A RETROSPECTIVE AUDIT OF HB CHILDREN UNDERGOING GA DENTAL TREATMENT: THE “F” WORD, AND SHOULD WE CARE?

HBDHB meetings, Tuesday 22 February and Wednesday 23 February, 2011.

David Marshall.

SO HOW ARE THINGS WITH CHILDREN’S ORAL HEALTH IN HAWKE’S BAY?

Like the rest of NZ, caries rates are slowly tracking down but there is a persistent group of children for whom caries has become almost a way of life.

The results of a recent 5 year retrospective audit of 0-15 year old children (DWM) having GA dental treatment were predictable but depressing.

A RETROSPECTIVE AUDIT OF HB CHILDREN UNDERGOING GA DENTAL TREATMENT FROM 2005-2010.

To examine the trends in day-stay dental treatment under GA in HB children.

To examine the sociodemographic characteristics of the children.

To examine the procedures carried out. To examine the income/costs of treating

these children. To examine the number of theatre sessions

available. To look at waiting times. To make recommendations....

Before looking at the results, just what are we talking about?

So what are some of the audit results?

NUMBER OF PATIENTS BY REGION:

NUMBER OF VISITS /PATIENTS BY DEPRIVATION DECILE.

2010

Number of Visits

1

7

7

15

7

7

10

36

23

78

191Sum: 229 209 233

82 406

217 1079

9 37

10 78 84 84

38 43

8 52

49 215

31 172

8 53 36 41

7 9 11 14

10 37

5 6

6 10 4 6

9 11

8 42

14 80

9 42

4 22 14 15

3 10 6 11

5 23

1 2

2 2 7 2

6

2009

Sum:

Number of Visits

1 10

Decile Ranking

Number of Visits

Number of Visits

Number of Visits

Discharge Financial Year 2006 2007 2008

By year by Deprivation Decile (Events with theatre link)

NUMBER OF VISITS/REFERRALS BY DECILE RANKING.

0

50

100

150

200

250

300

350

400

450

1 2 3 4 5 6 7 8 9 10

Nu

mb

er

of

Vis

its

Decile Ranking

NUMBERS FROM FLUORIDATED DOMICILES:Y: FLUORIDATED; N: NON-FLUORIDATED; P: PARTIALLY FLUORIDATED.

NUMBER OF REFERRALS FROM “TOP TEN” SUBURBS.

0

20

40

60

80

100

120

140

160

Wairoa Nelson Park

Maraenui Onekawa South

Hastings Central

Flaxmere East

Lochain Marewa Kingsley-Chatham

Akina

Nu

mb

er o

f V

isit

s

Suburb Description

NUMBER OF VISITS/PATIENTS BY AGE/YEAR. YEAR. YEAR.

3 28 3 21

1079Sum: 229 209 233 217 191

14 5

5 2 15

13 9 4 7 3 2 25

12 2 4 2

25

11 3 7 7 5 4 26

10 10 4 5

12 147 7

4 2

47

9 6 3 9 6 10 34

8 7

126

7 7 10 13 17 6 53

6 18 23 33

51 2346 55

26 26

240

5 35 50 53 34 48 220

4 65

65

3 40 29 25 37 31 162

2 16 11 12

1

8 18

1

1 6 2 2 6 3 19

0

2010

Sum:

Age in Years

Number of Visits

Number of Visits

Number of Visits

Number of Visits

Number of Visits

Discharge Financial Year 2006 2007 2008 2009

By year by age (Events with theatre link)

NUMBER OF DISCHARGES BY AGE AND YEAR.

0

10

20

30

40

50

60

70

2006 2007 2008 2009 2010

Nu

mb

er o

f V

isit

s

Discharge Financial Year

0

1

2

3

4

5

6

7

NUMBER OF VISITS BY ETHNICITY AND YEAR.

Discharge Financial Year

2009 2010

Ethnicity Description - Stats NZ Group

Number of Visits

Number of Visits

NEW ZEALAND MAORI 134 106

NOT STATED 2 1

OTHER 71 69

PACIFIC ISLANDER 10 15

Sum: 217 191

2006 2007 2008

126 110 128

By year by ethnicity (Events with theatre link)

604

Sum:

Number of Visits

Number of Visits

Number of Visits

92 81 84 397

2 4 4 13

229 209 233 1079

9 14 17 65

VISITS BY ETHNICITY AND YEAR.

0

20

40

60

80

100

120

140

2006 2007 2008 2009 2010

Nu

mb

er o

f V

isit

s

Discharge Financial Year

NEW ZEALAND MAORI

NOT STATED

OTHER

PACIFIC ISLANDER

NUMBER OF VISITS/PATIENTS BY GENDER AND YEAR.

Discharge Financial Year

2009 2010

Patient Sex DescriptionNumber of Visits

Number of Visits

FEMALE 110 85

MALE 107 106

Sum: 217 191229 209 233 1079

122 110 134 579

500

Sum:

Number of Visits

Number of Visits

Number of Visits

2006 2007 2008

107 99 99

By year by gender (Events with theatre link)

NUMBER OF VISITS BY GENDER AND YEAR.

0

20

40

60

80

100

120

140

2006 2007 2008 2009 2010

Nu

mb

er o

f V

isit

s

Discharge Financial Year

FEMALE

MALE

NUMBER OF THEATRE SESSIONS DEDICATED FOR PAEDIATRIC DENTAL CARE, AND CHILD POPULATION <14YRS.

PROCEDURES BY YEAR.

Year 2006 2007 2008 2009 2010 Grand total Sum of extractions 798 632 657 611 570 3268 Sum of fillings 989 945 757 693 593 3977 Sum of SS Crowns 55 11 0 3 14 83

INCOME/COST:

Each case treated under GA = 0.3556 caseweight, i.e. $1543.40.

S.D.B. average fee currently $586.23 Total income $2129.63, plus FSA and other

outpatient clinic payments: approx. $3000.00 or approx. $3M over five years.

Of course this also represents the cost to the taxpayer.

Surely this would be better used for other less preventable diseases?

WAITING TIME:

Range was from one day (acute cases) to 361 days.

Average waiting time on elective surgery waiting list was 112.2 days, nearly four months.

Not included was the time from date of referral to FSA.(not measured).

A number of children were waiting > six months, the MoH cut-off period.

The ambulance at the bottom of the cliff needs a new set of tyres and a bigger engine!

SO WHAT IS SOME OF THE SOCIAL BACKGROUND TO THIS PROBLEM?

1986, closure of Whakatu freezing works, loss of 2,200 jobs.

1994, closure of Tomoana freezing works, loss of 2,000 jobs.

“Mauri Matu” study. Loss of employment, five generations in one family. Increase in suicides.

1990, cutting of welfare benefits. 1991, sharp increase in State House rentals. 1991, passing of Employment Contracts Act.

CHILD ORAL HEALTH INEQUALITIES IN NZ,THOMSON, AYERS, BROUGHTON, 2003

“The combined outcome of these policy changes was an increase in poverty and a heightened sense of social exclusion and alienation among disadvantaged households, a sector of society which steadily increased in number during the 1990s. Maori and Pacific people have borne a disproportionate amount of the burden because of their being more over-represented among more socioeconomically deprived households.”

FENCE AT THE TOP OF THE CLIFF IS BECOMING STRONGER!

The preventive aspects of the Oral Health Business Case ($6.5M for HBDHB Oral Health Services to rebuild the School Dental Service).

Use of Hall Crowns (No local anaesthetic, no caries removal, no drilling or tooth preparation)

Increasing use of topical fluoride varnish and fissure sealants.

Maintenance of existing fluoridation schemes of public water supplies, and expansion into high risk areas.

NICOLA INNES AND DAFYDD EVANS, LUNCH IN DUNDEE.

We have a strong and growing link with the University of Dundee School of Dentistry

33

Bobbi-Lee: is this the face of children’s dentistry in the future in New Zealand? She had a Hall crown placed just seconds before this photo. She has no numb lip, there was no drilling, and she is smiling! And certainly there was no need for a General Anaesthetic.

THE “F” WORD, IT JUST WON’T GO AWAY!

FLUORIDATION IN HAWKE’S BAY: Hastings for 59 years. A referendum in Hastings in 1990 maintained

fluoridation, just. Fluoridation adopted in Wairoa in 2003, then

six weeks later rescinded. The CHB debate 2009, 6-1 for status quo. The Hastings debate 2010, 7-6 for status

quo. But the battle lines are drawn for 2011.

FROM THE EXECUTIVE SUMMARY OF THE NATIONAL ORAL HEALTH SURVEY, DEC. 2010

“...children and adults living in fluoridated areas had significantly lower lifetime experience of dental decay(i.e. lower dmft/DMFT).

There was a very low overall prevalence of moderate fluorosis (about 2%, no severe fluorosis was found).

Moderate fluorosis is very rare in NZ and the prevalence of any level of fluorosis was not significantly different for people living in fluoridated and non-fluoridated areas.”

Mild fluorosis:

SO WHAT ARE THE MAIN OBJECTIONS? Fluoridation is mass medication: well,

fluoride is already present in the water supply.

It poses numerous threats to health: after almost 60 years, where are the bodies?

It is inefficient: the NOHS Survey, the GA audit, and other reputable NZ surveys, say otherwise.

It causes increased risk of disfiguring fluorosis: the NOHS, and other NZ surveys have shown otherwise.

There is a need for increased topical fluoride application: yes, we all agree on that, and it is happening right now.

SO WHY DON’T WE CHANGE FAMILIES DIET AND BEHAVIOUR?

“after all, it’s not rocket science” Prof. Laurence Moore, Cardiff University who

has had extensive experience with teenage smoking programmes has said:

“no, it’s much more complicated than that”

SHOULD WE KEEP ON TRYING WITH FLUORIDATION?

Although it can be very uncomfortable, my personal view is emphatically yes.

We need to be tackling the issue from the front foot, not simply reacting.

Fluoride toothpastes have certainly had an effect, but water fluoridation remains the most cost-effective method of helping all sections of society.

We need the public endorsement of the HBDHB.

Children do not have a vote or a say, they need public advocates.

ACKNOWLEDGEMENTS:

Warrick Frater, COO, HBDHB

Pieter Albertyn, Information Services, HBDHB.

Wayne Blair, Charge Medical Photographer, HBDHB.

Thank you for your attention:

WHAT ARE THE LIKELY EXTRA COSTS FOR HBDHB IF FLUORIDATION IS DISCONTINUED IN HASTINGS AND CHB?

Based on increase in decay rates experienced in Ashburton after fluoridation was discontinued:

Cost of preparing and delivering submissions.$???

Additional GA dental sessions, 25-30/ year Based on data from “Titanium” (School Dental

Service treatment in fluoride and non-fluoride areas), Oral Health Services estimates a one-off capital cost of one two-chair clinic (fixed or mobile) of $460K.

And ongoing operational costs of $250K/ annum.