09/02/2017 How can we impact on the oral health status of 0-6 year old children with disabilities in Ireland? Dr. Siobhan Stapleton Senior Dental Surgeon.

09/02/2017 How can we impact on the oral health status of 0-6 year old children with disabilities in Ireland? Dr. Siobhan Stapleton Senior Dental Surgeon (HSE Mid West) February 9th 2017

Why this cohort of patients?
09/02/2017 Why this cohort of patients? It is painful for the child, disturbs eating and sleeping patterns and is distressing for both child and parent (child and family impact) Treatment is challenging and often requires secondary and specialist care under conscious sedation or general anaesthesia outside of primary care It may impact on the developing permanent dentition, self- esteem and aesthetics; It highlights the lack of targeted oral health policies and the development of a disease that is preventable

09/02/2017 Background Oral health status of 0-6 year-olds with disabilities in Ireland largely overlooked by policy makers and dental profession Standardised caries risk assessment not routinely used by Irish dental services to determine treatment outcomes

09/02/2017 Background Caries levels in Irish children with special care needs similar or lower than children attending mainstream schools Considerable variation in caries experience between groups with different types and severity of disabilities

09/02/2017 Past studies Only Irish study of this cohort (20132) showed traditional oral health promotion as ineffective Asthma, diabetes and obesity are most prevalent chronic childhood illnesses in U.S. Dental caries 5-8 times more common than asthma (Widström et al 2004)

09/02/2017 Background 5-year-olds, 37% of children in fluoridated areas and 55% in non-fluoridated areas have experienced decay More than one fifth of 8-year-olds have experienced decay Half of all 12-year-olds have experienced decay 75% of all 15-year-olds have experienced decay in their permanent teeth (Whelton et al 2006)

09/02/2017 Background To resort to general anaesthesia for these children for dental treatment is far from an ideal oral care strategy for the future, medically, psychologically or from an economic perspective. Well-recognised that GA is required for dental treatment for some patients with disabilities (Murray 1993) Access to conscious sedation is poor in Ireland (Fisher et al 2011)

09/02/2017

Methods – Paediatric GA
09/02/2017 Methods – Paediatric GA Retrospective analysis of children aged 0-6 with disabilities Comprehensive dental treatment under GA in Our Lady’s Children Hospital, Crumlin in 2013 Data collected on patient demographics, staffing details, dental treatment provided under GA, duration of GA and duration of hospital stay to create a total estimate Details from Finance department, HIPE department and Dental department, OLHC

09/02/2017 Results – Paediatric 113 children, 93% day-cases, 75 minutes average procedure Cost Breakdown Salary costs (medical and dental) €564.10 Equipment/materials (medical and dental) €845.50 Equipment servicing €95.50 Travel Costs €77.50 Overheads €474.80 Total cost per patient Day-case €2,057 Overnight bed +€1,227

09/02/2017 Results – Adults 22 adults, 95% day-cases, >120 minutes average procedure Cost Breakdown Hospital Costs (D40Z & GA & adult) Day-case €1,335 Salary costs (including overheads) €767.73 Dental materials €76.50 Equipment servicing €34.77 Travel Costs €28.90 Total cost per patient Day-case €2,243 Overnight bed +€1,213

09/02/2017 Aims and Objectives Carry out an individualized caries risk assessment on 2 groups of 0-6 year-olds with disabilities Apply a tailored oral health promotion programme and prevention program as an intervention to one group only Understand issues and experiences of parents who are caring for preschool children with disabilities and explore the factors related to safeguarding the oral health of their children Re-assess risk status of both groups over an 18-month period, on 3 separate visits Create an individualised oral health promotion tool to cater for this particular patient group

09/02/2017 “If prevention of oral disease is to be taken seriously in Ireland, it must be provided for this [pre-school] age group” (Gelbier 2002)

Qualitative Focus Groups Generating Evidence
09/02/2017 Qualitative Focus Groups Generating Evidence MI approach to OHP with combined preventive programme Control Group N=78 No intervention Traditional oral health promotion when requested Intervention Group N=99 MI derived oral health promotion preventive programme Caries risk assessment 6 month intervals 3 visits over 18 months Clinical data collection Patient demographics Oral health knowledge questionnaire

Motivational Interviewing
09/02/2017 Motivational Interviewing Traditional oral health education consists of advice or information given, often in one direction, where the dental professional gives repetitive standard advice to parents regarding diet and oral hygiene instruction. These are known sometimes as the health education model (Watt 2002) MI attempts to understand the patient’s expectations, beliefs, perspectives, and concerns about changing their health behaviours, and links educational approaches with the patients’ readiness to change and willingness to hear the information (Borrelli et al 2015)

A Parent’s perspective
09/02/2017 A Parent’s perspective What are their lived experiences caring for their child? What coping mechanisms do they use? What are their priorities in caring for their child? What are the personal factors influencing their behaviours around oral health?

Materials and Methods 1 Qualitative approach
09/02/2017 Materials and Methods 1 Qualitative approach Purposive sample of parents with pre-school 0-6 year-olds with a wide range of disabilities 5 Focus groups Recruitment and Gate-keeping - Early Intervention Centres 5-7 participants per focus group Ethics approval gained Important due to the emotive nature of the emerging data Most appropriate to understands what under pins the behaviours and explore rich source of dataset in

Topic Guide Daily Routine
09/02/2017 Topic Guide Daily Routine What were the most important aspects of their daily care? What are the challenges they faced in the provision of oral hygiene? How does this compare with their experiences with siblings? Who was in their care team? Do they have a dentist? Can they go to any dentist? Does that work for them? How did they communicate with their child?

09/02/2017 Reflexivity Training in conducting focus groups and designing topic guide Topic guide designed to allow oral health to naturally present itself Non dental setting Participants unknown to moderator All assured there was no right or wrong answers Technical and dental jargon avoided

Results All focus groups recorded and transcribed
09/02/2017 Results All focus groups recorded and transcribed 5 focus groups sufficient to saturate the data N=32 (29 female, 3 male) No new themes emerging from last 2 focus groups Cross sectional thematic analysis of the whole dataset of the focus group discussions out with coding on transcribed data

Themes to shape oral health promotion
09/02/2017 Competing priorities Feeding Nutrition Speech and Communication Mobility Coping Emotions Skills Family Access to services Physical Access Isolation Emergency Access Dental/Oral health awareness Brushing Techniques Bruxism Aspiration Flouride Sensitivity to textures Diversity Individual needs More time consuming care Higher risk of failure

What are the competing priorities?
09/02/2017 What are the competing priorities? Feeding - Peg feds, nasogastric tubes, poor muscle tone, poor swallow, pureed foods, poor clearance, aspiration Nutrition - high calorie diets for weight gain, fussy/faddy eaters, comfort food to manage behaviour, gluten-free diets, sensory to textures and consistency Speech/communication - inability to explain daily functions and understand pain, use of toothbrushes, spoons, cups over bottles Mobility - walking coordination and dexterity

09/02/2017 Parent: “It would be the speech and language, to bring on their movement in the mouth and the feeding and that – you know if the muscles are moving and when he starts eating, it’s like someone said, when he starts eating solids, when he starts being able to chew, I was told that, let him chew, because the movements in the mouth, is actually making the movements for the speech to come through, so the speech is big.” Parent: “I am always busy trying to get the best wheelchair for her, they keep putting me off, I am worried cos, (sigh) she already has signs of scoliosis.”

09/02/2017 Parent: “Her big thing is the tube. We were waiting for a feeding tube for ages but we got a cancellation in Temple St., but we were no sooner out from the procedure then she ended up getting bronchiolitis and then reflux, she has the really bad reflux,... if we could just get the reflux under control, and then get the feeding and now, then everything is thickened with her as well and just ya, that is probably my big thing. It is just to get her feeding more sorted and stuff, ya.”

Coping Huge challenges in daily life
09/02/2017 Coping Huge challenges in daily life Coping skills focus on current issues Dealing with siblings Majority are aware they have put oral health at end of the list of health issues Can only focus on day to day living and managing healthcare appointments

09/02/2017 “The food in our house is you can have mince, you can have chicken, sausages, not the end of sausages (when you cook them you have to take off the ends) not skinless sausages. If you give her a sausage without the skin she just won’t eat it. It’s the little things.” “It’s very hard with Sean. He is very bad with teeth and he is easily distracted. We get dressed then and he has a loose tooth and it is hard. He does get a brush in, but he doesn’t like the sensation of toothbrush or toothpaste. And then he goes to school. Danny is older so it is different. Danny will do it himself. But with Sean it’s different. He’s better to eat when he comes home from school, but in groups or at a party he has a problem, he will just sit back and not eat anything.”

Access Extensive multidisciplinary team but no dental personnel
09/02/2017 Access Extensive multidisciplinary team but no dental personnel No dental intervention for this age group except for emergency treatment No reference to oral health by any other healthcare worker No dental point of contact except through Public Health nurse or general medical practioner

09/02/2017 “We would use our outreach nurse, if we thought we had a problem with his teeth. We would like a contact person; we have a contact person for everything else. We have a contact in Beaumont for his hearing, we have contact in the regional for his eyes and I have a book with names and numbers and I have everything else but no dentist contact. But is that the dentists fault? Dentists know as well that there are children there and there are handicapped children there, so why aren’t they putting in their spoke to look after these children, the dieticians are, the others are? Dental seems to be the one thing that is a private thing, everything else is not. You have to pay for it. “

Where is the Dentist? Exposed to Full multidisciplinary Team
09/02/2017 Where is the Dentist? Exposed to Full multidisciplinary Team Occupational therapist Dietician Public Health Nurse/liaison Nurse Speech therapist/Physiotherapist Range of consultants for medical needs Neurologists, Psychologists, Psychiatrists No mention of oral health by this team

09/02/2017 Who is to blame? Parent: “I suppose as parents we didn’t really know what we were looking at, ya and if someone had said to us look you need to be referred to a dentist children like JJ will have problems, or that you need to try and get him to a dentist ….., it was an automatic thing with the girls, when they get home you get a toothbrush into them. Where as with JJ he would never allow you to do it, and you kind of think, that definitely we had no information. We should have a leaflet to start with and you then need a referral, because each child is different and you need to see a dentist to talk about the individual child’s needs and then if you were seen you would have a review. You see if the dietician and the dentist were linked it would make more sense.. wouldn’t it?”

Dental Awareness Brushing techniques
09/02/2017 Dental Awareness Brushing techniques random, poor coping skills with sensory issues - vibrations, textures, smells, tastes, reflux - to brush or not sugary syrup medicines - to brush or not clamping down on toothbrush - causes distress use of toothpastes/mouthwashes - concerns over swallowing Poor cognitive and communication skills not helping Vague understanding of benefits of fluoride and it’s presence in water, toothpaste and mouthwash

Diversity within disability
09/02/2017 Diversity within disability Huge range of disabilities Broad range within individual disabilities Coping strategies more evident in parents with children with greater needs Priorities more focused in parents with children with greater needs Oral health more difficult to fit into daily routine with more complex needs

Conclusions Parent’s perspective
09/02/2017 Conclusions Parent’s perspective Acknowledge their role as parent and carer Need to fit in to their values to motivate them Need to tie it into their concerns over nutrition and communication As Professionals We need to work together as a multidisciplinary team We need to individually risk assess We need to make access points easily accessible

Qualitative Focus Groups Generating Evidence
09/02/2017 Qualitative Focus Groups Generating Evidence MI approach to OHP with combined preventive programme Control Group N=78 No intervention Traditional oral health promotion when requested Intervention Group N=99 MI derived oral health promotion preventive programme Caries risk assessment 6 month intervals 3 visits over 18 months Clinical data collection Patient demographics Oral health knowledge questionnaire

09/02/2017 Materials and Methods Ethics: The study was reviewed and granted ethical approval by the Limerick Regional Hospital and Waterford Regional Hospital (2013) Inclusion Criteria: All children with a disability or awaiting diagnosis between 0-6 years of age within either of these 2 Early Intervention Centres.

09/02/2017 Materials and Methods Sampling: A convenience sample was taken from Early Intervention Centres in Limerick and Tipperary; all recruitment was through a gatekeeper; Limerick as Intervention group (response 99/154) and Tipperary as control group (response 78/146) Data Collection: Patient demographics - Age, Sex, SES, Disability Type, Fluoridation status Parent Demographics - Age and Occupation Risk Categorization - Caries Risk Assessment Tool Clinical data - Caries detection, dmft values Oral Health Education and Quality of Life Questionnaires Data Analysis: All data coded and analysed using SPSS package + appropriate statistical tests

The Caries Risk Assessment Checklist (CRAC)
09/02/2017 The Caries Risk Assessment Checklist (CRAC) CRAC has been developed for the Irish public dental service to encourage a formal, risk-based approach to the management of caries in Irish school children. It is best described as a checklist in which the child’s caries risk status is recorded based on the dentist’s assessment of the balance between caries risk indicators and protective factors for the individual patient (Irish Oral Health Services Guidelines Initiative 2009).

Materials and Methods Caries Risk Assessment Tool Indicators
09/02/2017 Materials and Methods Caries Risk Assessment Tool Indicators Aged 0-3 with caries (cavitated or uncavitated) Aged 4-6 with dmft > 2 New Caries lesions in last 12 months Hypomineralised molars A medical condition for which dental caries will put the patient’s general health at risk A medical condition that may reduce their oral health or complicate dental treatment Protective Factors Fissure Sealants Brushing Twice a day or more Using a toothpaste containing 1000ppm or more Fluoridated water supply

Caries Risk Assessment
09/02/2017 Caries Risk Assessment High or No Risk Recall every 6 month (Control) and 3/6 month (Intervention) Each risk assessment was documented with reason for change on each visit

Intervention based on Risk
09/02/2017 Intervention based on Risk MI approach to oral health promotion Prevention: Fluoride increases in toothpastes/ clinical application Restorations where possible: Glassionomer/fissure sealants Adjunctive where necessary for extractions - DGA

09/02/2017 Dental Aids

09/02/2017 Results 300 children whose parents received an invitation to take part in this study 185 consented to take part 177 completed the programme 78 were in control group 99 were in the intervention 128 (72.3%) males and 49 (27.7%) females in the study

09/02/2017 Results Age Distribution in Control and Intervention groups: mean age 4.32, 4.02

09/02/2017 Disability Type

09/02/2017 Parent demographics Both Mother groups had very similar age distributions and so the whole sample showed that most mothers were in year and year ranges Fathers in both groups had very similar age ranges: both predominately between 33-49, with a greater number of fathers in age bracket

09/02/2017 Parent demographics Both control and intervention groups showed very similar occupation status within father and mother groups Dominant mother’s occupation category “All others gainfully occupied”, This group includes unemployed and stay at home mothers Expected result – mothers appear to be the first choice as the carer for their child with a disability

09/02/2017 Socioeconomic status

Caries Risk In Both Groups
09/02/2017 Caries Risk In Both Groups Control Group Intervention Group

Caries risk distribution
09/02/2017 Caries risk distribution Distribution of caries risk in 1st visit by the group shows p-value from the Chi-square test is (>0.05) no significant difference between the distribution of the risk in the two groups Distribution of caries risk at 3rd visit by the group shows p-value from the Chi-square test is <0.0001 significant difference between the distribution of the risk in the two groups children in the intervention group were less likely to be at risk in the 3rd visit, while children in the control group were more at risk

At risk 3rd visit Twice as likely to have medical cards
09/02/2017 At risk 3rd visit Twice as likely to have medical cards Majority were in cognitive disability

09/02/2017 Clinical Findings Dental caries in this study not detected in children less than three years of age Early childhood caries evidently not a problem for this particular cohort of patients Suggests that health behaviours need to be targeted at an earlier age (0-3 years), to combat unhealthy eating habits and increase good oral hygiene habits while making sure that the protective effects of fluoride are optimised for this age group

dmft in 5 year olds – the whole sample
09/02/2017 dmft in 5 year olds – the whole sample 5 year old (n=44): mean dmft_1 = 0.52 (SD=1.27) mean dmft_2 = 0.79 (SD=1.47) mean dmft_3 = 1.04 (SD=1.89)

Comparisons to previous studies
09/02/2017 Comparisons to previous studies A previous study (Sagheri et al 2013) reported a dmft of 0.6 in 5 year olds with disabilities in Ireland while The last national oral health survey indicated a mean dmft of 1.2 in 5-year-olds in the general population (Whelton et al 2006).

Caries progression 09/02/2017

09/02/2017 DISTRIBUTION OF CARIES ON ALL TOOTH SURFACES – 1ST VISIT OF FULL SAMPLE

09/02/2017 DISTRIBUTION OF CARIES ON ALL TOOTH SURFACES – 2ND VISIT OF FULL SAMPLE

Oral Health Questions -Frequency
09/02/2017 Oral Health Questions -Frequency

ORAL HEALTH QUESTIONS-FLUORIDATION
09/02/2017 ORAL HEALTH QUESTIONS-FLUORIDATION

09/02/2017 Discussion (1) The characteristics of the group that remained at high risk of dental caries across the whole sample after 3 visits indicated that two thirds of those children had a cognitive disability, and were twice as likely to have a family with a medical card Basis of a clinical approach was firmly focused on risk assessment which was documented and rigorously directed at each clinical session. Value of this was both patient-centred care efficiency and effectiveness of the practical running of clinical services

09/02/2017 Discussion (2) In contrast to previous studies with traditional style of Oral Health Promotion, the tailor-made programme saw a reduction in caries risk and caries experience The integration of the dental team into the Early Intervention Centre allowed open discussion between disciplines and the disability services were an invaluable instrument in the smooth running and success of the programme

Limitations and recommendations
09/02/2017 Limitations and recommendations Field study carried out over 18 month period; results much more beneficial over a longer timeframe As the sole researcher, despite regular collaboration with research colleagues and research supervisors regarding clinical decisions on risk assessment etc., an element of bias is always a danger The intervention programme should be implemented across all regions with standardized training in motivational interviewing, risk assessment protocols and appropriate preventive measures

09/02/2017 Recommendations it is clear that interventions need to be targeted at younger age groups in an effort to reduce caries levels at age five Creation of a dental home through the primary healthcare setting as it provides multiple opportunities for health promotion, anticipatory guidance and early intervention Strong clinical evidence exists for the efficacy of early professional dental care complemented with caries-risk assessment, anticipatory guidance, and periodic supervision (Savage., et al 2004).

Thank you any questions?

09/02/2017 REFERENCES (1) BORRELLI, B., TOOLEY, E.M. & SCOTT-SHELDON, L.A. (2015). Motivational Interviewing for Parent-child Health Interventions: A Systematic Review and Meta- Analysis. Journal of Pediatric Dentistry, 37 (3), 254–265. GELBIER, S. (2002). Oral and Dental Specialisation in Ireland: Department of Health and Children. Available from: < [Accessed 2 September 2009]. SAGHERI, D., MCLOUGHLIN, J. & NUNN, J.N. (2013). Dental caries experience and barriers to care for children with disabilities in Ireland. Quintessence International, 44, WATT, R.G. (2002). Emerging theories into the social determinants of health: implications for .oral health promotion. Community Dental and Oral Epidemiology, 30, 241–247.

09/02/2017 REFERENCES (2) WHELTON, H., O’MULLANE, D., HARDING, M., GUINEY, H., CRONIN, M. & KELLEHER, V. (2006). North South Survey of Children's Oral Health in Ireland Available from: < content/uploads/2014/03/oral_health_report.pdf> [Accessed 16 February 2012]. WIDSTRÖM, E. & EATON, K.A. (2004). Oral healthcare systems in the extended European Union. Oral Health and Preventive Dentistry, 2(3), 155–194. WEINSTEIN, P., HARRISON, R. & BENTON, T. (2004). Motivating parents to prevent caries in their young children - one year findings. Journal of American Dental Association, 135 (6),

09/02/2017 References (3) SHEIHAM, A. & WATT, R. G. (2000). The common risk factor approach: a rational basis for promoting oral health. Community Dentistry and Oral Epidemiology, 28, SAGHERI, D., MCLOUGHLIN, J. & NUNN, J.N. (2013). Dental caries experience and barriers to care for children with disabilities in Ireland. Quintessence International, 44, Irish Oral Health Services Guideline Initiative. (2009). 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 (Full guideline).

09/02/2017 References (4) IDC, I. D. C. (2005). Code of Practice Relating to the Administration of General Anaesthesia and Sedation and on Resuscitation in Dentistry. 57 Merrion Square, Dublin 2, Ireland, Irish Dental Council. Fisher V, Stassen L.F, Nunn, J.H (2011). “A survey to assess the provision of conscious sedation by general dental practitioners in the Republic of Ireland. J Ir Dent Assoc 57(2) : SAVAGE, M. F., LEE, J. Y., KOTCH, J. B. & VANN, W. F. (2004). Early preventive dental visits: effects on subsequent utilization and costs. Pediatrics, 114(4), e

09/02/2017 How can we impact on the oral health status of 0-6 year old children with disabilities in Ireland? Dr. Siobhan Stapleton Senior Dental Surgeon.

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09/02/2017 How can we impact on the oral health status of 0-6 year old children with disabilities in Ireland? Dr. Siobhan Stapleton Senior Dental Surgeon.

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Presentation on theme: "09/02/2017 How can we impact on the oral health status of 0-6 year old children with disabilities in Ireland? Dr. Siobhan Stapleton Senior Dental Surgeon."— Presentation transcript:

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