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versión On-line ISSN 1698-6946
Med. oral patol. oral cir.bucal (Internet) v.12 n.6 Madrid oct. 2007
Marta Bruna Del Cojo1, Nuria E. Gallardo López2, Joaquín De Nova García3, Mª Rosa Mourelle Martínez4
(1) Dentist. Student on course "Specialisation in holistic dental care for children with special needs"
(2) Associated Lecturer, Stomatology Department IV. Coordinating Lecturer on course "Specialisation in holistic dental care for children with special needs"
(3) Professor, Stomatology Department IV. Director of course "Specialisation in holistic dental care for children with special needs"
(4) Contract lecturer, Stomatology Department IV. Coordinating lecturer on course "Specialisation in holistic dental care for children with special needs". Faculty of Odontology, Universidad Complutense de Madrid (UCM)
The Spanish Public Health System is stepping up its efforts to meet all the medical needs of the population. Oral health is of increasing interest for society, especially for parents who are keen for their children to have healthy teeth. Disabled children with both physical and mental disabilities do not always receive the dental care they need. The purpose of this bibliographical review is to evaluate the services provided by the Spanish Public Health System to such children. We have noted marked differences in the types of dental treatment given to these patients in the different Autonomous Communities of Spain. Some, such as Asturias, Navarra and Extremadura, offer specific care for disabled children. Others, such as Ceuta and Melilla, provide more general care.
Key words: Disabled children, Public Health in Spain, dental care.
Cada vez son más los esfuerzos del Sistema Sanitario Público Español por cubrir todas las necesidades médicas que pueda tener la población. La salud bucodental es un aspecto que cada día interesa más a la sociedad, fundamentalmente a los padres que desean que sus hijos tengan una adecuada condición oral. Los niños discapacitados, tanto físicos como psíquicos, constituyen un colectivo que no siempre recibe las atenciones odontológicas que precisan. El objetivo de esta revisión bibliográfica es valorar los servicios que presta la Sanidad Pública Española a estos niños. Hemos observado que existe una importante discrepancia en cuanto a los diferentes tipos de tratamientos bucodentales que se realizan a estos pacientes según sea la Comunidad Autónoma a la que pertenezcan. Así, en ciertas Comunidades Autónomas, como Asturias, Navarra y Extremadura, incluso se lleva a cabo una atención específica de los pacientes discapacitados infantiles. En otras como, Ceuta, Melilla, la atención, por parte de la Sanidad Pública, es más generalizada.
Palabras clave: Niños discapacitados, Sanidad Pública en España, tratamiento odontológico.
The Declaration of the Rights of the Child (approved by the United Nations General Assembly on 20.11.50) states, "The child shall enjoy the benefits of social security. The child shall have the right to adequate nutrition, housing, recreation and medical services" (4th principle), and "The child who is physically, mentally or socially handicapped shall be given the special treatment, education and care required by his particular condition" (5th principle) (1). This means that all children, without any distinction, are entitled to receive proper oral health care.
We should consider disabled child patients as children with special needs with physical and/or mental disabilities. Such children may have more marked oral pathologies, either because of their actual disability or for other reasons of a medical, economical or social nature, or even because their parents find it very difficult to carry out proper oral hygiene. In addition, they may have special characteristics making it necessary, when providing dental care, to apply physical restriction techniques or even a general anaesthesia (2).
At the end of the last century, a process took place in Spain whereby the responsibility for public health care services was transferred from the Social Security authorities to the regional health departments. The Spanish Constitution of 1978, in its Title VIII (on the territorial organisation of the State), chapter 3 (on the Autonomous Communities), Article 148(3), states in paragraphs 20 and 21 that the Autonomous Communities may take on powers in the following areas social assistance and health and hygiene.
In 1986, the INSALUD (Spanish National Health Institute) drew up a programme for oral health aiming to foster health and prevent oral diseases but, in spite of much progress in public health, there are many authors who consider that dental care is a subject that has not yet been resolved in the Spanish Public Health System (4).
We therefore felt it would be both very interesting and necessary to draw up information on the dental services provided for such children by the Spanish Public Health System, through the Autonomous Communities. The aim is that dentists should receive this information because, until very recently, treatment was limited to extractions which are a problem for the child but may also be an emotional problem for the parents when they see their children with no teeth from an early age.
As with other areas of public health, each Autonomous Community has specific legislation on oral care for children. Only of a few of them include physically or mentally disabled children in their programmes, and regulations take different forms (Royal Decree, Order, Resolution, etc.). Table 1 covers the legislation in force in Spain on dental care for disabled children.
Dental treatment for disabled children based on health care programmes
Firstly, the difference between a health plan and a health programme must be clarified. A Health Plan "covers all the health care actions needed to meet the objectives of Health Departments" (General Health Act, article 54). Within the framework of a Health Plan, a Health Programme meets public health requirements by establishing a system of objectives and activities that are then implemented by the Health Departments.
Public health system oral care for disabled children in Spain can be classified in three groups:
I. Health Plan with Objectives for Oral Health
This is the case in the Autonomous Communities of Ceuta, Madrid, Melilla and Valencia (5). It addresses children aged 6 to 14 and covers:
- Information and education on oral health
- Outreach activities
- Preventive and health care measures: oral examinations (once a year), fluor treatment, scaling, sealing of pits and fissures and filling of permanent molars.
- Treatment of acute processes: exodontia of the tooth causing the process and, if necessary, prescription of pharmacological treatment.
- In the case of disabled people who, because of the disability, are unable to maintain the self-control necessary for proper oral health care without the help of sedatives, referral to the health care areas where proper treatment can be guaranteed.
Treatment is given in schools or in Primary Health Care centres by nursing staff or by the dentist and hygienist or, as in Valencia, in University Hospitals.
The Autonomous Communities of Madrid and Valencia offer dental care for disabled children:
Madrid: Since July 2003, there has been a Unit for Oral Health in the Hospital Infantil Universitario del Niño Jesús for disabled children in the Community of Madrid aged 6 to 18 who need to receive general anaesthesia for dental treatment. Patients are mainly referred by their Primary Health Care dentists or by a doctor in the Madrid Health Institute. The hospitals Stomatology Department treats children aged under 6. The services provided at present are: check-ups, training, fluor treatment, sealants, extractions, fillings in primary and permanent teeth, pulpotomies, pulp capping and scaling. Disabled patients aged over 18 who need sedation have been receiving treatment since 14 March 2005 in the Stomatology Department of the Hospital Universitario Gregorio Marañón. The services included are oral examination, fillings, extractions, elimination of sources of infection, scaling, gingivectomies and bone regularisation (6,7).
Valencia: An agreement for collaboration was reached on 2 July 1999 between the Valencian Governments Health Department, the University of Valencia (through the Masters Course in Odontology in Special Patients) and the Universidad-Empresa Foundation (ADEIT). As a result, in 2002 the Director of the Masters Course took charge of a Unit for Stomatology and Special Patients in the Dr. Peset University Hospital. In addition to dentistry equipment, the Unit has an operating theatre in the Day-Patient Surgery Unit (Unidad de Cirugía sin Ingreso UCSI) to provide treatments under general anaesthesia. Treatments are given to seriously disabled patients and to patients with complex medical conditions. They include: examination of the oral cavity, dental cleaning, fillings, periodontic treatments, extractions, mouth surgery and treatment of sources of infection. In 2003, the Valencian Governments Council for Social Welfare (8,9) set up a dental care service for people with mental disabilities of any age. This is managed by the Valencian Institute for Care for the Disabled (Instituto Valenciano de Atención al Discapacitado IVADIS) and the Consorcio Hospital General Universitario de Valencia (HGUV). It includes simple and surgical extractions, scaling and fillings. Treatments are given at the Stomatology Department in the Consorcio Hospital General Universitario de Valencia (8, 9).
II. Programmes for Childrens Oral Health
These exist in the Autonomous Communities of Andalusia (10-12), Aragon (13), Balearics (14), Canaries (15), Cantabria (16), Castilla la Mancha (17), Castilla y León (18), Catalonia (19), Galicia (20), La Rioja (21), Murcia (22) and the Basque Country (23).
They address children aged from 6 to 15 (Basque Country, from 7 to 15, Murcia from 6 to 14) and include:
- Annual check-up: clinical examination and oral health education.
- Basic care: sealing of pits and fissures in permanent molars, fillings in permanent molars, fluor treatment, root canal treatment, extractions, scaling.
- Emergency treatments: palliative pharmacological treatment.
- Special treatments: treatment for malformations or trauma in the incisor-canine group.
- Follow-up and evaluation.
The following are not included: repair work on primary teeth, extractions for orthodontic reasons, orthodontics, prosthetic and aesthetic treatment and treatment of trauma to the incisor-canine group when third parties are held liable for payment for treatment.
The services are provided by dentists belonging to the Autonomous Community Health System and by certified private dentists. The system uses health care cheques and parents or guardians may choose the childs dentist once a year.
The Autonomous Communities of Andalusia, Aragon, Castilla la Mancha, Galicia, Murcia and the Basque Country offer specific care for disabled children, including:
- Holistic dental care, including orthodontics, when the disability affects the scope, seriousness or difficulty of the oral pathology and when the child has serious malocclusion because of treatment for a labiopalatine fissure or other facial bone malformations.
- Treatments shall be given under a general anaesthesia when the pathology or the behavioural characteristics of the child make it necessary.
The following are the specific of treatment in each Autonomous Community:
Andalusia: The service is provided by the staff of the Andalusian Health Department and the Public Hospital Companies attached to the Andalusian Governments Health Department, such as the Hospital Materno Infantil in Cordoba where dental treatments are given under general anaesthesia (10-12).
Aragon: treatments are given by dentists belonging to the Aragonese Health Department and by private-sector dentists who voluntarily ask to participate and receive the necessary credential from the Department of Health and Consumer Affairs(13). In Aragon there is no list of hospitals treating such children. When a dentist requires this service and the parents request it, a report must be sent to the Health Department which decides which hospital shall provide the treatment (24).
Castilla la Mancha: Treatment is given by the Units for Oral Health in Castilla la Mancha, reporting to the Primary Health Care Management Units, and by private dentists registered with the Castilla la Mancha Health Department (17). In the province of Albacete, a Functional Unit for Oral Care for the Disabled has recently been set up to treat patients with a disability requiring treatment under general anaesthesia. One of the operating theatres at the University Hospital Perpetuo Socorro de Albacete (25) may be used.
Galicia: On 17 April 2001, an agreement was signed between the Galician Governments Department for Health and Social Services and the Santiago de Compostela University on a dental care programme for patients with severe disabilities. (The programme also covers patients who are no longer eligible for paediatric care but who, because of the severity of their disability, cannot be treated in the Primary Care Department of the Galician Health Service (20).
Murcia: Treatment is given by dentists working for the Murcian Health Department or in accredited private-sector clinics (22).
Basque Country: Treatment is given according to the provisions of the Community Dental Service within the Basque Health Department / Osakidetza (23).
III. Oral Health Programme for disabled patients:
There are two types of programme:
A) Programme for Dental Care for the disabled
This applies in Asturias (26) and Navarra (27-29). It addresses children who have a legally-accredited disability, and includes: diagnosis and treatment of medical-surgical conditions ranging from premalign lesions to periapical conditions; extractions; preventive dental treatments such as prophylactic measures, root planing and scaling, fillings, root canal treatment and prosthetics, only in exceptional cases.
Services are provided by Health Service dentists (Servicio Navarro de Salud / Osasunbidea), or by accredited private-sector clinics, using a cheque system. When necessary, either because of the type of treatment or the patients characteristics, surgical treatment is given under general anaesthesia in hospital, such as the Hospital Monte Naranco de Asturias.
B) Plan for dental health care for the mentally disabled (PADDI)
This applies in Extremadura (30). It addresses children aged over 6 having a mental disability in excess of 33%, and includes: health education, fillings, periodic scaling, extractions, prosthesis, root canal treatment and immediate care.
Services are provided by the Health Care dentists. Children requiring treatment under general anaesthesia are treated in hospitals, such as the Hospital del Perpetuo Socorro in Badajoz.
We understand that this is a matter of some concern for the members of the Health and Consumer Affairs Commission because in the sessions of the Senate held on 15 June 2005, the Agenda covered the creation of an Integrated Plan for Oral Health.
However, odontology has not yet been resolved in the Spanish Public Health System.
Just like any other child, the disabled are entitled to receive treatment from the Public Health System and, because of their individual characteristics, they may require specialist, specific dental care using specific resources which are either non-existent or are scarce in many Autonomous Communities.
Increasing efforts are being made by the Health Systems of the different Autonomous Communities to include a specific Plan for disabled children in their Oral Health Programmes.
The Autonomous Communities of Ceuta, Madrid, Melilla and Valencia, which only have a General Health Plan with objectives for oral health care only carry out: health information and education, preventive measures (examinations, fluor treatment, scaling, sealing of pits and fissures in permanent molars), restorative measures (filling of permanent molars) and treatments for acute processes involving extractions and pharmacological treatment with antibiotics, analgesics and anti-inflammatory drugs, amongst others. The public health systems in Madrid and Valencia have centres which provide specific dental care for disabled children. In Madrid, the Madrid Health Service (SERMAS) dentists provide full dental treatment for children who offer no collaboration. In Valencia, in addition to the above-mentioned actions, they also provide periodontal treatment.
The health services of Andalusia, Aragon, Balearics, Canaries, Cantabria, Castilla La Mancha, Castilla y León, Catalonia, Galicia, La Rioja, Murcia and Basque Country have a Childrens Oral Health Programme and, in addition to treatment offered under the Health Plan above, they also carry out root canal treatment and treatment on the permanent incisor/canine group when affected by malformations or trauma. The Public Health Services of Andalusia, Aragon, Castilla la Mancha, Galicia, Murcia and Basque Country provide specific care for children with special needs which, in addition to the above, includes orthodontic treatment only in some cases. They can also provide treatment for these children under general anaesthesia.
Asturias, Navarra and Extremadura have an Oral Health Care Programme for Disabled Patients. Asturias and Navarra have a dental health care programme for the disabled which includes prosthetic treatment, but only in exceptional cases. The public health services in Extremadura, with their dental health care plan for the mentally disabled (PADDI) provide practically all the dental treatments needed by these children.
There are, therefore, large differences in the dental health care provided for disabled children by the different Autonomous Communities. Children in Asturias, Navarra and Extremadura can be considered, in this respect, to be relatively "privileged".
In view of the above, we should encourage greater awareness amongst the authorities so that:
- Those who most need treatment receive it.
- This type of information becomes more widely available.
- Projects become reality.
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Dra. Nuria E. Gallardo López
Dpto. Estomatología IV.
Facultad de Odontología. UCM.
Plaza Ramón y Cajal s/n. 28040. Madrid, Spain