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

1. 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.

2. 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.

3. 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....

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

13. So what are some of the audit results?

14. Number of patients by region:

15. Number of visits /patients by deprivation decile.

16. Number of visits/referrals by decile ranking.

17. Numbers from fluoridated domiciles:Y: fluoridated; N: non-fluoridated; P: partially fluoridated.

18. Number of referrals from “top ten” suburbs.

19. Number of visits/patients by age/year. year. year.

20. Number of discharges by age and year.

21. Number of visits by ethnicity and year.

22. Visits by ethnicity and year.

23. Number of visits/patients by gender and year.

24. Number of visits by gender and year.

25. Number of theatre sessions dedicated for paediatric dental care, and child population <14yrs. • District Health Board Number of lists/month : Child population <14yrs • Northland 10 35,773 • Hutt 12 30,834 • Mid Central 16 32,403 • Southland (prior to amalgamation) 8 22,857 • Nelson/Marlborough 6 25,764 • Hawke’s Bay 5 34,080

26. Procedures by year.

27. 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?

28. 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.

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

30. 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.

31. 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.”

32. 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.

33. We have a strong and growing link with the University of Dundee School of Dentistry Nicola Innes and Dafydd Evans, lunch in Dundee.

35. 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.

36. 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.

37. 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.”

38. Mild fluorosis:

39. 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.

40. 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”

41. 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.

42. Acknowledgements: • Warrick Frater, COO, HBDHB • Pieter Albertyn, Information Services, HBDHB. • Wayne Blair, Charge Medical Photographer, HBDHB.

43. Thank you for your attention:

44. 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.