Children must wait years for orthodontic treatment in the public health ervice. Are new guidelines aimed at cutting the waiting lists merely masking he problem? Sylvia Thompson writes.
Thousands of children are facing a wait of up to four years for orthodontic treatment following assessment, in the midst of a dispute between a group of consultant orthodontists and the Department of Health and Children.
Orthodontists treat a wide range of problems, from overcrowding of teeth to prominent and buried teeth. Cleft lip and palate, extremely prominent teeth, crooked jaws and serious overcrowding are the more severe cases treated by orthodontists in the public healthcare system. Crooked teeth and moderate overcrowding are categorised as less severe cases.
The dispute centres on the refusal of three consultant orthodontists to follow new departmental guidelines, which were introduced to eliminate less severe cases from public waiting lists. The consultants in question - Ian O'Dowling, who works in the Southern Health Board region; Triona MacNamara, who works in the Eastern Region Health Authority area; and Ted MacNamara, who works in the Mid-Western Health Board area - continue to follow older, more inclusive guidelines, resulting in longer waiting lists for both assessment and treatment.
Dr Thérèse Garvey, who is president of the Orthodontic Society of Ireland, which represents orthodontists in private practice, says 23,686 patients are waiting for assessment and 11,995 are waiting for treatment in the public sector. Of these, 89 per cent live in the three health-board regions where the three consultants practise.
"It is ethically unacceptable and probably illegal to leave people on waiting lists for over two years only to then deny them a service by reasons of non-eligibility," says Garvey, who is a senior lecturer consultant at Dublin Dental School and Hospital.
There are long waiting lists in other health-board regions, but the new guidelines are shortening them substantially. "Waiting lists are high everywhere, but orthodontics is unlike any other component of the health service. It takes two years to treat a case, with patients attending every six to eight weeks for up to 20 visits," says Patrick McSherry, a consultant orthodontist in the North Eastern Health Board region and president of the Irish Consultant Orthodontists' Group.
"We are trying to meet demand but demand is much greater than need. A lot of decisions about who needs treatment are subjective. Parents see crooked teeth but it is the ones with the crooked jaws that we want to see," he adds.
O'Dowling says the guidelines result in some severe cases being excluded. "Minor problems aren't treated through the health boards and never were. In the case of prominent front teeth, the gap between the top teeth and bottom teeth at the bite must be 10 millimetres to be severe. If the gap is eight millimetres, the patient would still need treatment, but we could never offer these patients treatment," says O'Dowling.
The Irish Consultant Orthodontists' Group, which represents orthodontists in the public sector, has accepted the guidelines. It argues that the state system was overwhelmed, so priority had to be given to those in greatest need.
"There is a need for 100 specialists in the public health service and we only have 16," says Niall McGuinness, the group's secretary. Seventeen thousand patients are being treated in the public system. The group says more personnel would increase the number under treatment to 40,000, effectively eliminating waiting lists.
A joint Oireachtas committee on health and children heard presentations on orthodontics at the end of January. At the meeting, Dr Antonia Hewson, the chief dental officer of the Western Health Board, argued that children in the west with severe overcrowding, who are deserving of treatment and would have been deemed eligible before 1999, are not now receiving treatment.
"It is inexplicable in this time of unprecedented prosperity that children in the west of Ireland are finding it harder to get orthodontic services," she said.
The dispute highlights a wider problem with the provision of orthodontics within the public health service. Under the Healthcare Act (1970), all children are entitled to free dental and, by extension, orthodontic care. Some orthodontists in the public sector believe legislation will be required to specify that public-sector orthodontists can treat only severe cases.
The first public consultant orthodontist was appointed in 1985, and such consultants are now employed in all health-board regions.
As the dental health of Irish children improves, Irish parents are beginning to focus on the look of their children's teeth. Many feel their own teeth didn't get much professional attention when they were young, and they want to ensure their children have better access to services. As one orthodontist in private practice puts it, "there are certain schools in Dublin where very few girls haven't had orthodontic treatment."
"Orthodontic treatment is not like curing diseases or filling cavities. It creates its own demand. What was quite acceptable for you and I growing up is not now acceptable for children or their parents," says Hugh Bradley, an orthodontist in private practice in Dundalk and a former president of the Orthodontic Society of Ireland. "You'll find up to 65 per cent of the population would have the perception of needing orthodontic treatment."
The question is whether such cosmetic work should be funded by a public health system. Niall McGuinness, a consultant orthodontist with the Western Health Board, quotes studies from the United States and Britain that have shown that a third of adolescents need orthodontic treatment.
"One-third have a borderline need for treatment and one-third have no need for treatment. No other medical or surgical operation shows such a need for treatment in the general population apart from tooth decay or gum disease. We can't treat people for aesthetic reasons in the public health service. They have to have a dental-health component, such as prominent upper front teeth or impacted eye teeth." he says.
"No society has offered high-quality orthodontic treatment on demand," says Garvey, who believes there is a need to distinguish between need and demand.
Yet some parents will wait years for public orthodontic treatment rather than seek private treatment for their children. If those children are excluded from waiting lists under the new guidelines, their parents would have to choose between seeking treatment privately or letting their children get on with their lives with imperfect teeth.
Some orthodontists argue that timing is crucial and that results are best when treatment begins as soon as a problematic tooth appears. Others argue that orthodontics can be done at any age.
One thing is certain: parents' are influential lobbyists for public-sector orthodontic treatment for their children. Parliamentary questions on orthodontics outnumber those on any other health topic.
But the real issue lies in whether a public health service should provide free orthodontics to all children or treat only severe cases, offering tax relief and means-tested grants for cosmetic treatment.