A review of the reasons and sources of referral to a hospital paediatric dental service in Ireland.
Abstract: AIM: To examine the reasons for referral to the Paediatric Dental Department, Cork University Dental School and Hospital, Ireland and to study the profile of these reasons in terms of the various sources of referral. STUDY DESIGN: Clinical review. METHODS: Consecutive clinical records for children attending the service were reviewed with regard to a child's age at initial attendance, the reason for referral and the source of referral. Reasons for referral were recorded based on a defined list of acceptance criteria and were categorised by their different sources of referral. RESULTS: Records were available for 612 children with a mean age at time of initial consultation was 9.13 (SD [+ or -] 3.94) years. Reason for referral; children who had difficulty co-operating for dental treatment made up the largest group (36.1%). Children who only required treatment planning comprised 25.0% of the total. Source of referral: 56.0% of consultations were from the salaried public dental service and 31.2% from private dental practitioners. Forty seven patients (7.7%) were from emergency department, while 31 (5.1%) were from medical practitioners. From the public dental service, 51.0% of referrals were for children who had difficulty co-operating for dental treatment and 22.7% were for treatment planning only. Referrals from private dental practitioners were most commonly for treatment planning only (38.2%). The proportion of referrals from the public dental service for children who had difficulty cooperating for dental treatment was twice as high as from private dentists. The proportion of referrals for trauma and for extensive dental disease from private dental practitioners was twice as high as from the public dental service. Almost all attendances from an emergency hospital department were for dental trauma. The majority of attendances from medical doctors were for medically at risk patients. CONCLUSIONS: Children with difficulty co-operating for dental treatment made up the largest single group of children attending the service. The majority of children attending were referred from the salaried public dental service.

Key words: Children; dental hospital; referral; review.
Article Type: Report
Subject: Medical referral (Research)
Pedodontics (Research)
Dental care (Utilization)
Dental care (Usage)
Dental care (Research)
Authors: Stewart, C.
Lone, M.
Kinirons, M.
Pub Date: 04/01/2012
Publication: Name: European Archives of Paediatric Dentistry Publisher: European Academy of Paediatric Dentistry Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 European Academy of Paediatric Dentistry ISSN: 1818-6300
Issue: Date: April, 2012 Source Volume: 13 Source Issue: 2
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: Ireland Geographic Code: 4EUIR Ireland
Accession Number: 290066489
Full Text: Introduction

The Cork University Dental School and Hospital, Ireland, serves a population of 1.3 million people in the province of Munster, a mixed urban and rural region of the southern part of Ireland. With ever increasing demand on finite resources in hospital paediatric dental services it is incumbent on service providers to ensure that resources are utilised effectively. Priority must be given to those patients whose needs cannot be met outside of a dental hospital setting. An understanding of the profile of referral is helpful in the development of clearer criteria for acceptance to a hospital paediatric dental service (HPDS). Central to the current study is the reason for referral to the HPDS and the source of referral. In a previous study in the UK which examined the interface between primary and secondary care in dentistry [Morris and Burke, 2001] it was noted that the majority of dental care takes place in a primary care setting. Specialist dental services are described as a scarce resource and often oversubscribed. That work describes the interdependence of primary and secondary dental services and how the flow of patients between the two services must be appropriately balanced.

In Ireland, as in other countries, dental services for children are a priority but there is also a significant level of private care in general dental practice. The pattern of interaction between the primary and secondary dental care provision is broadly similar to other countries. The age at which a child is referred to dental hospital specialist service is dependent on the age of their first dental attendance in general dental services. It is a principle that dental attendance for children should commence at an early age [Sheiham, 2006; EAPD, 2008]. Subsequent early referral to a paediatric dental service for those children who require specialist treatment is desirable. At present no national data exists regarding the dental health of preschool children in Ireland [IOHSGI, 2009]. This is the first study in Ireland of the reason for consultation and source of referral to a hospital paediatric dental service.

The objectives of this study were:

1. To review the pattern of initial consultation at a hospital paediatric dental service in terms of patient age together with the reason and source of each referral.

2. To examine the relationship between the source of referral and reason for referral to the HPDS.

Methods

Six hundred and twelve consecutive referrals to the hospital paediatric dental service (HPDS) were examined in 2009. The patient's age and source of referral were recorded for each case. The reason for referral to the HPDS was determined at the first assessment visit by the specialist clinician using the clinical findings along with the relevant letter of referral.

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Patients were categorised according to a predefined list of reasons for admission to the service and in each case the primary reason was recorded. The categories were as follows:

Difficulty co-operating for dental treatment: physical or learning disability or children with levels of anxiety resulting in their inability to accept routine dental intervention including children of very young age.

Treatment planning only: child's dental needs could be met satisfactorily in the community setting with the guidance or treatment plan from the specialist paediatric dental service.

Dental trauma: children who had experienced dental alveolar trauma including crown fracture; root fracture; displacement injuries; luxations, avulsions or intrusion and alveolar fractures.

Extensive dental disease: children who had exceptionally high levels of dental caries based on a clinical assessment including nursing or rampant caries.

Dental developmental anomalies: children with dental developmental conditions including molar incisor hypomineralisation, amelogenisis imperfect, dentinogenisis imperfecta and hypodontia.

Medically at risk: children with a significant medical condition meriting treatment in a hospital setting. This included children with bleeding disorders, cardiac conditions and leukaemias.

The source of referral was determined and categorised as; public dental, private dental, hospital emergency or medical doctor. The records were made anonymous and recorded in an Excel data base. Analysis was conducted using an SPSS statistics package (PASW Statistics 18).

Results

Six hundred and twelve consecutive patient records, where the reason for referral to the hospital paediatric dental service (HPDS) was determined, were included in this review. The age distribution is shown in Figure 1. The mean age at the time of initial attendance was 9.13 years (SD [+ or -] 3.94). The distribution of the primary reasons for initial consultation at HPDS are shown in Figure 2. Children who had difficulty cooperating for dental treatment made up the largest group (36.1%) while children requiring only treatment planning for management of dental care comprised a further 25.0%. Ninety four referrals (15.4%) were for dental trauma and 56 (9.2%) were for children with extensive dental disease. Medically at risk children accounted for 44 (7.2%) of referrals. A further 44 (7.2%) referrals were for dental developmental anomalies.

Table 1 gives details of source of and reasons for referral from each source type. With regard to the source of referrals, 343 (56.0%) of referrals received were from the public dental service and 191 (31.2%) were from private dental practitioners. Onward referral from emergency attendance at dental casualty accounted for 47 patients (7.7%), while 31 patients (5.1%) were referred from medical practitioners.

From the public dental service the largest group comprised children who had difficulty co-operating for dental treatment (51.0%): 22.7% of referrals from the public dental service were for treatment planning only. The most common reason for referral of patients from private dental practitioners was treatment planning only (38.2%). The proportion of referrals from the public dental service of children who had difficulty co-operating for dental treatment was twice as high as from private dentists. The proportion of referrals for trauma and for extensive dental disease from private dental practitioners was approximately twice as high as from the public dental service.

Rates of consultation for medical conditions and developmental anomalies were similar from the two primary care dental service providers. Almost all referrals from the emergency department were for dental trauma. Medical doctors primarily referred patients who were medically at risk (64.5%) and a small number of patients for other reasons.

Discussion

The age distribution of the patients at initial attendance in the Paediatric Dental Department in the Cork University Dental School and Hospital indicates referral attendance peaks occurring at 7-9 years of age. The mean age at time of initial attendance was 9.13 (SD [+ or -] 3.94) years. This is consistent with previous studies reporting on referrals to specialist paediatric dental services [Stewart et al., 1977; Salam et al., 2005] that recorded mean ages of 9.5 and 9 years respectively. Eckersley and Blinkhorn, [2001] suggest that it is possible that asymptomatic dental attendance is not occurring at an early age when effective preventive and restorative intervention might be successful. Whilst acknowledging that different strategies may be appropriate according to individual circumstances, dental health provision for the youngest age group continues to challenge service providers internationally [Weerheijm and Frankenmolen, 2009]. This observation is consistent with findings reported in the USA where services for this age group are under-utilised [Kopycka-Kedzierawski and Billings, 2011]. A more extensive study would be necessary to ascertain the age profile of first dental attendances in Ireland. A recent study, reviewing specialist paediatric dental services in Sweden over a 25 year period [Klingberg et al., 2010], reported that the 7-12 years age group had consistently accounted for the majority of referrals to specialist paediatric dental services. These workers noted that although the age distribution had remained quite stable over the years, there was a trend towards increased proportions of teenagers being referred recently. The existence and availability of such data is important in demonstrating the need for the development of the specialty throughout Europe as advocated previously [Oulis et al., 2007].

The present study found that the majority of attendances (56.1%) were from the public primary dental care service and (31.2%) were from private dental practitioners. At first glance this might appear to be at variance with work done in the UK [Shaw et al., 1994] showing that the majority (84%) of referrals to a paediatric dental department were from general dental practitioners. However in interpreting this distribution it is important to appreciate that the large majority of UK general dental practitioners were providing primary care dental services for children within public health (NHS) arrangements while no such arrangement exists in Ireland. In Ireland the public dental service concentrates mainly on provision of dental care for schoolchildren and people with special needs [Hse.ie, 2011]. The 25 year survey of referral to paediatric dental specialists in Sweden [Klingberg et al., 2010] differentiated general dental practitioners working in public dental services and private dental practitioners.

In that work referrals from public dental services declined from approximately 80% of all referrals in 1983 to just over 60% in 2008. There was a concomitant rise in referrals from private dental practitioners. Thus the finding, in the present work, that most attendances at the paediatric dental specialty originate in the public dental service is consistent with that in the Swedish system.

In the present study children who had difficulty co-operating for dental treatment comprised the largest group (36%) of patients attending the service. Shaw et al. [1994] reported that behaviour management was the commonest reason for referral. An earlier study in Glasgow [Evans et al., 1991] had identified patient management as the main reason for referral.

A survey in Liverpool of dentists working in primary dental care in the UK, both in public dental service and general dental practice [Harris et al., 2008] explored pathways of referral for paediatric patients to a dental hospital. Their work reported that the main reason for referral given by general dental practitioners was treatment under general anaesthesia and inhalation sedation for anxious children. That work identified that general dental practitioners also refer children to the public dental service. With regard to referral for restorative care, almost half of the general dental practitioners identified lack of sedation facilities as a reason for referral.

In the current study, children who had difficulty co-operating for dental treatment accounted for half of the referrals from the public dental services but only one fifth of the referrals from private dentists. The public dental service has a remit to provide care for children with disabilities, many of whom would have difficulty co-operating for dental treatment. In addition it might be anticipated that children with a disability are more likely to attend public dental services than private dentists in the first instance as the association between social disadvantage and disability is well established [Shaar et al., 1994].

Conclusions

The reasons for referral indicate that the priorities for specialists in paediatric dentistry are the treatment of children who cannot easily co-operate, children who require treatment planning for care at primary care level, children with severe tooth trauma, extensive dental disease, medical complications and dental developmental anomalies. Paediatric dentists can expect to receive patients from a variety of sources and the treatment required at specialist level may vary considerably between these sources. It is important that paediatric dentists increase the level of knowledge of their services among all health care professionals.

References

EAPD. 2008. Guidelines on Prevention of Early Childhood Caries: An EAPD Policy Document. Available: http://www.eapd.gr/dat/1722F50D/flle.pdf [Accessed 26.07.11].

Eckersley AJ, Blinkhorn FA. Dental attendance and dental health behaviour in children from deprived and non-deprived areas of Salford, north-west England. Int J Paediatr Dent 2001; 11:103-109.

Evans D, Attwood D, Blinkhorn AS, Reid JS. A review of referral patterns to paediatric dental consultant clinics. Community Dent Health 1991; 8:357-360.

Harris RV, Pender SM, Merry A, Leo A. Unravelling referral paths relating to the dental care of children: a study in Liverpool. Prim Dent Care 2008; 15:45-52.

Hse.ie, HSE. 2011. Health Service Executive website Dental and Orthodontic Services in Donegal [Online]. Available: http://www.hse.ie/eng/services/ Find_a_Service/LHO/Donegal/Dental_and_Orthodontic_Services/ [Accessed18.08.2011].

IOHSGI. 2009. Irish Oral Health Services Guideline Initiative. Strategies to prevent dental caries in children and adolescents: Evidence-based guidance on identifying high caries risk children and developing preventive strategies for high caries risk children in Ireland. Available: http://www.dentalhealth.ie/download/pdf/full_strategies_finaleb.pdf [Accessed 21.06.11].

Klingberg G, Andersson-Wenckert I, Grindefjord M et al. Specialist paediatric dentistry in Sweden 2008--a 25-year perspective. Int J Paediatr Dent 2010: 20:313-321.

Kopycka-Kedzierawski DT, Billings RJ. Prevalence of dental caries and dental care utilisation in preschool urban children enrolled in a comparative-effectiveness study. Eur Arch Paediatr Dent 2011: 12:133-138.

Morris AJ, Burke FJ. Primary and secondary dental care: the nature of the interface. Br Dent J 2001; 191:660-664.

Oulis C, Curzon MEJ, Martens L, Koch G. Paediatric dentistry as a specialty in Europe: recognition and development. Eur Arch Paediatr Dent 2007: 8:131-135.

Salam S, Al Badri S, Lee GTR. A review of referrals of new patients to the paediatric department of a teaching hospital during a six-month period in 2004. Prim Dent Care 2005; 12:106-111.

Shaar KH, McCarthy M, Meshefedjian G. Disadvantage in physically disabled adults: an assessment of the causation and selection hypotheses. Soc Sci Med 1994; 39:407-413.

Shaw AJ, Nunn JH, Welbury RR. A survey of referral patterns to a paediatric dentistry unit over a 2-year period. Int J Paediatr Dent 1994; 4:233-237.

Sheiham A. Dental caries affects body weight, growth and quality of life in pre-school children. Br Dent J 2006; 201:625-626.

Stewart DJ, Elliott RH, Kernohan DC, Pielou WD, Saunders ID. A regional paediatric hospital dental service. J Dent 1977; 5:67-72.

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C. Stewart, M. Lone, M. Kinirons

Paediatric Dentistry, Cork University Dental School and Hospital, University College Cork, Ireland.

Postal address: Dr C. Stewart, Paediatric Dentistry, Cork University Dental School and Hospital, University College Cork, Ireland.

Email: c.stewart@ucc.ie
Table 1 Relationship between sources of referral and reasons for
referral for specialist paediatric dentistry in Cork (Ireland)

                         Difficulty
                        Co-operating                         Extensive
                         for Dental    Treatment   Dental     Dental
                         Treatment     plan only   Trauma     Disease

Public Dental Service       175           78         25         25
                          (51.0%)       (22.7%)    (7.3%)     (7.3%)

Private Dentist              40           73         25         27
                          (20.9%)       (38.2%)    (13.1%)    (14.1%)

Emergency Department         0             0         44          3
                            (0%)         (0%)      (93.6%)    (6.4%)

Medical Doctor               6             2          0          1
                          (19.3%)       (6.5%)      (0%)       (3.2)

Total                       221           153        94         56
                          (36.1%)       (25.0%)    (15.4%)    (9.2%)

                                     Dental
                                    Develop-
                        Medically    mental
                         at Risk    Anomalies   Total

Public Dental Service      14          26        343
                         (4.1%)      (7.6%)

Private Dentist            10          16        191
                         (5.2%)      (8.4%)

Emergency Department        0           0        47
                          (0%)        (0%)

Medical Doctor             20           2        31
                         (64.5)      (6.5%)

Total                      44          44        612
                         (9.2%)      (7.2%)
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