Sherry, A. H. and Murdoch A. E. (2006) The Treatment of Special Needs Patients in the McCall Summer Clinic at McGill University, Montreal. BDS Elective Report.
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The Treatment of Special Needs Patients in the McCall Summer Clinic at McGill University, Montreal
0209492 0206555 5390 words
Contents
Pages 3 4 5 6–7 8-9 10 - 11 12 - 13 14 - 15 16 - 18 19 - 20 21 - 23 24 25 - 26 27 Abstract Review of the Literature Introduction The McCall summer clinic Comparisons between Montreal and Glasgow Undergraduate Clinics Behaviour Management Techniques Visit to Montreal Children’s Hospital Disabilities encountered Data Collection Results Discussion Conclusion References and Reading List Acknowledgements
28 - 30
Appendix 1 - The Canadian Health System
31 - 32 33 - 34
Appendix 2 - History of Montreal Appendix 3 - Data Collection Sheet
Abstract
Introduction We attended the McCall Summer Clinic at McGill University in Montreal to observe the treatment of children with special needs. Method We used a questionnaire to record the patients’ age and disability, the treatment they underwent and how they coped with the whole process. Results The children we saw had an average DMFT score of 8. They averaged a score of 3 on the Frankl Rating and a score of on the Houpt Scale. Conclusion We were pleasantly surprised by the number of patients who were able to accept treatment under local anaesthetic but we were disappointed to see that few behaviour management techniques were used with the more difficult patients. We were also surprised by the use of restraint for uncooperative children to allow treatment to be carried out. The experience overall allowed us to gain experience working with special needs patients.
Review of the Literature
1. We were curious as to whether children with a disability have better or poorer oral health than those without. Consulting ‘The Correlation between oral health status and the severity level of disabled children’ (C. Huang et al; Journal of Disability and Oral Health, 2006), we learned from this study that the oral health of a child with a disability is associated with the severity of their condition. 2. From the same journal, in ‘Caries risk groups in children with disabilities’ by Jukka H. Meurman, it was concluded that prevention is a key factor in the treatment of disabled children but that this must be tailored to the individual’s needs. It is paramount that the medical and drug history of these children is accurately recorded. 3. As part of our elective, we recorded the presence or absence of oral mucosal disease. ‘Gingival disease in children with disabilities’ by Goran Dahllof states that there is an ‘increased risk of compromised oral health and problems related to eating, swallowing, communication, chewing and drooling.’ It also says that extractions in young patients with learning difficulties are mainly a result of periodontal disease.
Introduction
Our experience with Paediatric special needs is limited at Glasgow Dental Hospital because most cases are dealt with in specialised clinics in Yorkhill Hospital. We went to observe in the Summer Dental Clinic in Montreal General Hospital for two weeks and arranged our elective with Dr. Meyers, the head of the Dental Department of McGill University. We were not insured to provide any treatment for patients in the Summer Clinic but we were allowed to assist provided we had full Hepatitis B immunisation. We decided which aspects we wanted to look at most and used a data collection sheet to record information on the patients we saw. The clinic is available to patients of all ages and abilities but we focused on children with special needs. Our preparation involved reading up on the sorts of special needs cases we may encounter in the clinic in textbooks and journals (see appendix).
Aims and Objectives In this elective we intend to:
•
Gain experience working with special needs children in a dental clinic, of which we have limited experience in Glasgow Dental Hospital.
• • • •
Observe the behaviour management techniques used during treatment. Assist the dental students when required. Compare the McGill summer clinic to Glasgow undergraduate clinics. Collect data on the patients we saw.
The McCall Summer Clinic
The McCall Summer Clinic, held in July, is run by McGill University Faculty of Dentistry, and started 25 years ago. Canada has ten Provinces and ten dental schools, two of which are in Montreal. McGill University is English speaking and the UQAM is the French speaking University but it does not run a summer clinic. The students speak both English and French. Students who come from Montreal are generally bi-lingual but some students from other areas of Canada had to learn French since moving to Montreal. The students are from many different cultural backgrounds and some were fluent in three or four languages. This is useful in a country that attracts people of all nationalities from around the world. Until four years ago the students could chose whether or not to take part in the clinic but it is now compulsory for third year students. The clinic provides a dental service for those who do not have access to treatment in a general dental practice so their visit to the clinic can be their only dental visit in the year. Patients may be severely physically disabled, mentally disabled, elderly who are financially handicapped, and 10-18 year olds who are housed in group homes or young offenders institutions. Some patients with severe disabilities cannot be treated by students and are referred to a specialist clinic at the Children’s Hospital of Montreal or the Jewish General Hospital. Every patient has an exam, a scale and polish and usually four bitewing radiographs. New patients to the clinic complete a medical history form and sign a consent form before treatment. Each student sees four patients a day and they are responsible for sterilising instruments between each patient. Removal of decay is a priority, so some conservation work was done on their first visit. Oral surgery is performed in the last two weeks of the clinic and the last day is reserved for orthodontic treatment. There is also an outreach day in the middle of the clinic on 12th July where children from group homes were brought in. A new screening system was implemented this year and hopefully was successful in selecting the patients most suitable for treatment in the undergraduate clinic. Patients pay for their treatment in the student clinic although the cost is reduced. If they are unable to pay then they cannot receive treatment after the Summer Clinic this can be very distressing for patients who need a lot of treatment but cannot afford it.
McGill Dental School
McGillUniversity
The student records the history of the presenting complaint of the patient, and their medical, dental and drug history. They then carry out an exam were existing restorations and treatment required are recorded. The decision whether to carry out any treatment is done by combining the information obtained from the clinical examination and radiographs. If they are able to pay for future treatment then a summary of work is written, including extractions, endodontics, orthodontics, advanced conservation work and implantology. The first week of the clinic we attended was devoted to examinations and scaling. Some treatment was carried out in the second week, including the extraction of deciduous teeth and amalgam and composite fillings. Amalgam is not used routinely but it was used for high caries risk patients. The aim of the clinic is to maintain a patient’s oral health from one summer to the next and to give the students more experience so that they can gain confidence and speed in the clinic.
Differences Between the McGill Summer Clinic and Glasgow Undergraduate Clinic
Rubber Dam Placement The placement of rubber dam is compulsory at McGill before any treatment is carried out including fissure sealants. Rubber dam was placed with a clamp on children as young as four as routine. The students often did not give anaesthesia around the tooth that was being clamped and some patients found this painful. Placing rubber dam on was difficult in some cases and added considerably to the length of the treatment. It is used to control saliva and provide isolation because the students do not work with a nurse. They also do not use saliva ejectors as routine as we would do in Glasgow Dental Hospital. We do not place rubber dam routinely for most fillings and definitely not on very young patients. We use rubber dam for endodontic treatment and for certain composite fillings. Periodontal Assessment A periodontal assessment was carried out on most patients but not children. This is probably due to the uncomfortable nature of this exam and the unlikely chance that a young child would have periodontal disease. Hopefully any childhood periodontitis would be detected in radiographs or other clinical findings. In McGill University they use the ‘Periodontal Screening Record’ system rather than the ‘Community Periodontal Index of Treatment Need’. The system is very similar to ours in that a grid with six squares is drawn and a score is allocated to each sextant according to the pocket depth and whether there is any bleeding on probing. Four-Handed Dentistry and Two-Handed Dentistry The students do not have help from a nurse during their undergraduate training. They do everything for themselves and essentially carry out two-handed dentistry. This meant that they had to use saliva ejectors when using the cavitron and had to have rubber dam in place to use a high-speed hand piece. They found it hard to have us assist them as they were not used to it. On the other hand, we are trained to practice four-handed dentistry and also spend a lot of time working by ourselves because nurses are not always available to assist us.
Scaling/OHI
A notable difference between how poor oral hygiene is dealt with in the two dental hospitals is that every student in the McCall clinic used the cavitron on every patient to remove plaque and calculus. They often applied a disclosing solution to show up the plaque deposits more clearly. In the Glasgow Dental Hospital we are taught to use the cavitron to remove gross supragingival calculus and then to use hand scalers for smaller deposits and subgingival calculus, because this gives more control. The students gave a toothbrush to most of the patients they saw but they rarely spent time discussing oral hygiene methods or interdental cleaning aids. Some children who were at high risk of developing caries had a high concentration of fluoride varnish applied to their teeth as we would do but most students didn’t discuss other forms of fluoride delivery with the patient or their parent or guardian. This is a very important method of preventing dental decay in young handicapped patients who have poor oral hygiene.
Preventive Resin Restorations and Fissure Sealants
We noticed that the students at McGill were very keen to fissure seal all teeth as their patients were high risk while we fissure seal mostly first and second molars on eruption. They placed lots of PRRs on sound teeth with deep fissures while in Glasgow Dental Hospital, we tend to monitor the occlusal surface clinically and take radiographs every six months for evidence of early decay. They achieved isolation by using rubber dam but some children patients had learning difficulties or physical disabilities which made isolation very hard as rubber dam could not be placed and reduced the success rate of the sealant.
White Fillings and Amalgam Restorations
Most of the students we spoke to had very little clinical experience of using amalgam both in phantom head and with patients. They are taught to use a composite material in posterior teeth which is similar to the Z100 used in Glasgow Dental Hospital while we would routinely place amalgams. Although composite is more technique sensitive than amalgam and there is the potential hazard of microleakage and staining, the clinicians in Montreal feel that the benefits of the superior aesthetics of white filling make it preferable to amalagam. It is bonded, placed, cured and finished using techniques similar to ours in Glasgow.
Local Anaesthesia
Lignocaine with 1:100,000 adrenaline was used routinely in the Montreal General dental clinic. The students tend to use a smaller volume of local anaesthetic than we would in Glasgow. The cartridges they were supplied with contained 1.8ml solution, while in Scotland the cartridges are of 2.2ml of solution. For most patients, except young children, there would be few situations in Glasgow where it would be advisable to administer less than a full cartridge of local anaesthetic before either an extraction or removal of decay. The students in the summer clinic frequently gave half of a 1.8ml a cartridge for a routine filling in an adult tooth and administered more anaesthetic as it was needed, according to the patient’s response to the treatment. This has the benefit of limiting the volume of anaesthetic that needs to be given so that the risk of injecting a toxic dose is minimised. However, the patient may lose confidence in their dentist if they experience pain and have a phobia of needles.
Behaviour Management
We were very interested to find that very few behaviour management techniques were used in Canada when treating children. Usually the child was not helped to accept treatment but was actively restrained instead. The children who were unable to understand or accept the treatment required due to their disability were normally referred for GA. We would often employ a number of techniques before a GA referral and we would certainly not restrain a child for treatment. The methods listed below used in Glasgow for children should be combined with good verbal and non-verbal communication. 1. Positive Reinforcement: The presentation of a stimulus that will increase the likelihood of a behaviour being repeated. E.g. verbal praise or stickers
2. Tell, Show, Do: This familiarises a patient with a new procedure before it is carried out. It employs an age appropriate explanation of the technique, a demonstration of the procedure in a non-threatening manner and the treatment is carried out with minimal delay.
3. Acclimatisation: The planned sequential introduction of the dental environment, people, instruments and procedures to the child. 4. Systematic Desensitisation: This is based on the assumption that repeated non-distressing exposure to an anxiety-provoking stimulus will result in the reduction of anxiety. 5. Voice Control: The controlled alteration of voice volume, tone or pace to influence and direct the patient’s behaviour. 6. Distraction: The technique of diverting the patient’s attention away from what may be perceived as a distressing procedure, e.g. telling a story when administering local anaesthesia. 7. Role Modelling: This uses the fact that children learn much about their environment from observing the consequences of other people’s behaviour. A child of similar age who is having similar treatment is best.
The Montreal Children’s Hospital
The Children’s Hospital of Montreal has a dental clinic for children with complex medical histories, disabilities and for those who will not accept treatment in a general dental practice. The clinic is in a separate building from the main children’s hospital and it resembles a house which is comforting for children who spend a lot of time in hospitals. The waiting room and treatment rooms were spacious and brightly coloured, creating a light, child-friendly atmosphere. The new residents started in the clinic on 1st July, so they were still settling in when we spent the day with them. They have their own room and dental nurse. Each appointment is an hour long and the child’s parents stay in the room during treatment. Most of the children strongly resisted dental treatment because they were extremely anxious or phobic. Most children we saw that day would score 1 or 2 on the Frankl rating and either 1,2 or 3 on the Houpt behaviour rating. Young children who were very distressed and refused to be treated were often physically restrained by the dental nurse, with the help of the child’s mother. There is little or no acclimatisation for the children. The residents aim to treat the children with local anaesthesia whenever possible, whether or not it results in an overall bad experience for the child. During injections and treatment the child would try to pull away, wriggle, kick their legs or cry and try to resist have a needle or a drill in their mouth. To prevent injury to the child or the dentist, the dental nurse would put an arm over the children’s arms and chest or hold their hands gently while the mum or dad held their legs. The children usually calmed down once the injection was over and some were able to have treatment with some coaxing but most would not accept treatment without being restrained. Some were frightened of the noise of the drill and a few had problems with the effectiveness of the anaesthesia. In such cases the Consultant Paediatric dentist would take over treatment. While active restraint was used we did not witness any use of the HOMAR technique (hand over mouth, with active restraint). The situation was distressing to watch so it was undoubtedly more so for the children and may leave them with a negative attitude to dental treatment. Two cases that we witnessed involved a young boy of about 7 years old and a young girl of about 9 years old. Neither child had a physical disability but both had attended the Children’s Hospital before. The young boy had visible swelling of the left side of his face and his mother informed the resident that he had been in a lot of pain which had stopped him eating and sleeping. The boy looked quite unwell and it was decided that the tooth needed to be extracted to drain the abscess around the 64.
Unfortunately the infection meant that the anaesthetic was ineffective so that once the resident began to extract the tooth the pain returned and the child got very distressed and would not let them continue without restraint. The resident eventually extracted the tooth and a lot of pus was released. In this case the treatment was needed immediately, so restraint was necessary. The young girl came in for her first appointment and a treatment plan was made after bitewings were taken. She needed a pulpotomy on her 54 and a mesial Class II on her 55, to be carried out that day. She was in pain throughout the treatment and strongly resisted, so she had to be physically restrained. She became more distressed and uncooperative as the treatment progressed, so the consultant completed the procedure and the situation was distressing for all involved. The Canadian approach to paediatric dentistry is very different to ours in Scotland. There are many methods of acclimatisation which can help children to accept dental treatment. The use of physical restraint may be unpleasant for the child but it does ensure that immediate treatment is completed relatively safely under local anaesthetic and it avoids the use of general anaesthesia or sedation which has medical risks associated with it.
The Children’s Hospital, Montreal The Children’sDental Hospital
Disabilities Encountered
The McCall summer clinic introduced us to some forms of disability that we hadn’t come across, so we researched these conditions to give us a better understanding of how the disability affects the lives of patients and their treatment. Attention Deficit Hyperactivity Disorder ADHD is an incurable neurological disorder. It is usually diagnosed in childhood, but 60% of sufferers retain traits of the disorder into adult life. It is estimated to affect 5% 8% of children in the USA. Symptoms include inattention, failure to follow instructions, mood swings, restlessness and forgetfulness. ADHD is treated with a combination of psychotherapy and medication to control behaviour. Treatment of these children can be very difficult because they cannot usually tolerate sitting in the dental chair for long and are usually uncooperative. Friedreich’s Ataxia This form of ataxia is a genetic disease which is autosomal recessive and affects both sexes. The first symptoms appear between 5 and 15 years of age. This slowly progressive disturbance of the nervous system causes weakness of the limbs, slurred speech, loss of coordination and impaired vision and hearing. However, the individual’s intellectual ability is not affected. The patient who attended the clinic with this disease was confined to a wheelchair and could not communicate verbally with the dental student.
Autism Autism is a neurodevelopmental disorder which manifests itself by three years of age. It is three to four times more common in boys than girls. The child displays abnormal behaviour patterns, is unable to interact socially, and has poor communication skills. Autism is a spectrum disorder which is associated with Asperger’s syndrome. Autistic individuals are unable to regulate their behaviour and are prone to verbal outbursts, violence and crying. Most prefer a set daily routine and can become very upset if this is disrupted. The autistic children we saw were upset by their surroundings and had a poor understanding of the student’s intentions. refused to be treated. One adolescent we saw
Dysphasia This is the impairment of speech and inability to comprehend language. It is caused by damage to the left hand side of the brain where the language centres are situated. Damage to the frontal lobe causes Broca’s dysphasia where the individual can understand what is being said to them but they have difficulty forming complete sentences. Damage to the temporal lobe causes Wernicke’s dysphasia where the individual can form sentences that have little meaning and they have difficulty in aural comprehension. Children we saw with this impairment had to have a relative with them to facilitate communication between them and the dental student. Encephalopathy This altered brain structure and function can be caused by a tumour, infection (e.g. bacterial or viral meningitis), increased intracranial pressure, lack of blood flow to the brain or poor nutrition. Symptoms include memory loss, lack of concentration, lethargy, seizures, muscle atrophy and weakness, and impaired cognitive ability. The treatment of these patients was not affected in terms of behaviour management, but their dentist must know how what to do if the patient was to have a seizure in the dental surgery.
Data Collection
The data collection sheets (Appendix 3) were used for every patient under eighteen years of age who had a disability. The sheets were designed to be filled in quickly, by simply circling yes or no, rating systems or answers of a few words, using information from the patient’s notes. We recorded the patient’s date of birth but not their name or address in order to ensure anonymity. We then classified the nature of the patient’s disability under different headings. • Learning - Variety of disorders including hyperactivity, dyslexia and hearing problems that interfere with the ability to learn. • Physical - Any condition confining the individual to a wheelchair or limits mobility. • • Sensory - Deaf, blind and/or dumb. Mental - Any impairment, retardation, degenerative or developmental condition resulting in subnormal intellectual development. • • Financial - Patients who cannot otherwise afford routine dental care. Other - Details of any condition that cannot be included in the above categories. We then recorded whether the patient had previously attended the Clinic. Many patients visit sporadically over the years. For others, the clinic is the only place they get regular professional dental attention. It is important to try to keep the young patients free from disease from one year to the next. We noted whether patients visited their own GDP. This may indicate whether the patient is likely to have poor oral health. If they are not registered with their own dentist, then the student may treat existing decay to prevent any dental pain arising between annual visits to the Clinic.
We recorded whether the patient themselves or their parent/carer was mainly responsible for oral hygiene maintenance. This gave an insight into the possible reasons behind poor plaque control and dental decay. The intra oral findings were recorded in the form of a table to chart the DMFT. The chart is set out with the 32 teeth of an adult mouth, divided into quadrants. If a primary tooth was present rather than a permanent tooth, this was written on the chart i.e. 56, 66, 76, 86. Whether the teeth were present, absent (unerupted, extracted or congenitally absent), filled or decayed was recorded. The presence or absence of any oral mucosal disease was noted and the nature of the disease was described, although most of the young patients rarely had anything other than gingivitis. Treatment completed and required was recorded as follows: • • • • • • Examination Scale & Polish Restorations (number) Extraction (number) Root Canal Treatment Surgical procedure
The type of radiographs taken were noted - bitewings, periapicals or oral pantamographs. The students always took bitewings if possible, sometimes before they had done an intra oral examination. The students didn’t ask their patients whether they had had any dental radiographs in the last year or not. On the orientation day, emphasis was placed on the fact that these children would not have access to regular dental care, so the students took the opportunity to thoroughly investigate the dentition for evidence of early decay. Clinical assistants were responsible for developing the x-rays. They favoured the bisecting angle technique, using bitewing films with adhesive tabs and collimators were not used. This increases the area of facial tissues exposed to radiation but it reduces the chance that the teeth in the region of interest will be missed from the film if the patient does not stay completely still. The Frankl Behaviour Rating, devised by Victor Frankl, gives an explanation of how each child behaved during dental treatment. As we observed the student and their patient, the lowest applicable value was circled.
1 - Distress/crying/refusal to accept treatment/fearful 2 - Unco-operative,/reluctant to accept treatment/negative attitude 3 - Positive attitiude/acceptance of treatment/reserved/willing to comply 4 - Interested/enjoyed/good rapport with dentist The Houpt Behaviour Rating indicated how good or bad behaviour on behalf of the patient influenced the success of treatment. 1 - Aborted, no treatment possible 2 - Poor, treatment interrupted, only partial treatment completed. 3 - Fair, treatment interrupted but eventually completed 4 - Good, difficult but all treatment completed 5 - Very good, some limited crying or movement 6 - Excellent, no crying or movement
Results
Age Range of Patients Number of Patients
Form s of Disability Number of Patients 10 8 6 4 2 0 Learning Physical Sensory Mental Financial Other Disability
10 8 6 4 2 0 9 10 11 12 13 14 15 16 17 18 Ages of Patients
Proportion of Patients w ith Previous Experience of Program
Proportion of Patients Receiving Regular Dental Care
33%
Patients w ho received previous treatment on program 67% Patients w ho have not received previous treatment on program
37% 63%
Patients receiving regular dental care
Patients not receiving regular dental care
Prim ary Provider of Oral Hygeine Maintenance
Number of Patients 8 6 4 2 0 1 2 3 4 5
DMFT Scores
20% Self Carer 80%
6
7
8 DMFT
9 10 11 12 13 14 15
Proportion of Patients w ith oral m ucosal dise ase
Number of Patients 10 8 6 4 2 0
Form of Oral Mucosal Disease
37% 63%
Oral mucosal disease present
Oral mucosal disease not present
ginivgitis
gingival hyperplasia Form of disease
Ulcer on left pharynx
Treatment Required by Patients
Number of Patients
Radiographic V ie w s
Examination
50 40 30 20 10 0
3%
10%
PA
Restorations
Extractions
Root canal treatment
Scale & Polish
Surgical procedure
BWs
OPT
87%
Treatm ent
Frankl Behaviour Rating
Houpt Behaviour Rating
Number of Patients
12 10 8 6 4 2 0 1 2 3 4 Rating (1-4)
Number of Patients
10 8 6 4 2 0 1 2 3 4 5 6 Rating (1-6)
Discussion
Patient Ages We saw patients in the clinic ranging from age 9 to 18. Most children under 10 were seen at the Children’s Hospital. 27% of patients were 16. This may be because children came in large groups from young offenders institutions or children’s homes and were largely in their late teens. The majority of patients were teenagers (77%). A parent or guardian accompanied all child patients. Disabilities Mental disabilities such as autism or encephalopathy accounted for 27% of the children who attended the clinic. Learning disabilities such as ADHD were the next most common (23%). Physical disabilities such as quadraplegia and Friedreich’s ataxia were less common (13%). 3% had a hearing impairment and fell into the category of sensory disablement. 7% were financially disadvantaged, but in reality, the majority of patients in the clinic came because they could not afford treatment at a general dental practice. The ‘other’ category covered 27% of young patients. These were individuals who could not be put into any other category eg severe asthma or Hirschprung’s (bowel) disease. Previous Treatment Two thirds of the patients had been to the summer clinic before, indicating that the child and their parents were satisfied with the standard of treatment provided and were not frightened to return. One third of patients were new to the program. Regular Dental Care Of all the children attending the clinic, 63% were not receiving regular dental care. The 37% who did receive dental care elsewhere attended another community dental service or they were referred by their own dentist because they were highly anxious. Provision of Oral Hygeine Maintenance Of the young handicapped patients we saw, 80% were responsible for their own oral hygiene. 20% of patients relied on their parent or carer for oral hygiene maintenance because the nature of their disability meant that they lacked the dexterity to brush their own teeth.
DMFT Scores
A DMFT of 8 accounted for 23% of the children with special needs in the clinic. of children had a score of 4 and 17% had a score of 9. The highest DMFT we recorded was 15 and the lowest was 1. The majority of children and adolescents had no fully erupted third molars, so this was counted as four missing teeth in most cases. One of the drawbacks of the DMFT system is that the stage of a patient’s dentition can suggest that their dental health is worse than it really is. The mean DMFT for this group of children was 8. The mean DMFT of five year olds in Greater Glasgow as recorded by SHBDEP in their study in 1999-2000 was 3.51. The group of children in the clinic in Montreal had a much higher DMFT. This is not a fair comparison due to the age difference between the two studies but it did give us a comparison between the two cities. The reason for the higher score in the Canadian children could be due to medical problems, lack of parental care or the fact that they came from a deprived area of the city. Oral Mucosal Disease Only 37% of the children showed clinical evidence of oral mucosal disease. Nine of these children had gingivitis due to poor oral hygiene. One child who wore a fixed brace had gingival hyperplasia in response to poor plaque control. One child had an ulcer on their left pharyngeal wall. Treatment Required Every patient was given an examination on their initial visit. A full mouth scale and polish was carried out on 70% of the children. Those who did not receive a scaling would not tolerate having a cavitron or hand instruments in their mouth. During our two weeks, there was a total of 41 restorations which were either planned for future treatment or that we were able to assist the students with. Two children had deciduous teeth extracted because they urgently needed to be taken out. One child needed a root canal treatment at a later appointment. None of the children required a surgical procedure and one child was referred for orthodontic treatment. Radiographs 87% of patients were sent for bitewing radiographs. Periapicals were taken to look at anterior teeth which had experienced trauma in 10% of the children. Only 3% had an oral pantamograph taken as part of an orthodontic assessment. 20%
Frankl Behaviour Rating None of the patients we saw scored 4 in this rating system because every child was withdrawn to some degree due to being in an unfamiliar environment or because they couldn’t understand what was going to happen. 33% were given a rating of 3 during treatment and their behaviour was generally positive. 23% scored a Frankl rating of 2 because they were uncooperative and reluctant to have treatment. Only 10% of patients were given a rating of one. These were the children who were the most fearful and strongly resisted treatment. We were surprised at these results because we had anticipated that most handicapped children would be highly uncooperative but this was not the case.
Houpt Behaviour Rating In our results 10% of the children had treatment stopped completely because of anxiety. 20% allowed partial treatment to be carried out, although their behaviour interrupted it. 27% interrupted treatment but permitted it to be completed and were allocated a score of 3. 17% of the patients were distressed by the procedure but they allowed it to be completed without a lot of difficulty. For 10% of the patients, treatment went well and there was little crying. For 20%, of the patients, treatment was easily completed and behaviour was excellent. We had thought that treatment would be far more difficult and that a number of children would require sedation or general anaesthesia but they allowed treatment to be completed under local anaesthetic.
Conclusion
The elective gave us a fantastic opportunity to observe how paediatric dentistry for special needs patients is carried out in another country. The health system in Canada appears to fail the poorest in the community who cannot afford dental treatment. With NHS dental services struggling to cope with the demand from patients in Scotland, the group of people who no longer have access to affordable dental care is growing. We hope the methods employed to stop this trend will work effectively, as everybody should be entitled to government funded dental care. Our results cannot reflect the dental health of Montreal or Canada as a whole but gives an insight into the oral health of special needs patients. Our experience highlighted the similarities and differences between the treatment techniques in Canada and Scotland. The most startling difference was the use of restraint when treating children and its widespread acceptance by the population and also the absence of behaviour management strategies. We were impressed by how well the McGill students coped with handicapped patients of all ages. By the time we left, we felt we would be better equipped to deal with young patients with special needs. These experiences are invaluable as a dental student and may be beneficial in the undergraduate course.
McGill Dental Students in the Summer Clinic
Montreal General Hospital
References
Wikipedia - Montreal en.wikipedia.org/wiki/Montreal Accessed Sept 2006 Wikipedia - Health Care System in Canada en.wikipedia.org/wiki/Health Care in Canada Accessed Sept 2006 Wikipedia - McGill University en.wikipedia.org/wiki/McGill University Accessed Sept 2006 Wikipedia - Spina Bifida en.wikipedia.org/wiki/Spina_bifida Accessed Sept 2006 Wikipedia - ADHD en.wikipedia.org/wiki/ADHD Accessed Sept 2006 Wikipedia - Autism en.wikipedia.org/wiki/Autism Accessed Sept 2006 Wikipedia - Dysphasia en.wikipedia.org/wiki/Dysphasia Accessed Sept 2006 Wikipedia - Encephalopathy en.wikipedia.org/wiki/Encephalopathy Accessed Sept 2006 Fact Sheet - Friedreich’s Ataxia www.mda.org.au/specific/mdafa.html Accessed Aug 2006
National Institute of Mental Health www.nimh.nih.gov/publicat/autism.cfm Accessed Aug 2006 Scottish Health Board’s Dental Epidemiological Programme (SHBDEP) www.dundee.ac.uk/dhsru/publications/shbdep99 Accessed Sept 2006 A Comparative Clinical Audit of a Dental Service for Disabled Adolescents in Montreal, Canada and Glasgow, Scotland. A. Keightley & D. McSporran 2005 (previous elective) Accessed June 2006
Reading List
‘How do children with ADHD interact in a clinical dental examination?’ European Journal of Oral Science 2005 June; 113(3): 203-9 Blomqvist M, Augustsson M, et al ‘A retropective study of dental behaviour management problems in children with attention and learning problems’ European Journal of Oral Science 2005 Apr; 113(2):184 Journal of Disability and Oral Health 2006 ‘The correlation between oral health status and the severity level of disabled children’ C.Huang et al ‘Caries risk groups in children with disabilities’ Jukka H. Meurman ‘Gingival disease in children with disabilities’ Goran Dallhof
Acknowledgements
We would like to thank: Dr Jeffrey Myers Miss Romantha Descartes (Summer Clinic Co-ordinator) The third year dental students at McGill Univesity The assistants and teaching staff at McGill University The residents and consultants at Montreal Children’s Hospital
Appendix 1 -The Health Care System in Canada
Canada's health care system is generally considered one of the world's best, placed in the top ten in most measures of quality. Despite this it does have several problems that are major political issues in Canada. Canada is seen as a country with a publicly-funded health care system, with the government paying about 70% of health care costs. Canada is unusual in that the government pays for almost 100% of hospital and physician care, but contributes very little in areas such as prescription drug costs and dental treatment. The first organized health care in Canada was a series of hospitals set up by Catholic religious orders in New France. Religiously run hospitals were the norm up to the early twentieth century and they were generally for the poor and would only receive essential care. Wealthier citizens would be cared for in their homes by expensive doctors. In the late nineteenth century a movement began that called for the improved health care for the poor, focusing mainly on sanitation and hygiene, which up until this period had been of very poor standards. This period saw important advances including the provision of safe drinking water to most of the population, public baths and beaches, and waste removal services in the city. The early twentieth century saw the first widespread construction of government run hospitals, mainly asylums for the mentally ill and sanitariums for those suffering from tuberculosis. Calls for increased government involvement also became common, and the idea of a national health insurance system had considerable popularity. William Lyon Mackenzie King promised to introduce such a scheme, but while he created the Department of Health he failed to introduce a national program. During the Great Depression calls for a public health system were widespread. Doctors who had long feared such an idea reconsidered hoping a government system could provide some stability as the depression had badly affected the medical community. However, governments had little money to enact the idea. In 1935, the United Farmers of Alberta passed a bill creating a provincial insurance program, but they lost office later that year and the Social Credit Party scrapped the plan due to the financial situation in the province. The next year a health insurance bill was passed in British Columbia, but its implementation was halted over objections from doctors. It was not until 1946 that the first Canadian province introduced near universal health coverage. Saskatchewan had long suffered a shortage of doctors, leading to the creation of municipal doctor programs in the early twentieth century in which a town would subsidize a doctor to practice there. Communities joined to open union hospitals under a similar model. There had thus been a long history of government involvement in Saskatchewan health care, and a significant section of it was already controlled and paid for by the government. In 1946, Tommy Douglas' Co-operative Commonwealth Federation government in Saskatchewan passed the Saskatchewan Hospitalization Act, which guaranteed free hospital care for much of the population. Douglas had hoped to provide universal health care, but the province did not have the money. In 1949, British Columbia created a program similar to Saskatchewan's. Alberta however created Medical Services (Alberta) Incorporated (MS(A)I) in 1948 to provide prepaid health services. This scheme eventually provided medical coverage to over 90% of the population. In 1957, the federal government passed the Hospital Insurance and Diagnostic Services Act to fund 50% of the cost of such programs for any provincial
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government
that
adopted
them.
The
HIDS
Act
outlined
five
conditions,
public
administration,
comprehensiveness, universality, portability, and accessibility. These remain the pillars of the Canada Health Act. By 1961, all ten provinces had agreed to start HIDS Act provinces. In Saskatchewan, the act meant that half of their current program would now be paid for by the federal government. Premier Woodrow Lloyd decided to use this freed money to extend the health coverage to also include physicians. Over the sharp disagreement of the Saskatchewan College of Physicians and Surgeons, Lloyd introduced the law in 1962. The Saskatchewan program proved a success and the federal government of Lester B. Pearson, pressured by the New Democratic Party who held the balance of power, introduced the Medical Care Act in 1966 that extended the HIDS Act cost-sharing to allow each province to establish a universal health care plan. It also set up the Medicare system. In 1984, the Canada Health Act was passed, which prohibited user fees and extra billing by doctors. The various levels of government pay for about 70% of Canadians' health care, although this number has decreased somewhat in recent years. By far the largest government health program is Medicare. Almost all government health spending goes through Medicare. The federal government directly administers health to groups such as the military, and inmates of federal prisons and some care to the Royal Canadian Mounted Police and veterans, but these groups mostly use the public system. The largest group the federal government is directly responsible for is First Nations. Native peoples are a federal responsibility and the federal government guarantees complete coverage of their health needs. For the most part First Nations people use the normal hospitals and the federal government then fully compensates the provincial government for the expense. The federal government maintains a network of clinics and health centre’s on Native Reserves. In 1996 a large budget shortfall caused the merger of health transfers with transfers for other social programs into the Canada Health and Social Transfer and overall funding levels were cut. This placed considerable pressure on the provinces, and combined with population ageing and the generally high rate of inflation in health costs has resulted in problems with the system. In Canada the private sector has always been the frontline in healthcare. Canadian doctors operate for profit businesses and are the primary gatekeepers to the whole healthcare system. The doctors also have no controls placed on them by the primary payer for services, the government, and they are therefore in a position to easily recommend more visits and are guaranteed payment by the government. About 30% of Canadians' health care is paid for through the private sector. This mostly goes towards services not covered or only partially covered by Medicare such as prescription drugs, dentistry and optometry. Many Canadians have private health insurance, often through their employers, that cover these expenses. There are also large private entities that can buy priority access to medical services in Canada. Increasingly, there are private clinics that offer some of the same services as the public system such as hip replacements and MRI scans which are perfectly legal. Selling private health insurance that could cover these procedures, however, is not legal, making these services too expensive for most Canadians. In June 2005, the Supreme Court of Canada ruled these laws unconstitutional, potentially opening the door to much more private sector participation in the health system. The Quebec and federal governments asked the high court to suspend its ruling for 18 months. Less than two months after its initial ruling, the court agreed to suspend its decision for 12 months, retroactive to 9th June 2005. This meant that there would be no change to the status quo. As a result of delays in receiving tests and
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surgeries, patients have suffered and even died in some cases which is a great tragedy. The Canadian system is for the most part publicly funded, yet most of the services are provided by private enterprises and private corporations. Most doctors do not receive an annual salary but receive a fee per visit or service. As Dentistry is not covered by Government funding then a lot of Canadian’s cannot afford treatment and for this reason the McCall Summer was set up to provide a basic service for those most in need of care. Canadian Health Care Compared to the G7 Countries Provided by the WHO This table was found at http://www3.who.int
Per capita Life Country expect a-ncy Infant mortality rate expenditure health (USD) on
% Healthcare costs as GDP % of government revenue spent health
of
% health
of
% health
of
costs paid by on government
costs paid by private sector
Australia
80
5.6
1,741
9.2
16.8
67.9
32.1
Canada France
79.3 79.3
5.6 5.7
2,163 2,109
9.5 9.6
16.2 13.7
70.8 76
29.2 24
Germany Japan UK USA
78.2 81.4 77.5 77
5.2 4.1 5.9 6.4
2,412 2,627 1,835 4,887
10.8 8 7.6 13.9
16.6 16.4 15.4 17.6
74.9 77.9 82.2 44.4
25.1 22.1 17.8 55.6
These figures include figures for dentistry, optometry and drugs.
Appendix 2 - History of Montreal
Jacques Cartier became the first European to reach Montreal in 1535 when he entered the village of Hochelega while in search of gold. Seventy years later, Samuel de Champlain unsuccessfully tried to create a fur trading post but local Iroquois defended their land. Ville Marie, the first permanent European settlement was established in 1639 on the Island of Montreal. Jeanne Mance founded the Hôtel-Dieu, the first hospital in North America, in 1644. Montreal became a centre for the fur trade and French expansion into New France until 1760, when it surrendered to the British army, following the Battle of the Plains of Abraham. British immigration expanded the city once under British rule and began the city's golden era of fur trading.
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Montreal was incorporated as a city in 1832. The population was mainly Francophone until 1830 and then became Anglophone. The city's growth was spurred by the opening of the Lachine Canal and Montreal was the capital of the United Province of Canada from 1844 to 1849. Growth continued and by 1860 Montreal was the largest city in British North America and the undisputed economic and cultural centre of Canada but by 1918 Montreal was a Francophone city again. During the 1920s and 1930s the Prohibition movement in the United States turned Montreal into a haven for Americans looking for alcohol, gambling and prostitution. This helped to fuel the Jazz Culture in the City and it now hosts one of the largest international Jazz Festivals in the world every summer. As with the rest of the world, the Great Depression brought unemployment to the city but this waned in the mid 1930s and skyscrapers began to be built. World War II brought protests against conscription and caused the Conscription Crisis of 1944. Montreal's populations surpassed one million in the early 1950s. A new metro system was added, Montreal's harbour was expanded and the St. Lawrence Seaway was opened during this time. Its international status was cemented by Expo '67 and the 1976 Summer Olympics.
The Oratoire St Joseph
View from Mount Royal Park
The Scottish and Montreal From the early 18th century Scottish immigrants made up only a small percentage of Montreal's population but they had an impact on the city far beyond their numbers. They were instrumental in building the Lachine Canal that turned the city into one of the most important and prosperous ports in North America. They constructed Montreal's first bridge across the Saint Lawrence River and founded many of the city's great industries, including Morgan's, the first department store in Canada, the Bank of Montreal, , and both of Canada's national railroads. The city boomed as railways were built to New England, Toronto, and the west, and factories were established along the Lachine Canal. The Scottish established and funded numerous Montreal institutions such as McGill University, the Literary and Historical Society of Quebec and the Royal Victoria Hospital. James McGill, the founder of McGill University, was originally from Glasgow.
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Appendix 3 - Data Collection Sheet
Patient Age: ___ DOB (DD/MM/YY): ___/___/___ Disability Learning Physical Sensory Mental Financial Other Please specify: ___________________ Has patient had previous treatment on program? Y / N Does patient receive regular dental care? Y / N Primary provider of oral hygiene maintenance: Self /Carer DMFT a = Present r = Missing F = Filled D = Decayed 8765432112345678 8765432112345678 Oral Mucosal Disease? Y / N If yes, please specify: ___________________ Treatment: Examination Scale & Polish Restorations Number: ___ Extractions Number: ___ Root Canal Treatment Surgical Procedure Were radiographs required? Y / N If yes, views: BWs PA OPT Other Frankl Behaviour Rating – During Treatment (circle lowest applicable value) 1 Refusal / distress 2 Unco-operative / reluctant 3 Co-operative / reserved 4 Interested / enjoyed Houpt Behaviour Rating – Outcome of Treatment (circle lowest applicable value) 1 Aborted, no treatment rendered 2 Poor, treatment interrupted, only partial treatment completed 3 Fair, treatment interrupted but eventually completed 4 Good, difficult but all treatment was completed 5 Very Good, some limited crying or movement 6 Excellent, no crying or movement
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