Australian Dental Journal
The official journal of the Australian Dental Association
Australian Dental Journal 2015; 60: 73–79 doi: 10.1111/adj.12269
Caries burden and efficacy of a referral pathway in a cohort of preschool refugee children P Nicol,* R Anthonappa,† N King,† L Slack-Smith,† G Cirillo,‡ S Cherian*§ *School of Paediatrics and Child Health, The University of Western Australia, Perth, Australia. †School of Dentistry, The University of Western Australia, Perth, Australia. ‡Dental Health Services, WA Department of Health, Perth, Australia. §Department of Paediatric and Adolescent Medicine, Princess Margaret Hospital for Children, Perth, Australia.
ABSTRACT Background: This study aimed to assess the early caries experience and the efficacy of a community based dental referral pathway in preschool refugees in Western Australia. Methods: Preschool refugee children referred to the Western Australian paediatric hospital Refugee Health Clinic were prospectively screened for caries by a paediatric dentist before being referred to community dental clinics. Dental forms and medical records were audited to assess decayed, missing and filled teeth (dmft), medical data and dental services engagement. Poisson regression analysis determined the contribution of count variables to the final model. Results: Among the 105 screened children (54% male, median age 3.2 years, 41% Burmese), community dental clinic engagement was low (46%, n = 48). Of the 62% with caries (n = 65/105, mean dmft 5.2, SD 4.1), 45% were recommended for specialist dental services and 48% were treated. After adjustment for age, gender and total number of teeth, caries incidence was significantly associated with BMI-for-age Z score (p = 0.02). Conclusions: Preschool refugee caries burden was high. The community dental referral pathway was ineffective compared to co-located intersectorial dental screening. Specialist dental service needs are high in this cohort and require a targeted approach. Keywords: Early childhood caries, intersectorial collaboration, oral health screening, refugee, referral pathways. Abbreviations and acronyms: BMI = Body Mass Index; CDC = community dental clinic; dmft = decayed, missing and filled primary teeth; DMFT = decayed, missing and filled permanent teeth; DHS = Dental Health Service; ECC = early childhood caries; HEHS = Humanitarian Entrant Health Service; OHCWA = Oral Health Centre of WA; RHC = Refugee Health Clinic; SEIFA = Socio-Economic Indexes for Areas. (Accepted for publication 23 April 2014.)
INTRODUCTION Early childhood caries (ECC) is a significant health care problem that is largely preventable.1 The term ECC encompasses any form of caries occurring in infants, toddlers and preschool-aged children.2 The pain associated with ECC is debilitating and may increase the likelihood of poor growth, disturbed sleep, and disrupted developmental, academic and social outcomes.3–5 Untreated dental caries is likely to require emergency care, antibiotic, anaesthetic and surgical intervention accounting for 6.7% of hospital admissions among 5–9 year olds in Western Australia (WA).6,7 Many children under five years old do not receive routine dental care but of those that do, some require hospital admission for the treatment of dental caries.8,9 © 2015 Australian Dental Association
Many humanitarian entrant refugee children already have severe dental disease when they enter Australia, often progressively worsening after resettlement.10 Limited dental pathways exist for children aged 0–4 years in WA; concession card holders can access public care at subsidized fees and non-card holders need to access private dentists. As such, at the time of study inception, preschool refugees in WA were neither eligible for, nor were their treatment requirements generally covered by, free governmentfunded dental services,11 thus worsening morbidity due to delayed presentation once children reached school age when they were eligible for free School Dental Services. Refugee families, who face many barriers in accessing culturally appropriate health services post-resettlement, are also less likely than non73
P Nicol et al. refugee children to access private dental health services commonly due to cost barriers.12–14 The state’s tertiary children’s hospital dental department treats otherwise well children who present emergently with medical conditions (e.g. abscess) by extraction of the most affected tooth/teeth, but is unable to offer treatment for the remaining dental disease unless the child has complex medical problems. This leads to a high representation rate and long waiting lists for treatment. Given the anecdotal evidence of high rates of ECC in preschool refugee children in WA and wait lists for treatment, this study gathers data on the oral health status and dental service needs of preschool refugee children in WA and introduces and tests a new ‘standard’ community dental referral pathway. This study aimed to: (1) define the caries experience of ECC in resettled preschool refugees in WA; (2) examine factors associated with the presence of ECC in this cohort; and (3) assess the efficacy of the recently implemented ‘standard’ community dental screening pathway for preschool refugee children.
METHODS
Outcome measures Initial dental screening The baseline dental assessment was conducted by the research registered paediatric dentist during the multidisciplinary RHC appointment using either the standard lap to lap position or with the child sitting on the parent’s lap. Data were recorded on the Dental Health Service (DHS) population data collection form. The number of sound, decayed, missing and filled primary (dmft) and permanent (DMFT) teeth plus a gingival inflammation score were recorded. Dental caries was defined as a visual break in the enamel surface, pit and fissure discolouration with adjacent opacity, evidence of marginal ridge undermining, or anterior shadowing on transillumination. The inflammation score was a count of the number of sextants in which gingival inflammation was observed. Due to ethical concerns regarding very young and/or traumatized children, detailed examination could not be undertaken without the aid of sedation, thus dmft/DMFT scores were utilized by the dental staff (baseline and community assessments), rather than other measures.16
Study participants
The new community ‘standard’ pathway
This prospective study used a cross-sectional design and a purposive sampling technique to enrol a cohort of refugee children who were referred to the paediatric hospital Refugee Health Clinic (RHC). Children were less than six years of age, who were not enrolled in school and had erupted teeth. Most (90%) refugee children were referred to the RHC following postresettlement health checks at the Humanitarian Entrant Health Service (HEHS), a specialist service that undertakes voluntary post-resettlement health assessment on over 80% of refugees resettled in WA.15 Based on previous clinic data, a sample of at least 100 children could be recruited over nine months.
Prior to the study, there was no formal free dental screening or referral pathway for these children. Community refugee nurses would assist families as needed to source community or private dental services as part of resettlement services. As such, the new community ‘standard’ pathway evolved with the aim of linking all preschool refugee children with a local community dental clinic (CDC) dentist for treatment and preventive care. The research dentist screened within the RHC as a ‘baseline measure’ following consent from parents using professional interpreters prior to CDC referral. Baseline RHC dental screening was completed as a comparator to assess: (1) the percentage of children who successfully navigated CDC screening pathways compared to universal onsite assessment; and (2) the time taken to attend CDC screening. Funding for the RHC dental screening was through research funds and not part of the government community pathway. RHC paediatricians and liaison nurses completed the necessary documentation that was forwarded to the CDC nearest to where the family was currently living. The CDC sent an appointment to the family and notified the liaison nurses of the appointment time. The liaison nurses followed up the families by telephone to assist in clinic attendance. The CDC agreed to prioritize these appointments over their usual wait times. A small co-payment was required as CDC reviews were not free, but heavily
Setting The RHC is a multidisciplinary team comprising paediatric medical, nursing and allied health staff (dietitian, social worker and education liaison teacher). Prior to the study, there was no formally appointed RHC paediatric dentist. Refugee children (humanitarian entrants and asylum-seeking children 0. There were only three children with permanent teeth, and of these four of the nine permanent teeth exhibited caries.
There was a significant correlation between age and dmft (rho = 0.60; p < 0.001). Children with dmft >0 were significantly (p < 0.001) older than children with dmft = 0 (median age 3.5 vs 2.2 years). There was no significant difference in the dmft between gender, countries of origin or language. A higher BAZ score was protective against dmft (p = 0.025), independent of age, total number of teeth and gender.
Anthropometric data The mean Body Mass Index (BMI)-for-age Z score (BAZ) was 0.4; 4.3% were less than 1.6 standard deviations (SD) and 10.6% were greater than 1.6 SD from the norm. Medical data
Engagement with CDC (standard pathway) and referrals Less than half (48/105, 46%) of the screened and referred refugee cohort subsequently engaged with the 10 metropolitan CDCs, of whom 13/48 (27%) were
45
The number of children with a dmft count from 0–20 count
40
RHC baseline screen n=105 dmft>0=65 (62%)
n=48/105 (46%) examined at 10 community dental clinics Md=4 wks; Range 2-18
n=13/48 (27%) referred to OHCWA
35
45% n=29/65 required specialist referral
n=17/105 (16%) referred to PMH
30 25
n=15/48 treated with fillings Md = 5 fillings; Range 1-10
20
n=6/13 (46%) treated Md = 20 wks, Range 12-33
4/17 PMH ED
n=16/17 (94%) PMH Dental Md = 4 wks Range 0-16
15 10 n=15/48 (31%) community treated
5 0
Total n=31/65 (48%) treated to date PMH, OHCWA + community
n=10/16 (62.5%) treated
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Fig. 1 The range from 0–29 for dmft count data preschool refugee children’s primary teeth (n = 105). 76
Fig. 2 Baseline screening, community and specialist dental service referrals. © 2015 Australian Dental Association
Caries burden and referrals in preschool refugees DISCUSSION Refugee preschool children in this study had a worryingly high ECC experience, suggesting they will have a high DMFT in their permanent dentitions. The mean dmft score was higher compared to resident Australian five year olds and was also presenting at a much younger age.14 Numerous risk factors are likely to be present as most children were born during transit and had significant co-morbidities.10 Many had nutritional issues, some with associated low weight for age, and in some a protective relationship for caries with higher BMI was noted. Since the work of Acs et al.19 identified ECC to be associated with low body weight, one investigation has found no relationship;20 while in older children, only one study with a high level of evidence found a direct association between obesity and dental caries.21 Central obesity has more recently been found to be associated with ECC; however, the importance of the method of assessing obesity may be greater than previously thought.22 Therefore as this relationship was not specifically investigated in depth, in this present study it is inappropriate to draw strong conclusions from the findings. Point of care paediatric dental screening in the RHC within the multidisciplinary team enabled: (1) accurate and timely identification of dental disease; and (2) appropriate direct referral for those children with severe disease to the specialist dental clinic. Furthermore, refugee families embraced the opportunity to engage with dental staff, reflected in the overwhelming study participation response. There has been a direct translation of these research findings into clinical practice, both within the institution and the wider paediatric dental faculty. The paediatric refugee dental review is now routine RHC practice and is provided by paediatric dental registrars. Further benefits are the provision of cultural awareness training for dental professionals, accessible preventive oral health training for all refugee families and improved oral health training for general health professionals. The use of a paediatric dental registrar to conduct the oral examination could be perceived as being a costly luxury; nevertheless, it had several benefits. They were voluntary and it formed part of their postgraduate education in community and refugee studies. Most importantly, they were able to quickly, accurately and empathetically conduct the examination, thus reducing the stress on an already traumatized refugee child. Their ability to assess the treatment need meant that the most appropriate referral could be made, facilitating the expedient delivery of emergency care. Furthermore, those children who would benefit from preventive measures were identified and separated from those requiring treatment so © 2015 Australian Dental Association
that preventive care could be delivered before active treatment was required. Conversely, the trial ‘standard’ referral pathway was ineffective with less than half of the children attending CDCs. Engagement with specialist dental services (OHCWA) was slightly higher but still less than half the children referred were treated. There is little available comparable referral data. Anecdotally in our study cost was reported as a significant access factor; a second qualitative study explored the cultural issues and barriers to access and will be reported separately. Financial costs were associated with CDC attendance by refugee families but wider community priorities were also associated with delayed presentation to CDCs. For some children there was also the cost associated with the need for extensive treatment plus anaesthesia. Results from the National Dental Interview Survey 2010 found that 9% of 2–4 year olds had delayed or avoided a dental visit due to financial cost,23 which would be much lower when compared to our socio-economically deprived cohort. Given the complexity and level of treatment required for these children, the Federal preschool dental scheme is unlikely to meet their needs. Ten elements of a framework for good practice12 have been previously identified that if applied are likely to facilitate improvements in refugee health care and reduce the gap between health needs and currently available services. These include comprehensive health screening; coordination of initial and ongoing health care; integration of physical, developmental and psychological health care; consumer participation; culturally and linguistically appropriate service provision; intersectoral collaboration; accessible and affordable services and treatments; data collection and evaluation to inform evidence-based practice; capacity building and sustainability; and advocacy.12 This study has resulted in effective interdisciplinary screening within a general health facility, but followup culturally appropriate dental service provision remains problematic. Data from the second qualitative study will inform on the development of a revised referral pathway. These data contribute further evidence to support the need for a new model of care such as that proposed by Nguyen et al.24 Consideration must be given to culturally aware services, intersectorial collaboration, priority access and fee exemption policies. Limitations of the study One limitation of this study was cohort size and variation in dental service provision nationally, potentially limiting its generalizability. However, the cross-section of ethnicities is representative of pre77
P Nicol et al. school refugee children that have resettled in other developed nations, who are also facing similar problems with ECC and preventive dental health.
6. Department of Health, Western Australia. Our children our future: a framework for Child and Youth Health Services in Western Australia 2008–2012. Perth: Health Networks Branch, 2008. Available from: ‘http://www.healthnetworks.health. wa.gov.au/modelsofcare/docs/WA_Child_&_Youth_Framework_ 2008-2012.pdf’.
CONCLUSIONS
7. Alcaino E, Kilpatrick NM, Kingsford Smith ED. Utilization of day stay general anaesethesia for the provision of dental treatment to children in New South Wales, Australia. Int J Paediatr Dent 2000;10:206–212.
It is clear from this study that resettled preschool refugee children have severe debilitating dental disease in the context of multiple other co-morbid medical and psycho-social concerns. Furthermore, the available dental services are currently failing to manage their dental disease. As a direct result of this study, preschool dental screening by a paediatric dentist is now embedded practice within the multidisciplinary RHC. Furthermore, a direct specialist dental service referral pathway will be trialled, obviating the community dental pathway delays and logistic barriers. The significant trend in increasing caries with age will result in increasing morbidity and economic costs unless affordable treatment is provided for refugee children on arrival in Australia, effective preventive therapy is made available and access barriers are minimized. The results highlight the need to develop an effective child and family-focused culturally appropriate model of care.25–27 ACKNOWLEDGEMENTS This study was funded by the Public Health and Ambulatory Care Unit, North Metropolitan Area Health Service, WA Department of Health. Thanks to Dr Guicheng Zhang (School of Paediatrics and Child Health, University of Western Australia; School of Public Health, Curtin University) for support with statistical analysis, and to the staff of the RHC and HEHS, the community refugee health service, community dental clinics and refugee families without whom this study would not have been possible. REFERENCES 1. Newacheck PW, Hughes DC, Hung YY, Wong S, Stoddard JJ. The unmet health needs of America’s children. Pediatrics 2000;105:989–997. 2. Petersen PE. Global policy for improvement of oral health in the 21st century–implications to oral health research of World Health Assembly 2007, World Health Organization. Community Dent Oral Epidemiol 2009;37:1–8. 3. Gussy MG, Waters EG, Walsh O, Kilpatrick NM. Early childhood caries: current evidence for aetiology and prevention. J Paediatr Child Health 2006;42:37–43. 4. McGrath C, Broder H, Wilson-Genderson M. Assessing the impact of oral health on the life quality of children: implications for research and practice. Community Dent Oral Epidemiol 2004;32:81–85. 5. Cunnion DT, Rich SE, Casamassimo P, et al. Pediatric oral health-related quality of life improvement after treatment of early childhood caries: a prospective multisite study. J Dent Child 2010;77:4–11.
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8. Slack-Smith L, Colvin L, Leonard H, Kilpatrick N, Bower C, Brearley Messer L. Factors associated with dental admissions for children aged under five years in Western Australia. Arch Dis Child 2009;94:517–523. 9. Slack-Smith L, Colvin L, Leonard H, Kilpatrick N, Read A, Messer LB. Dental hospital admissions in children under two years – a total-population investigation. Child Care Health Dev 2013;39:253–259. 10. Davidson N, Skull S, Calache H, Murray S, Chalmers J. Holes a plenty: oral health status a major issue for newly arrived refugees in Australia. Aust Dent J 2006;51:306–311. 11. Davidson N, Skull S, Calache H, Chesters D, Chalmers J. Equitable access to dental care for an at-risk group: a review of services for Australian refugees. Aust N Z J Public Health 2007;31:75. 12. Woodland L, Burgner D, Paxton G, Zwi K. Health service delivery for newly arrived refugee children: a framework for good practice. J Paediatr Child Health 2010;46:560–567. 13. Davidson N, Skull S, Calache H, Chesters D, Chalmers J. Equitable access to dental care for an at-risk group: a review of services for Australian refugees. Aust N Z J Public Health 2007;31:74. 14. Australian Institute of Health and Welfare. Dental decay among Australian children. Research Report Series no. 53. Cat. no. DEN 210. Canberra: AIHW, 2011. Available from: http:// www.aihw.gov.au/publication-detail/?id=10737419604. 15. Mutch RC, Cherian S, Nemba K, et al. Tertiary paediatric refugee health clinic in Western Australia: analysis of the first 1026 children. J Paediatr Child Health 2012;48:582–587. 16. Iranzo-Cortes JE, Montiel-Company JM, Almerich-Silla JM. Caries diagnosis: agreement between WHO and ICDAS II criteria in epidemiological surveys. Community Dent Health 2013;30:108–111. 17. Australian Bureau of Statistics. 2033.0.55.001 – Census of Population and Housing: Socio-Economic Indexes for Areas (SEIFA), Australia – data only, 2006 [Internet; updated 27 March 2013; cited 30 March 2013]. Available from: http:// www.abs.gov.au/AUSSTATS/[email protected]/DetailsPage/2033.0.55. 0012006. 18. Cultural Diversity Unit. Delivering a Healthy WA: WA Health Language Services Policy [Internet]. Public Health Division, Department of Health, 2011 [Internet; updated September 2011; cited 30 March 2013]. Available from: http://www.health.wa.gov.au/multiculturalhealth/docs/WA_Health_L_S_Policy.pdf. 19. Acs G, Lodolini G, Kaminsky S, Cisneros GJ. Effect of nursing caries on body weight in a paediatric population. Pediatr Dent 1992;14:302–305. 20. Sheller B, Churchill SS, Williams BJ, Davidson B. Body mass index of children with severe early childhood caries. Pediatr Dent 2009;31:216–221. 21. Kantovitz KR, Pascon FM, Rontani RMP, Gavi~ao MBD. Obesity and dental caries – a systematic review. Oral Health Prev Dent 2006;4:137–144. 22. Peng SM, Wong HM, King NM, McGrath C. Is dental caries experience associated with adoposity status in pre-school children? Int J Paediatr Dent 2014;24:122–130.
© 2015 Australian Dental Association
Caries burden and referrals in preschool refugees 23. Harford JE, Luzzi L. Child and teenager oral health and dental visiting: results from the National Dental Telephone Interview Survey 2010. Australian Institute of Health and Welfare Dental Statistics and Research Series No. 64. Cat. no. DEN 226. Canberra: AIHW, 2013. Available from: http://www.aihw.gov.au/. 24. Nguyen T, Casey S, Maloney M, Rich S. Final Report: Refugee Oral Health Sector Capacity Building Project. Australian PolicyOnline: Research and Evidence Base [Internet; cited 1 October 2013]. Available at: http://www.apo.org.au/research/finalreport-oral-health-sector-capacity-builing-project. 25. Kuhlthau KA, Bloom S, Van Cleave J, et al. Evidence for family-centered care for children with special health care needs: a systematic review. Academic Pediatrics 2011;11:136–143. 26. Wilkins A, Leonard H, Jacoby P, et al. Evaluation of the processes of family-centred care for young children with intellectual disability in Western Australia. Child Care Health Dev 2010;36:709–718.
© 2015 Australian Dental Association
27. Pediatric Oral Health Research and Policy Center. Patient Centred Care: American Academy of Pediatric Dentistry, August 2013. Available from: http://www.aapd.org/assets/1/7/PatientCenteredCarePolicyBrief.pdf.
Address for correspondence: Associate Professor Pam Nicol School of Paediatrics and Child Health (M561) Faculty of Medicine, Dentistry and Health Science The University of Western Australia 35 Stirling Highway Crawley WA 6009 Email: [email protected]
79
The official journal of the Australian Dental Association
Australian Dental Journal 2015; 60: 73–79 doi: 10.1111/adj.12269
Caries burden and efficacy of a referral pathway in a cohort of preschool refugee children P Nicol,* R Anthonappa,† N King,† L Slack-Smith,† G Cirillo,‡ S Cherian*§ *School of Paediatrics and Child Health, The University of Western Australia, Perth, Australia. †School of Dentistry, The University of Western Australia, Perth, Australia. ‡Dental Health Services, WA Department of Health, Perth, Australia. §Department of Paediatric and Adolescent Medicine, Princess Margaret Hospital for Children, Perth, Australia.
ABSTRACT Background: This study aimed to assess the early caries experience and the efficacy of a community based dental referral pathway in preschool refugees in Western Australia. Methods: Preschool refugee children referred to the Western Australian paediatric hospital Refugee Health Clinic were prospectively screened for caries by a paediatric dentist before being referred to community dental clinics. Dental forms and medical records were audited to assess decayed, missing and filled teeth (dmft), medical data and dental services engagement. Poisson regression analysis determined the contribution of count variables to the final model. Results: Among the 105 screened children (54% male, median age 3.2 years, 41% Burmese), community dental clinic engagement was low (46%, n = 48). Of the 62% with caries (n = 65/105, mean dmft 5.2, SD 4.1), 45% were recommended for specialist dental services and 48% were treated. After adjustment for age, gender and total number of teeth, caries incidence was significantly associated with BMI-for-age Z score (p = 0.02). Conclusions: Preschool refugee caries burden was high. The community dental referral pathway was ineffective compared to co-located intersectorial dental screening. Specialist dental service needs are high in this cohort and require a targeted approach. Keywords: Early childhood caries, intersectorial collaboration, oral health screening, refugee, referral pathways. Abbreviations and acronyms: BMI = Body Mass Index; CDC = community dental clinic; dmft = decayed, missing and filled primary teeth; DMFT = decayed, missing and filled permanent teeth; DHS = Dental Health Service; ECC = early childhood caries; HEHS = Humanitarian Entrant Health Service; OHCWA = Oral Health Centre of WA; RHC = Refugee Health Clinic; SEIFA = Socio-Economic Indexes for Areas. (Accepted for publication 23 April 2014.)
INTRODUCTION Early childhood caries (ECC) is a significant health care problem that is largely preventable.1 The term ECC encompasses any form of caries occurring in infants, toddlers and preschool-aged children.2 The pain associated with ECC is debilitating and may increase the likelihood of poor growth, disturbed sleep, and disrupted developmental, academic and social outcomes.3–5 Untreated dental caries is likely to require emergency care, antibiotic, anaesthetic and surgical intervention accounting for 6.7% of hospital admissions among 5–9 year olds in Western Australia (WA).6,7 Many children under five years old do not receive routine dental care but of those that do, some require hospital admission for the treatment of dental caries.8,9 © 2015 Australian Dental Association
Many humanitarian entrant refugee children already have severe dental disease when they enter Australia, often progressively worsening after resettlement.10 Limited dental pathways exist for children aged 0–4 years in WA; concession card holders can access public care at subsidized fees and non-card holders need to access private dentists. As such, at the time of study inception, preschool refugees in WA were neither eligible for, nor were their treatment requirements generally covered by, free governmentfunded dental services,11 thus worsening morbidity due to delayed presentation once children reached school age when they were eligible for free School Dental Services. Refugee families, who face many barriers in accessing culturally appropriate health services post-resettlement, are also less likely than non73
P Nicol et al. refugee children to access private dental health services commonly due to cost barriers.12–14 The state’s tertiary children’s hospital dental department treats otherwise well children who present emergently with medical conditions (e.g. abscess) by extraction of the most affected tooth/teeth, but is unable to offer treatment for the remaining dental disease unless the child has complex medical problems. This leads to a high representation rate and long waiting lists for treatment. Given the anecdotal evidence of high rates of ECC in preschool refugee children in WA and wait lists for treatment, this study gathers data on the oral health status and dental service needs of preschool refugee children in WA and introduces and tests a new ‘standard’ community dental referral pathway. This study aimed to: (1) define the caries experience of ECC in resettled preschool refugees in WA; (2) examine factors associated with the presence of ECC in this cohort; and (3) assess the efficacy of the recently implemented ‘standard’ community dental screening pathway for preschool refugee children.
METHODS
Outcome measures Initial dental screening The baseline dental assessment was conducted by the research registered paediatric dentist during the multidisciplinary RHC appointment using either the standard lap to lap position or with the child sitting on the parent’s lap. Data were recorded on the Dental Health Service (DHS) population data collection form. The number of sound, decayed, missing and filled primary (dmft) and permanent (DMFT) teeth plus a gingival inflammation score were recorded. Dental caries was defined as a visual break in the enamel surface, pit and fissure discolouration with adjacent opacity, evidence of marginal ridge undermining, or anterior shadowing on transillumination. The inflammation score was a count of the number of sextants in which gingival inflammation was observed. Due to ethical concerns regarding very young and/or traumatized children, detailed examination could not be undertaken without the aid of sedation, thus dmft/DMFT scores were utilized by the dental staff (baseline and community assessments), rather than other measures.16
Study participants
The new community ‘standard’ pathway
This prospective study used a cross-sectional design and a purposive sampling technique to enrol a cohort of refugee children who were referred to the paediatric hospital Refugee Health Clinic (RHC). Children were less than six years of age, who were not enrolled in school and had erupted teeth. Most (90%) refugee children were referred to the RHC following postresettlement health checks at the Humanitarian Entrant Health Service (HEHS), a specialist service that undertakes voluntary post-resettlement health assessment on over 80% of refugees resettled in WA.15 Based on previous clinic data, a sample of at least 100 children could be recruited over nine months.
Prior to the study, there was no formal free dental screening or referral pathway for these children. Community refugee nurses would assist families as needed to source community or private dental services as part of resettlement services. As such, the new community ‘standard’ pathway evolved with the aim of linking all preschool refugee children with a local community dental clinic (CDC) dentist for treatment and preventive care. The research dentist screened within the RHC as a ‘baseline measure’ following consent from parents using professional interpreters prior to CDC referral. Baseline RHC dental screening was completed as a comparator to assess: (1) the percentage of children who successfully navigated CDC screening pathways compared to universal onsite assessment; and (2) the time taken to attend CDC screening. Funding for the RHC dental screening was through research funds and not part of the government community pathway. RHC paediatricians and liaison nurses completed the necessary documentation that was forwarded to the CDC nearest to where the family was currently living. The CDC sent an appointment to the family and notified the liaison nurses of the appointment time. The liaison nurses followed up the families by telephone to assist in clinic attendance. The CDC agreed to prioritize these appointments over their usual wait times. A small co-payment was required as CDC reviews were not free, but heavily
Setting The RHC is a multidisciplinary team comprising paediatric medical, nursing and allied health staff (dietitian, social worker and education liaison teacher). Prior to the study, there was no formally appointed RHC paediatric dentist. Refugee children (humanitarian entrants and asylum-seeking children 0. There were only three children with permanent teeth, and of these four of the nine permanent teeth exhibited caries.
There was a significant correlation between age and dmft (rho = 0.60; p < 0.001). Children with dmft >0 were significantly (p < 0.001) older than children with dmft = 0 (median age 3.5 vs 2.2 years). There was no significant difference in the dmft between gender, countries of origin or language. A higher BAZ score was protective against dmft (p = 0.025), independent of age, total number of teeth and gender.
Anthropometric data The mean Body Mass Index (BMI)-for-age Z score (BAZ) was 0.4; 4.3% were less than 1.6 standard deviations (SD) and 10.6% were greater than 1.6 SD from the norm. Medical data
Engagement with CDC (standard pathway) and referrals Less than half (48/105, 46%) of the screened and referred refugee cohort subsequently engaged with the 10 metropolitan CDCs, of whom 13/48 (27%) were
45
The number of children with a dmft count from 0–20 count
40
RHC baseline screen n=105 dmft>0=65 (62%)
n=48/105 (46%) examined at 10 community dental clinics Md=4 wks; Range 2-18
n=13/48 (27%) referred to OHCWA
35
45% n=29/65 required specialist referral
n=17/105 (16%) referred to PMH
30 25
n=15/48 treated with fillings Md = 5 fillings; Range 1-10
20
n=6/13 (46%) treated Md = 20 wks, Range 12-33
4/17 PMH ED
n=16/17 (94%) PMH Dental Md = 4 wks Range 0-16
15 10 n=15/48 (31%) community treated
5 0
Total n=31/65 (48%) treated to date PMH, OHCWA + community
n=10/16 (62.5%) treated
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Fig. 1 The range from 0–29 for dmft count data preschool refugee children’s primary teeth (n = 105). 76
Fig. 2 Baseline screening, community and specialist dental service referrals. © 2015 Australian Dental Association
Caries burden and referrals in preschool refugees DISCUSSION Refugee preschool children in this study had a worryingly high ECC experience, suggesting they will have a high DMFT in their permanent dentitions. The mean dmft score was higher compared to resident Australian five year olds and was also presenting at a much younger age.14 Numerous risk factors are likely to be present as most children were born during transit and had significant co-morbidities.10 Many had nutritional issues, some with associated low weight for age, and in some a protective relationship for caries with higher BMI was noted. Since the work of Acs et al.19 identified ECC to be associated with low body weight, one investigation has found no relationship;20 while in older children, only one study with a high level of evidence found a direct association between obesity and dental caries.21 Central obesity has more recently been found to be associated with ECC; however, the importance of the method of assessing obesity may be greater than previously thought.22 Therefore as this relationship was not specifically investigated in depth, in this present study it is inappropriate to draw strong conclusions from the findings. Point of care paediatric dental screening in the RHC within the multidisciplinary team enabled: (1) accurate and timely identification of dental disease; and (2) appropriate direct referral for those children with severe disease to the specialist dental clinic. Furthermore, refugee families embraced the opportunity to engage with dental staff, reflected in the overwhelming study participation response. There has been a direct translation of these research findings into clinical practice, both within the institution and the wider paediatric dental faculty. The paediatric refugee dental review is now routine RHC practice and is provided by paediatric dental registrars. Further benefits are the provision of cultural awareness training for dental professionals, accessible preventive oral health training for all refugee families and improved oral health training for general health professionals. The use of a paediatric dental registrar to conduct the oral examination could be perceived as being a costly luxury; nevertheless, it had several benefits. They were voluntary and it formed part of their postgraduate education in community and refugee studies. Most importantly, they were able to quickly, accurately and empathetically conduct the examination, thus reducing the stress on an already traumatized refugee child. Their ability to assess the treatment need meant that the most appropriate referral could be made, facilitating the expedient delivery of emergency care. Furthermore, those children who would benefit from preventive measures were identified and separated from those requiring treatment so © 2015 Australian Dental Association
that preventive care could be delivered before active treatment was required. Conversely, the trial ‘standard’ referral pathway was ineffective with less than half of the children attending CDCs. Engagement with specialist dental services (OHCWA) was slightly higher but still less than half the children referred were treated. There is little available comparable referral data. Anecdotally in our study cost was reported as a significant access factor; a second qualitative study explored the cultural issues and barriers to access and will be reported separately. Financial costs were associated with CDC attendance by refugee families but wider community priorities were also associated with delayed presentation to CDCs. For some children there was also the cost associated with the need for extensive treatment plus anaesthesia. Results from the National Dental Interview Survey 2010 found that 9% of 2–4 year olds had delayed or avoided a dental visit due to financial cost,23 which would be much lower when compared to our socio-economically deprived cohort. Given the complexity and level of treatment required for these children, the Federal preschool dental scheme is unlikely to meet their needs. Ten elements of a framework for good practice12 have been previously identified that if applied are likely to facilitate improvements in refugee health care and reduce the gap between health needs and currently available services. These include comprehensive health screening; coordination of initial and ongoing health care; integration of physical, developmental and psychological health care; consumer participation; culturally and linguistically appropriate service provision; intersectoral collaboration; accessible and affordable services and treatments; data collection and evaluation to inform evidence-based practice; capacity building and sustainability; and advocacy.12 This study has resulted in effective interdisciplinary screening within a general health facility, but followup culturally appropriate dental service provision remains problematic. Data from the second qualitative study will inform on the development of a revised referral pathway. These data contribute further evidence to support the need for a new model of care such as that proposed by Nguyen et al.24 Consideration must be given to culturally aware services, intersectorial collaboration, priority access and fee exemption policies. Limitations of the study One limitation of this study was cohort size and variation in dental service provision nationally, potentially limiting its generalizability. However, the cross-section of ethnicities is representative of pre77
P Nicol et al. school refugee children that have resettled in other developed nations, who are also facing similar problems with ECC and preventive dental health.
6. Department of Health, Western Australia. Our children our future: a framework for Child and Youth Health Services in Western Australia 2008–2012. Perth: Health Networks Branch, 2008. Available from: ‘http://www.healthnetworks.health. wa.gov.au/modelsofcare/docs/WA_Child_&_Youth_Framework_ 2008-2012.pdf’.
CONCLUSIONS
7. Alcaino E, Kilpatrick NM, Kingsford Smith ED. Utilization of day stay general anaesethesia for the provision of dental treatment to children in New South Wales, Australia. Int J Paediatr Dent 2000;10:206–212.
It is clear from this study that resettled preschool refugee children have severe debilitating dental disease in the context of multiple other co-morbid medical and psycho-social concerns. Furthermore, the available dental services are currently failing to manage their dental disease. As a direct result of this study, preschool dental screening by a paediatric dentist is now embedded practice within the multidisciplinary RHC. Furthermore, a direct specialist dental service referral pathway will be trialled, obviating the community dental pathway delays and logistic barriers. The significant trend in increasing caries with age will result in increasing morbidity and economic costs unless affordable treatment is provided for refugee children on arrival in Australia, effective preventive therapy is made available and access barriers are minimized. The results highlight the need to develop an effective child and family-focused culturally appropriate model of care.25–27 ACKNOWLEDGEMENTS This study was funded by the Public Health and Ambulatory Care Unit, North Metropolitan Area Health Service, WA Department of Health. Thanks to Dr Guicheng Zhang (School of Paediatrics and Child Health, University of Western Australia; School of Public Health, Curtin University) for support with statistical analysis, and to the staff of the RHC and HEHS, the community refugee health service, community dental clinics and refugee families without whom this study would not have been possible. REFERENCES 1. Newacheck PW, Hughes DC, Hung YY, Wong S, Stoddard JJ. The unmet health needs of America’s children. Pediatrics 2000;105:989–997. 2. Petersen PE. Global policy for improvement of oral health in the 21st century–implications to oral health research of World Health Assembly 2007, World Health Organization. Community Dent Oral Epidemiol 2009;37:1–8. 3. Gussy MG, Waters EG, Walsh O, Kilpatrick NM. Early childhood caries: current evidence for aetiology and prevention. J Paediatr Child Health 2006;42:37–43. 4. McGrath C, Broder H, Wilson-Genderson M. Assessing the impact of oral health on the life quality of children: implications for research and practice. Community Dent Oral Epidemiol 2004;32:81–85. 5. Cunnion DT, Rich SE, Casamassimo P, et al. Pediatric oral health-related quality of life improvement after treatment of early childhood caries: a prospective multisite study. J Dent Child 2010;77:4–11.
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8. Slack-Smith L, Colvin L, Leonard H, Kilpatrick N, Bower C, Brearley Messer L. Factors associated with dental admissions for children aged under five years in Western Australia. Arch Dis Child 2009;94:517–523. 9. Slack-Smith L, Colvin L, Leonard H, Kilpatrick N, Read A, Messer LB. Dental hospital admissions in children under two years – a total-population investigation. Child Care Health Dev 2013;39:253–259. 10. Davidson N, Skull S, Calache H, Murray S, Chalmers J. Holes a plenty: oral health status a major issue for newly arrived refugees in Australia. Aust Dent J 2006;51:306–311. 11. Davidson N, Skull S, Calache H, Chesters D, Chalmers J. Equitable access to dental care for an at-risk group: a review of services for Australian refugees. Aust N Z J Public Health 2007;31:75. 12. Woodland L, Burgner D, Paxton G, Zwi K. Health service delivery for newly arrived refugee children: a framework for good practice. J Paediatr Child Health 2010;46:560–567. 13. Davidson N, Skull S, Calache H, Chesters D, Chalmers J. Equitable access to dental care for an at-risk group: a review of services for Australian refugees. Aust N Z J Public Health 2007;31:74. 14. Australian Institute of Health and Welfare. Dental decay among Australian children. Research Report Series no. 53. Cat. no. DEN 210. Canberra: AIHW, 2011. Available from: http:// www.aihw.gov.au/publication-detail/?id=10737419604. 15. Mutch RC, Cherian S, Nemba K, et al. Tertiary paediatric refugee health clinic in Western Australia: analysis of the first 1026 children. J Paediatr Child Health 2012;48:582–587. 16. Iranzo-Cortes JE, Montiel-Company JM, Almerich-Silla JM. Caries diagnosis: agreement between WHO and ICDAS II criteria in epidemiological surveys. Community Dent Health 2013;30:108–111. 17. Australian Bureau of Statistics. 2033.0.55.001 – Census of Population and Housing: Socio-Economic Indexes for Areas (SEIFA), Australia – data only, 2006 [Internet; updated 27 March 2013; cited 30 March 2013]. Available from: http:// www.abs.gov.au/AUSSTATS/[email protected]/DetailsPage/2033.0.55. 0012006. 18. Cultural Diversity Unit. Delivering a Healthy WA: WA Health Language Services Policy [Internet]. Public Health Division, Department of Health, 2011 [Internet; updated September 2011; cited 30 March 2013]. Available from: http://www.health.wa.gov.au/multiculturalhealth/docs/WA_Health_L_S_Policy.pdf. 19. Acs G, Lodolini G, Kaminsky S, Cisneros GJ. Effect of nursing caries on body weight in a paediatric population. Pediatr Dent 1992;14:302–305. 20. Sheller B, Churchill SS, Williams BJ, Davidson B. Body mass index of children with severe early childhood caries. Pediatr Dent 2009;31:216–221. 21. Kantovitz KR, Pascon FM, Rontani RMP, Gavi~ao MBD. Obesity and dental caries – a systematic review. Oral Health Prev Dent 2006;4:137–144. 22. Peng SM, Wong HM, King NM, McGrath C. Is dental caries experience associated with adoposity status in pre-school children? Int J Paediatr Dent 2014;24:122–130.
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Caries burden and referrals in preschool refugees 23. Harford JE, Luzzi L. Child and teenager oral health and dental visiting: results from the National Dental Telephone Interview Survey 2010. Australian Institute of Health and Welfare Dental Statistics and Research Series No. 64. Cat. no. DEN 226. Canberra: AIHW, 2013. Available from: http://www.aihw.gov.au/. 24. Nguyen T, Casey S, Maloney M, Rich S. Final Report: Refugee Oral Health Sector Capacity Building Project. Australian PolicyOnline: Research and Evidence Base [Internet; cited 1 October 2013]. Available at: http://www.apo.org.au/research/finalreport-oral-health-sector-capacity-builing-project. 25. Kuhlthau KA, Bloom S, Van Cleave J, et al. Evidence for family-centered care for children with special health care needs: a systematic review. Academic Pediatrics 2011;11:136–143. 26. Wilkins A, Leonard H, Jacoby P, et al. Evaluation of the processes of family-centred care for young children with intellectual disability in Western Australia. Child Care Health Dev 2010;36:709–718.
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27. Pediatric Oral Health Research and Policy Center. Patient Centred Care: American Academy of Pediatric Dentistry, August 2013. Available from: http://www.aapd.org/assets/1/7/PatientCenteredCarePolicyBrief.pdf.
Address for correspondence: Associate Professor Pam Nicol School of Paediatrics and Child Health (M561) Faculty of Medicine, Dentistry and Health Science The University of Western Australia 35 Stirling Highway Crawley WA 6009 Email: [email protected]
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