Dr Myria Akhtar details how GDPs can manage paediatric patients who are waiting for an assessment by hospital and community services.
COVID-19 has had an impact on the dental care of children. Following stopping dental general aesthetic (GA) and routine appointments, the waiting list for GA and sedation have increased.
This means that managing existing patients on the waiting lists and urgent new referral has become a challenge to say the least. As a general dental practitioner (GDP) you must see this everyday where patients can be waiting months for their procedures.
This is why triaging paediatric patients is the key to reducing the waiting times and making paediatric dentistry more efficient. Children with asymptomatic caries in the primary dentition should be managed within the practice and referrals for this are likely to be rejected by specialised and specialist services, unless you have a local undergraduate facility needing patients.
How to write an effective referral for hospital/community dental services triage
Before any referral is sent always try the procedure with the child. This is very important as many referrals for sedation/GA can be avoided. Utilising a dental therapist in practice could aid with the assistance of paediatric patients as they are trained highly is treating deciduous dentition.
Questions that can aid in the triage of the referral you make are as follows:
- Did the child sit in the dental chair?
- Did they let you examine them?
- Their fear or nervousness insight
- Are they actually anxious or just pre co-operative ie very young and inexperienced
- Were you able to give local anaesthetic or even attempt?
- Always try to take a radiograph and send it with the referral
- Is the child in any pain?
- Can the child eat as normal? Or is it painful to eat? Can they sleep?
- Has the child been referred by a colleague either within the practice or by another practice? Multiple referrals do not get patients seen quicker… they just make patients wait longer due to multiple appointments with different providers.
Ensure you provide the comprehensive information above in your referral to prevent delays. Of course, there will be times where you cannot assess the child at all and providing this information is equally valuable.
If a referral has been made the next step for the GDP is to manage the child whilst they are waiting. Seeing the child for regular dental checks as per the NICE guidelines. Remember, the child will ultimately be discharged back to your care and it is your responsibility to support the child while they are waiting for assessment.
The most important aspect of this is to inform parents whilst they are on the waiting lists that if any pain occurs then to arrange an appointment with practice immediately. Any changes in the clinical situation can then be highlighted to the hospital or community dental service and thus may alter the original triage decision
GDP management of parent expectation
- Making patients aware of the exact waiting time. If you are not sure as a practice gather the information from your local dental hospital or community dental settings
- Make parents/legal guardians aware their first referral appointment will not be treatment but an assessment
- Ensure you tell the parent or legal guardian that they must attend the appointment otherwise decisions cannot be made. Many a grandparent, step parent or sibling gets angry because they have not been given this information by the practice
- Explain to the parent and guardian that they cannot miss the appointments. Parents/guardians should be advised to cancel an appointment if not convenient as wasted appointments increase waiting times for all patients. Advise parents that multiple missed appointments will be investigated and followed up, as this could be an indication of dental neglect or other safeguarding concerns; this communication is key. Should the child not be taken for assessment the practice may be contacted to arrange investigation and follow up. Practices must have a ‘Was not brought’ policy that will support practice staff in undertaking this responsibility.
Ways to manage the patient
At the review or recall appointment, the first thing to assess is if the child is in pain. For example, a child may have broken down teeth with multiple sinuses draining, however they might not be in pain at all. Or a child might have multiple cavities but no pain or discomfort.
In these situations, continue to monitor the child and check to make sure the parent has not missed the assessment appointment. Continue providing preventative advice as below.
Preventative advice: oral hygiene and fluoride
A common problem that is seen is a parent providing the wrong concentration of fluoride toothpaste for a child. A child who is at risk of dental decay should use a toothpaste with a concentration of 1,300- 1,500ppm fluoride 1,500ppm. Most 6+ toothpastes do contain this level of fluoride, so the child may not need to change to an adult toothpaste and can stay with the preferred flavour.
In children over 10 years old who are at risk of caries, a dentist should consider prescribing 2800ppm fluoride toothpaste. Also remind all parents to avoid sensitive toothpastes, as these contain stannous fluoride which can camouflage dental pain. Some might argue this would be good because the child will not be in pain.
However, this will mean a parent might be unaware of the damage that is happening to a child’s teeth.
Routinely see the child whilst they are on the waiting list for GA or sedation every three months to apply 2.26% fluoride varnish.
Preventative advice: diet
Diet advice should already have been given at the initial assessment appointment. Many parents, however, remain in denial, and we have all heard parents say: ‘But my child does not eat sugar.’ It is imperative to find the source of the of the problem and use this review apportionment to keep the messages going. Using a food diary can help parents see the high sugar products in the diet, to which they may have been oblivious.
What a child is drinking can be another huge factor to dental decay. If child drinks squash, fizzy drinks and fruit juices all day their teeth will constantly be battling with that sugar and acid attack.
Educating children on the relevance of water is significant in diet advice. Parents can be aided by using the Food Scanner app (provided by the NHS) on their smartphones. It is a simple tool which can help parents figure out how much sugar their child is having.
Reinforce previous advice about bottles and sippy cups. Current recommendation is that children from six months old should only use an open cup to reduce the risk of grazing on sugary drinks. Don’t forget to consider breast feeding.
In the UK, the recommendation is to stop breast feeding at 12 months old. However, different cultures and ethnicities may have different views. Do not be surprised to find children as old as four years still having breast milk! Parents are often shocked to find that breast milk is cariogenic and may be the cause of their child’s dental decay.
Fissure sealants
Have any permanent teeth erupted since the child last attended? Fissure sealants are key to helping high caries risk paediatric patients. This is a form of prevention. We want to prevent the permanent first molars from getting carious lesions.
If caries can multiply so fast in deciduous teeth it is more than likely for this decay to extend into the first permanent molars when they develop. Fissure sealants are usually well accepted by children and, again, this is practice building for the future.
What do you do when the child is experiencing pain?
Is this a change in symptoms since the child was referred? Having said this, you need to be aware that with waiting times so long, priority is always given to children with infection. Hospital and community services are required to prioritise patients based on clinical need.
The days where referred children were seen in order of referral have been superseded. This in effect means that other children you refer may be seen before the child in pain. Consequently, you will need to help the child. Options include:
– Recommendation of analgesia
Paracetamol based medication is the medication of choice. This is as long as the child has no allergies. If paracetamol is to be prescribed then check the dose for the child’s age and weight, information can be found in the children’s BNF.
A handy tool for all practitioners is the BNF app, which is updated regularly. Always prescribe sugar free medication and also encourage parents to ask doctors to do this too.
– Temporisation
Has a temporary restoration been lost? If so, use a non-white material to temporise the tooth. This reinforces to the child and parent that it is a temporary solution only. An example of this could be pink glass ionomer.
– Intraoral swelling
Intraoral swelling can be visible swelling around the gingival margin of a tooth or in the form of a sinus draining which is causing pain. This alone is considered to be a localised issue.
Now the child is experiencing signs or symptoms, they may be more motivated to accept treatment in the practice. If there is a long wait the child may also be more capable of receiving treatment too.
If treatment is not an option, follow the FGDP guidelines 2021 on antimicrobial prescribing pathway. It may be that antibiotics are not indicated at this time and parents should be advised to monitor the situation.
Remember the Guidelines should be followed when antibiotic prescription is needed as we need good stewardship of antibiotics to prevent resistant infections developing in the future (Dental antimicrobial stewardship: toolkit).
If symptoms have changed since you referred, inform the service where you have referred to. It may affect the triage of the child.
– Extraoral swelling
Extraoral swelling can be life threatening and a risk of sepsis is high. If the swelling is restricting the airway or has closed the eye to fully shut then A&E is priority. A cover letter should be sent with the child and parents advised to take the child immediately.
It is important to assess the child for sepsis. The UK Sepsis Trust has a simple check list that can be followed below:
- Is the child breathing very fast
- Has the child had a ‘fit’ or convulsion
- Looks mottled, blush or pale
- Has a rash that does not fade when you press it
- The child is very lethargic or difficult to wake
- Feels abnormally cold to touch.
In this insistence you might consider calling 999 for assistance.
The child may have a facial swelling which is not life threatening and will need immediate management to prevent escalation of the swelling. Whilst draining a fluctuant swelling is ideal, this will often not be possible in children and antibiotic prescription is a kinder way to manage the child.
Again, refer to the guidelines about antibiotic prescription and check doses. There has been a relatively recent change increasing the amount of antibiotic dose which many practitioners may not be aware of. Do not forget to consider known allergies too.
Again, will the child now accept management in practice as the pain is worsening? It is very important to offer to attempt the procedure if a child attends back in pain. Sometimes building that rapport will aid the child to trust and let you carry out the procedure.
If a child is still uncooperative then it’s necessary to contact the referral centre with further update so the child can be triaged and made a priority. History of facial swelling will also always increase the priority of your referral.
Conclusion
Managing children has changed as a result of the pandemic. Minimally invasive dentistry should mean more children can be managed within the dental practice, especially where the diagnosis is caries in the primary dentition, thus decreasing the need to refer.
Services are currently overwhelmed with referrals and parents should be warned about the long waits. Children with sepsis will be prioritised over all other referrals. Referrers are required to maintain and support children whilst they are waiting, and can do much to reduce disease progression by basic preventive methods.
Should clinical signs or symptoms change, update your referral. This will ensure your paediatric patient is placed on the most appropriate clinic and triaged based on the most up-to-date information.
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