled immediately.
(8) Specialist training places were funded by the State and attached to health authorities for three years but funding was stopped recently despite the fact that the target figure of 50 specialists at a minimum has not been achieved. Trainees will now have to pay their own fees.
(9) There is still only one consultant Orthodontist in most of what were the Health Board areas and this is not enough for the public service patients’ needs. Most of these people are not full-time and have private practice commitments.
(10) No trainee specialists are yet being taught in Cork but should be by the Autumn when some necessary work is done to improve facilities. A professor of Orthodontics was appointed to Cork over a year ago and is in place. There are enough consultants to teach specialist trainees but he would like additional appointments. While the number in Dublin has not increased to 24, it is nearly so. Six dentists graduated from the Dublin Dental Hospital programme in 2004 and there are currently eleven specialist trainees who are due to finish their training in September 2005. There are an additional two specialist trainees funded by the H.S.E. Midland Area (formerly the Midland Health Board) who are also due to finish their training in September 2005.
Of the thirteen specialists who are due to complete their training in September 2005,
3 are from the former South Eastern Health Board
2 are from the former North Eastern Health Board
2 are from the former Midlands Health Board
2 are from the former Western Health Board
1 is from the former North Western Health Board, and
1 is from the North Eastern region of the former Eastern Regional Health Authority. Each trainee has cost the taxpayer in excess of 100,000 euro for each year of their three year training, (fifty thousand for salary, the rest for fees and expenses).
(11) It is not possible to say with certainty whether flexibility is being shown to Dentists with experience in Orthodontics but they are certainly not being discouraged.
(12) The former Health Boards were funding trainees to go to the U.K. for training but this funding has ceased recently, too. There are three specialist trainees attached to Cardiff University. They will receive a Cardiff M.Sc. and a British M. Orth. qualification. They will enter the U.K. register of Orthodontists and then transfer to the Irish register. The same applies to two trainees attached to Leeds University and two in London.
(13) There is a shortage of places for training in the U.K. but some trainees are there with or without Health Board funding.
(14) Section 34 of the Dentists Act of 1985 covers the Council’s duties in relation to education and training and is as follows:
34. - It shall be the duty of the Council from time to time to satisfy itself -
(a) as to the suitability of the dental education and training provided by any body referred to in the Second Schedule to this Act,
(b) as to the standards of theoretical and practical knowledge and clinical experience required at examinations for primary qualifications, and
(c) as to the adequacy and suitability of postgraduate education and training provided by bodies recognised by the Council for the purpose of dental specialist training.
This has not been amended to ensure that the number of people in training is adequate to meet public needs.
(15) Specialist manpower levels would not be such that only 250 completed cases were treated by specialist orthodontists each year.
(16) The Grade of Specialist Orthodontist has been recognised by the Department of Health. Appendix B gives the job description. The starting salary this year is 121,244 Euro.
(17) Progress has been made and more Specialist Orthodontists are in position but not all are whole time. It will be very difficult to retain these practitioners because private orthodontic practice is very lucrative. The prestige of whole time positions might be improved by promoting funding those in them to attend international meetings, involve themselves in research in the Dental Schools, etc.,
(18) Recruitment on the international scene is not obvious but may have happened during the massive drives for medical and nursing staff abroad over the last few years. Recruitment for a professor for the Dublin School will be international.
(19) No information pack, attractive or otherwise, has been brought to my attention.
(20) There has certainly been an improvement in filling specialist posts in the Eastern area. There is less clarity about the Southern Area. It is very important the Specialists, who are trained and qualified to work unsupervised, should practice in the peripheral clinics and not just in the same location as the Consultant Orthodontists who could supervise a trainee while working themselves.
(21) There does not appear to have been a recruitment in North America or Scandinavia except in relation to professorial posts.
(22) State funding for specialists has been stopped and does not appear to be in place for consultant upgrading. However, it is possible that two years additional experience in a recognised centre may be enough to achieve consultancy status. There are divided views on this issue. The Post-Graduate Medical and Dental Board (now defunct) felt the above was so, apparently.
(23) No free accommodation has been offered.
DELIVERY OF ORTHODONTIC SERVICES
(24) The most recent figures for waiting lists available are for Category A and Category B at the end of 2004. They are in Appendix C. No waiting list for Category C is available.
(25) Orthodontic appointment systems vary in their implementation.
(26) No legislation has been brought in to provide for Grants in Aid. This would be useful.
(27) Discussion with the Dental Schools regarding the provision of orthodontic treatment is on-going but the Schools do not see this as their primary focus, teaching and training under and post graduate being their priority. However, patients are needed for these activities and several hundred attend both schools.
(28) Video conferencing appears to take place in the training of Dental Hygienists or nurses but not in the training of orthodontists.
(29) The Chief Dental Officer of the Department of Health and Children resigned last year and has not been replaced. The new appointee should be offered a position of equal status with the Consultant Orthodontists as recommended.
(30) Oral surgery is carried out in Dublin, Cork, Limerick and other centres. There is a shortage of oral surgeons still in Ireland. Two qualify each year in Dublin and the facilities for two to qualify in Cork as well. A team approach may be needed in some cases.
(31) Quality assurance and clinical audit is vital, as is knowledge of the compliance rate of patients. Some orthodontists prefer not to continue with the treatment if the child’s oral hygiene is poor, the fixed appliances making the possibility of decay more likely.
Facilities and treatment for public patients should be to as high if not a higher level than those for private patients. The Dental Council exists to protect the public and to supervise the training and behaviour of the profession. Council Directive of the then E.E.C. now E.U. 78/687/EEC concerning the mutual recognition of diplomas, certificates and other evidence of formal qualifications of practitioners of dentistry (Appendix D attached) was brought into law in Ireland in 1999 by the establishment of the Dental Council as the statutory body to do so by the Minister for Health. The Dental Council set up the Irish Committee for Specialist Training in Dentistry which was to undertake the role in supervising training both academic and practical in orthodontics. This had previously been carried out in Ireland by the Joint Committee from the United Kingdom. At present all except two of the Regional Orthodontists in Ireland act as trainers. The academic modules are carried out in the Dental Schools in Ireland, the United Kingdom or Northern Ireland.
Irish degrees, graduate and post-graduate have very high standing nationally and internationally. It is absolutely imperative that in the rush to acquire more specialist orthodontists for the public service anything should be done to damage the value of these degrees. Sub standard training will get us nowhere and public patients deserve just as good treatment as those who attend private practitioners.