Do Poor Children Deserve Perfect Teeth?
Bill Toner, SJ
The current debate about the availability of free orthodontic treatment for children may seem a fairly trivial issue, compared with other problems facing our society. Yet it raises serious questions about our values, our priorities and our standards. Basically the background to this issue is that throughout the western world people are setting themselves ever more exacting standards in regard to personal appearance. Due to increased resources and new medical technology, \'blemishes\' which are accepted by one generation as a fact of life become less socially acceptable. Many conditions which are often \'corrected\' nowadays (such as eye squint, birthmark and hare-lip) were not always attended to in the past. For older people who can afford them there are a whole range of cosmetic \'improvements\' available, such as \'face-lifts\', hair replacement, silicon implants in breasts and so on. Currently there is a particular focus is on teeth. It appears that today\'s image-makers have decided that straight even teeth, with no gaps, should be the norm. This new standard is probably much influenced by American television, particularly soaps like Friends and Baywatch.
The problem is that while some of the former \'blemishes\' mentioned were relatively rare, uneven teeth are very common, occurring in over 50 per cent of children. In numeric terms, uneven teeth can be said to be \'normal\'! If nothing else, the sheer cost of straightening every crooked tooth in the country forces us to ask a number of hard questions about the road we are heading down. For instance, how do we define what is \'normal\', and who defines it? Are those who are not \'normal\' discriminated against in some way? Do we reinforce social distinctions through what we define as \'normal\'? Is appearance more important than, say, personality? Is it even more important to us than health, given that, for instance an obsession with slimness is giving rise to serious health problems in many young women?
Before attempting to answer some of these questions, it may be helpful to give an outline of the dental services currently available to children here. If poor children are to have healthy teeth, orthodontic treatment is only one component in achieving this goal. Routine dental care is at least as important.
Dental Services for Children in Ireland
In Ireland, the general state of dental health among younger people is quite good by international standards. The addition of fluorine to water has dramatically reduced ordinary tooth decay, and health education has improved the standard of health care. Even in poor areas, the amount of shelf space devoted to toothbrushes, toothpaste and dental floss has steadily increased in recent years. A recent survey reveals that nowadays young people aged 16-24 have an average of 26-27 natural teeth, regardless of social class. (Note 1).
All children in national school are entitled to free oral care, and this has recently been extended to children up to 14 years of age in most secondary schools (16 years in the case of dependents of medical card holders). In practice this means either that a dentist visits the school and inspects the children\'s teeth, or appointments are made for children at the local clinic. In national school children are usually examined in second, fourth and sixth classes, and this is now being extended into secondary school as eligibility for all children is extended to 14 years of age. One hears complaints that examinations every second year are not frequent enough for children. It is true that many dentists will recommend six-monthly examinations, but it has to be remembered that they are also promoting their business interests. Privately many dentists will say that since the introduction of water fluoridation it is sufficient to have a check-up every 18 months or two years. Nowadays most infants living in areas where water is fluoridated have no tooth decay at all. Only about a quarter of five years olds in such areas have any cavities.
Particularly in poor areas, there are parents who pay less attention to their children\'s teeth than is desirable. This may be because they have many other things on their mind, such as chronic money shortage or debt, or problems with their children, and dental care is not top of their list of priorities. Appointments for clinics made in schools are not always kept. A random survey of 112 appointments made in a west Dublin clinic from local primary schools showed that 16 of them were not kept (14.2%). Follow-up calls may reduce missed appointments (known in the trade as \'DNAs\' for \'Did Not Appear\') by about half, which suggests that perhaps about 7% of children in poor areas miss at least some of their dental checks in primary school.
Health education is an important part of dental care. The Eastern Health Board has just appointed eight \'dental educators\', mainly former dental nurses, to visit schools. The biggest issue in dental care is around sugar consumption between meals. A Working Notes researcher was told that in some schools children have been encouraged to make use of baby teeth that have fallen out for an interesting experiment. The tooth is immersed in a tumbler of lemonade (or other sugary drink) and it is noted that in three or four days the tooth has turned to brown mush! Though health consciousness is not as high in working class areas as in middle class ones, it is difficult to know if working class children consume more sugar between meals than middle-class children. Middle-class children may be more likely to have parents who nag about sweet-eating, but they also have more money to spend on sweets.
There is now better hope that the good dental care provided to poorer children in school will not be undone as they grow older. The coverage of the Dental Treatment Service Scheme or DTSS (the scheme for medical card holders) has been steadily increasing. However there is still no routine treatment available for people between the ages of 34 and 65 (though people in this age group are entitled to dentures and treatment associated with them). At present people in the 34-65 age group can get dental treatment only by going through their G.P. and being referred for treatment on medical grounds; by presenting themselves as an emergency case at a clinic; or by paying for treatment privately. This age group includes many poor and vulnerable people. Many have young children and are financially very stretched.
In fact it has recently been discovered that 51% of the DTSS budget is being spent on \'emergency\' treatment, so it is possible that a large number of 34-65 years olds are getting treatment under this heading. If so, it might be simpler, and not hugely expensive, to extend the cover to this age group, which numbers 224,000.
As suggested above, the current \'hot topic\' in relation to children\'s dental health is orthodontic care. There is an orthodontic service connected with the school dental service, but it is not aimed at rectifying all \'defects\'. Orthodontic \'defects\' are noted in primary school, though the child will often have left primary school by the time treatment is carried out.
While many middle class parents can afford to have even minor \'defects\' in their children\'s teeth rectified, this is not true of working class parents, since the average cost of orthodontic treatment is £2,000. Why is it so expensive? Firstly because it may involve repeated frequent visits to the dentist, as many as fifteen visits a year for two years. Secondly, because training to be an orthodontist requires four years training on top of basic dentistry, and orthodontists are anxious to get a return on their investment. Of course there may also be the problem of an artificially restricted supply of practitioners, as occurs in many professions, so that prices are inflated.
For many years the Department of Health and Health Boards were theoretically committed to the concept of comprehensive orthodontic care. The dental profession prioritizes orthodontic care in four categories. The first category would include severe bone defects and, for instance, cleft palate. The second category includes such conditions as severe crowding of front teeth or a bad overbite. The third category includes crooked teeth, badly crowded back teeth, and large spaces between teeth. The fourth category includes mild crowding and smaller spaces between teeth. A few years ago there was a waiting list in the Eastern Health Board area of one year in respect of Category One, and seven years for Category Two. Notionally the other categories could be treated when the Category Two cases were cleared but this rarely happened. In recent years the Department of Health/Health Boards have been more effective and more honest. In the E.H.B. area there is now no waiting list for Category One, and the Category Two list is down to three years. But there is no longer any intention of treating \'defects\' in Category Three or Four. The current government policy is that if people want these \'defects\' treated they must pay for it themselves.
Behind this policy is the view, which most dentists will agree with, that orthodontics in Categories Three and Four does not fit into the medical model of health. This view sees a lot of orthodontics as purely cosmetic. In this view slightly crooked or crowded teeth may not look very well to some, but they have no medical significance. Indeed most dentists would agree that there is some degree of risk in orthodontic work, so that appearance might be approved but other damage can be done.
The problem here is, of course, that while crooked teeth may have no medical significance, they may come to have social significance. As stated above young people who have very crooked teeth are in danger of becoming \'stigmatized\' in an increasingly middle class, and increasingly polarised society. For people below a certain age, crooked teeth, like certain accents, are in danger of becoming a badge of class.
The main reason for limited scope of orthodontic treatment is lack of resources. But dentists are quick to point out that there may be other reasons for not carrying out orthodontic treatment. Basic dental work has to be in order. If teeth are decayed, orthodontic work cannot be carried out on them. Orthodontic care also needs a good deal of organisation by the family over a long period. In the EHB region the children have to visit St. James\'s Hospital every three or four weeks for up to two years to get springs tightened and to inspect progress. Dental hygiene must be maintained or there is a danger that the teeth being treated could decay Thus, if the prospects for dental care seem poor, the dentist will not recommend orthodonty. This policy, though it may be justified, in practice bears more heavily on disadvantaged children living in disorganised households. The absence of a phone or car may be an added complication. Children who avail of the ortodontic service in St James\'s Hospital are reported to be predominantly from middle-class families.
Though lack of resources is not the only issue in relation to orthodontic treatment, it is a major issue. The Department of Health, and the Health Boards, are concerned that increased orthodontic treatment will divert resources away from routine dental care which is an important component of good general health. If it is true that half the children in the state have some defects in their teeth, and the state provided free comprehensive orthodontic care for all of them, it could cost the taxpayer as much as £60m. a year for orthodonty alone (on the basis that there are about 60,000 children in any one-year age cohort and that half of them would require treatment at £2,000 a time!).
What Changes are Needed?
With regard to basic dental care, there are a few improvements that could be made in the Dental Service as resources become available.
· More resources could be made available for dental care of infants. Tooth decay in infants living in \'fluoridated\' areas is infrequent (25% of five year olds), but where it occurs it is due to incorrect diet, and particularly eating sugar between meals. If this is spotted early on it may be possible to educate parents and correct diet, avoiding further trouble down the road.
· Follow-up on the \'DNAs\' can always be improved. There is a possibility of the Health Board appointing \'facilitators\', whose job it will be to chase up children (and their parents) who miss appointments. There is already a pilot scheme in place. And while children from some schools have 100% attendance at appointments, in other schools the rate of attendance is less than 80%. It would be important, and fairly easy, to identify the schools with most \'DNA\'s\' and find out what the reasons for this are. Apart from the issue of basic dental care, some of the children who miss out have fairly severe orthodontic problems.
· Waiting lists in the Dental Treatment Service Scheme need to be constantly monitored, but the evidence is that there have been big improvements in this area. In the past, delays of six months or more for routine treatment were being reported. Currently the E.H.B. has set itself a target of 30 days for the issuing of orders related to routine treatment under the DTSS, and they are satisfied that this target is being reached at present. To this 30 days has to be added the delay in getting an appointment with the dentist, but there is no reason why this should be longer for public than for private patients. Working Notes (and the agencies) would be glad to hear of any unreasonable delays in recent times.
· Fluoridation of water in rural areas (where most of the real poverty in Ireland exists) must continue to be given priority status in public health spending. Only about 65% of national school children live in areas where water is fluoridated.
Regarding the question posed by the title above, \'Do Poor Children Deserve Perfect Teeth?\', there may be room for expansion of the scope of orthodontic care, and the Department of Health and the Health Boards should keep an open mind about this. The fact is that, increasingly, badly-formed teeth are just one more \'handicap\' that disadvantaged children carry through life, along with a \'flat\' accent and a \'poor\' address. Poor teeth will be noted in job interviews, especially where appearance is at a premium, and they also act as a \'marker\' of social class. And while there is something of an ideological battle being fought regarding the \'rightness\' or \'wrongness\' of comprehensive cosmetic orthodontic care, it would not be right if the only victims in the battle were the poorest children who know nothing about the finer points of the argument but find themselves discriminated against socially and on the job market.
Nevertheless, taking the longer view, it is wrong that as a society we should be dominated to this extent by the image-makers. Uneven teeth do not generally constitute a medical problem, and it seems entirely inappropriate that we should now begin to define them as a social problem. There is a major problem for society if it starts to invent new categories by which the most vulnerable people in society are stigmatized, made feel self-conscious and even discriminated against. There are also serious questions to be asked about a social trend that places such a premium on physical appearance, that would seem to judge the book more by the cover than by the content.
An even more serious issue is the diversion of resources that \'cosmetic\' orthodonty threatens to give rise to. There is now enormous pressure being brought on political representatives on doorsteps by articulate middle-class parents who want the state to spend several thousand pounds to straighten their children\'s\' teeth. At the same time resources to treat those in serious need of orthodontic care ( those in Categories One and Two outlined above) are quite stretched. It would also be unacceptable if large amount of public funds were to be spent on cosmetic treatment, while many unemployed people living on £65 a week are either paying for routine dental care out of their own resources or going without.
While the dental profession cannot be considered as the only engine driving the new trend towards \'designer\' teeth, they must take some of the responsibility for it. Many of them have been willing collaborators in the fudging of the line between the medical and the merely cosmetic. There is much anecdotal evidence that some dentists are \'selling\' orthodontic treatment, which is expensive and medically quite unnecessary, to parents. Given that most people go to dentists to get a \'medical\' judgment on oral problems, there is certainly scope for confusion here. At the moment dentists can probably do more than any other group in society to create a climate in which excessive attention to appearance is seen more as an eccentricity than as a legitimate cause for concern.
My thanks to Tom Giblin S.J. and Bill McKenna S.J. for helpful comments in relation to this article, and also to the health professionals and other who gave generously of their time to discuss the issue.
Note 1: D. O\'Mullane & H. Whelton. Oral Health of Irish Adults 1989-1990. Dublin: Stationery Office, 1992.