Dr Rose-Marie Daly looks at potential areas of risk for dental practices and public dental clinics that provide dentistry for children in Ireland

Professional standards of dental care for children are progressing rapidly. This change reflects ongoing clinical research, continued development of guidelines, new patterns of reimbursement through insurance products, diminished funding in the Public Dental Service (PDS), increased parental expectations, the influence of social media, advancements in legal standards for the protection of constitutional and international legal rights of children in healthcare and growing access to paediatric dentists (PD)¹.

This paper will present the unique Irish context in which dentistry for children is changing and how this relates to the law in terms of potential complaints. Three risk-prone clinical scenarios, where treatment planning and clinical care can be demanding and complex will be outlined. Points for discussion at the treatment planning stages for the management of this risk will be enumerated. The paper will evaluate our ethical, legal and contractual obligations in relation to paediatric dentistry.

How is paediatric dentistry changing in an Irish context?
In recent years, the number of PD in Ireland who have undergone postgraduate specialist training has grown significantly. Many PD provide both primary and specialist care in contrast with other comparable specialties. Increased uptake of dental insurance products has facilitated better access to PD and, additionally, health insurance now usually covers most of the associated medical costs of treatment under general anaesthetic. This shift in access and affordability has had a very positive impact on the number of Irish children receiving high quality
dental care.

Together with greater online connectedness and access to improved standards of clinical care, this pattern is gradually influencing societal attitudes towards dentistry for children. Furthermore, parents are continually researching and learning about what is achievable through modern specialised care. This trend will continue to augment the demand for paediatric dental care and this presents new and dynamic challenges for practitioners. The time is ripe to reflect upon how these changes may influence risk management for child patients.

Perspectives on standards of dental care naturally change over time. Traditionally, the standard of care has been determined according to the Bolam test: A clinician does not breach the legal standard of care if the practice is supported by a reasonable body of similar professionals. In Ireland, the landmark case of Dunne v the National Maternity Hospital² set out the law on the appropriate standard of medical care. It was stated that “if a medical practitioner charged with negligence defends his conduct by establishing that he followed a practice which was general, and which was approved by his colleagues of similar specialisation and skill, he cannot escape liability if in reply the plaintiff establishes that such practice has inherent defects which ought to be obvious to any person giving the matter due consideration”³. Much of the guidance on dental management of children comes from PD.

Untreated decay in primary teeth (two to eight years)
The case of untreated caries in the primary dentition illustrates this point. Untreated primary caries causes tangible harms to children ⁴ and is a major cause of preventable general anaesthesia⁵. Poor oral health seriously impacts on children’s general health and quality of life⁶. The weight of available evidence suggests that leaving untreated dental decay is not in a child’s best interest ⁷.

This is very relevant to practitioners in the PDS. While the common practice of not restoring primary teeth might be covered by employer indemnity due to the fulfilment of a contractual obligation, the potential for a complaint to the Dental Council or fitness to practice hearing is not. Thus, unless there is a specific clinical indication not to restore, parents of children with decayed primary teeth should be given the option of comprehensive dental care including space maintenance as necessary ⁸. For young children, this may often mean a referral to a PD.

Helpful discussion points for managing potential complaints regarding primary caries:

• All guidelines recommend first visits start at ı2 months
• Discuss feeding practices, age-appropriate fluoride use, hygiene practices, caries risk, pacifier use and recall at the first infant visit
• When decay is present in young children, rapid progression of disease should be anticipated
• Primary caries frequently leads to pain, sepsis and reduced quality of life especially in very young children
• Primary caries can and should be treated
• If X-rays are not possible, inform the parents more decay may be present between molars
• If advanced restorative or behavioural management out with the skill of a general dentist is required, refer early to a PD.

Molar-incisor-hypomineralisation (MIH) (six to nine years)
MIH is a relatively common developmental condition. It presents some real clinical challenges and the management of expectations is essential for risk limitation.

Helpful discussion points when treatment planning for MIH:

• The tendency for rapid caries progression in affected molars
• Risk of post eruptive breakdown
• Risk of enforced extraction of affected teeth causing unfavourable orthodontic outcomes
• Dental anxiety secondary to hypersensitivity and hyperalgesia
• Difficulty with placement of quality fissure sealants due to hypersensitivity
• Frequent restoration failure due to unpredictable bonding to defective enamel
• Specific timing requirements for extractions if appropriate
• The need for integrated orthodontic planning.

MIH can be especially demanding clinically when all these factors are combined, leading to unnecessary pain and anxiety for the patient, disappointment on behalf of the parents and unfavourable clinical outcomes with long-term implications.

Early and thorough discussion of these potential problems will greatly assist in the reduction of the risk of complaints ⁹.

Trauma to adult teeth in growing patients (seven to 15 years)
Trauma to developing adult teeth is an area of risk where clinical management is complicated by the growth of facial bones and associated structures and because of the potentially serious long term implications of treatment decisions.

Parents can become unhappy due to the length of time treatment takes and also when a poor prognosis is hard to avoid. It is valuable to set time aside initially to discuss the time scale for treatment, the likely prognosis, all potential injury complications and the option of a specialist referral.

Tips for questions in risk management:

1. Ask if the complexity of this case is suitable for my level of skill and training in dental trauma?
2. Is the diagnosis consistent with the results from the clinical evaluation, special tests and radiographic findings?
3. Has the prognosis been clearly outlined?
4. Have the potential complications of the injury (e.g. ankylosis and its clinical implications) been explained?
5. Has the timeframe for the treatment been clearly discussed?
6. Do the treatment options offered reflect current guidelines? ¹⁰

Summary
Our domestic laws are increasingly recognising the rights of children in healthcare¹¹. While guidance is lacking in relation to when children should be referred to PD, the Dental Council of Ireland recommends that “if you do not have the necessary skills to carry out a recommended treatment, you should refer the patient to another dental healthcare professional who does”.

Irrespective of long standing practices such as not restoring primary teeth, our ethical obligations towards our patients must be guided by the available scientific evidence and current clinical guidelines. We must be mindful of changing expectations to allow us to justify a course of clinical action by reference to wider, socially accepted norms and values ¹².

About the author
Dr Rose-Marie Daly, BDS NUI, MFD RCSI, M Dent Sci (Paeds), M Paed Dent RCS Edin, FFD RCSI (Paeds), LLM, is a native of county Laois. She began her studies in dentistry at University College Cork. Following several years working in hospital, community and general dental practice she went on to complete her specialist training in Paediatric Dentistry at the Leeds Dental Institute in the UK. Here she graduated with distinction and was awarded prizes from the British Society of Paediatric Dentistry and the European Academy of Paediatric Dentistry for her masters research in dental caries and glycaemic index.

Dr Daly was awarded a fellowship in Paediatric Dentistry from the Royal College of Surgeons of Ireland and has a specialist membership in Paediatric Dentistry from the Royal College of Surgeons of Edinburgh. She has a Masters of Law specialising in Medical Ethics awarded by the University of Edinburgh. She achieved a distinction for her research evaluating oral health care for Irish preschool children in relation to the United Nations Convention on the Rights of the Child. She worked as a Consultant in Paediatric Dentistry for more than seven years at the Bon Secours Hospital in Tralee,
Co Kerry, before moving to Dublin to establish Northern Cross Dentistry for Children.

Dr Daly is a passionate advocate for children’s oral health in Ireland. She has published many articles in the media and in peer reviewed scientific journals on this topic and lectures regularly on Paediatric Dentistry. She is past chair of the Public Affairs and Public Relations Committee of the Irish Dental Association and is a scientific reviewer for the International Journal of Paediatric Dentistry and the European Archives of Paediatric Dentistry. She is also past President of the Kerry Branch of the Irish Dental Association.

References

1. Bross DC. Managing Pediatric Dental Patients: Issues Raised by the Law and Changing views of Proper Child Care. Pediatric Dentistry. 26 (2) 2004.

2. Dunne v Maternity Hospital [1989] IR 91.

3. Samanta A and Samanta J. Legal standard of care: a shift from the traditional Bolam test. (2003) (5) Clinical Medicine 443-446.

4. Finucane D, “Rationale for restoration of carious primary teeth: a review” (2012) 13 (6) European Archives of Paediatric Dentistry.

5. It is estimated that between eight to ten thousand children require admission to hospital each year for dental treatments requiring general anaesthesia in Ireland. Dentists outraged at HSE’s sudden closure of St James’s Hospital Dental Clinic, 21 October 2014 [accessed 20-5- 2015]; Moles D, Ashley P, Hospital admission for dental caries in children: England 1997-2006 (2009) 206 British Dental Journal E14.

6. Sheiham A, Dental caries affects body weight, growth and quality of life in pre-school children. (2006) 201 (1) British Dental Journal 625-6.

7. Dental Protection. Policy statements – what’s the risk? (2009) 17 Riskwise Ireland 1-2.

8. 137 Dental Council of Ireland, Professional Behaviour and Dental Ethics (s3.3).

9. Lygidakis NA, Wong F, Jälevik B, Vierrou AM,  Alaluusua S,  Espelid I. Best Clinical Practice Guidance for clinicians dealing with children presenting with Molar-Incisor-Hypomineralisation (MIH). 2010 (11) 2. European Archives of Paediatric Dentistry.

10. http://www.dentaltraumaguide.org/ [accessed 31-07-2016].

11. Kilkelly U, Savage E, “Child-Friendly Health Care” (2013) ISBN 978-1-907074-25- 7. This is a report commissioned by the Ombudsman for Children.

12. Mason J, Laurie G, Mason and McCall Smith’s Law and Medical Ethics. (9th edn, Oxford University Press).