Dr. Andrew Bolas:

The committee will note that the table on page 19 lists two categories: grade 5 and grade 4. This is a historic way of assessing who needs orthodontic treatment. It is based on a UK guideline called the index of orthodontic treatment need. Those in category 5 are usually people who need surgical intervention where they have unerupted teeth or may have a cleft pallet or cleft lip. These are the extreme cases that need not just an orthodontist but also other inputs from an oral surgeon, such as myself.

Those in category 4 are what we would call - if I can use a layman's term - people with buck-teeth or crooked teeth. These people have a functional need for treatment. Within the grading system, a number of years ago everybody in category 5 and category 4 received treatment. The problem, however, was that huge numbers qualified for waiting lists. Therefore, the Department decided that only certain sub-categories in category 4 would qualify. People with crooked teeth had to have a very unpleasant condition before they would get past the goalposts.

Many of the statistics for the number of patients on waiting lists, even from anecdotal evidence of working in the HSE, are not strictly accurate. In the midlands area it is 175, for example, but the consultant orthodontist for the midlands moved to Cork in the middle of this period, so people were not being put on the waiting list.

I work in the Sligo-Leitrim region where we hold assessment days when we bring in 150 children on a single day. The consultant orthodontist will examine each child and decide who qualifies and who does not. We try to work on the principle that people are not waiting to see the orthodontist to go on another waiting list. It is much better to do it en masse and get them assessed, so they know whether or not they qualify. That gives patients the opportunity, if they can afford it, to seek private treatment if they do not qualify. It also gives a consultant the opportunity to tell us that a patient does not need to go on the waiting list, but that we could do the following treatment which would have a good result. We do a lot of interceptive orthodontics, taking out teeth to allow other teeth to grow.

As regards many waiting lists, there may be a consultant but he does not have any specialists working under him. There is an artificially large waiting list due to the manpower issue. The consultant is dealing with category 5 patients, while category 4 people are put on the long finger. As Deputy Naughten said, that was the case for a long time in Galway where there was no consultant. The specialists with orthodontic qualifications will not necessarily tackle cleft lips and cleft pallets, but they will deal with category 4 patients which is their bread and butter, so to speak.

I suppose the solution would be to have more orthodontic centres around the country with a consultant here and a consultant there. For instance, in Sligo we share a consultant with Donegal, so we only have him three days a week and he is gone for the other two days.

We only have him three days a week. It is also a question of providing him with the facility whereby he has more specialists working under him and a good number of aesthetically challenged patients get treatment in a timely fashion. That comes down to allowing the resources to be invested in dental schools to train people. Unfortunately, the way things are, as we train orthodontists, it is much more lucrative to be in private practice than to work for the HSE. In the UK, they used to fund the course and make the student sign up to a contract to provide two or three years' service to the State prior to embarking on his or her studies. That allowed the State to recoup the cost of the training by having the graduates treat those who were stuck on waiting lists. A little investment in orthodontics would go a long way.

Someone asked why we only deal with these things when people reach the age of 13. The development of the mouth is a bit like a car park. It is not until all the cars are in the car park that one can see what one has to deal with. Many orthodontists will not treat eight and nine year olds. They put them on a waiting list knowing they will have to wait for four years when they are 12 or 13. At that point, the whole mess will be dealt with at once. There is a school of thought that interceptive orthodontics, which involves fitting appliances to the young mouth as it is growing, has advantages. It is something we used to do. I joined the North-Western Health Board in 1997, at which time we did a lot of interceptive orthodontics. We put in retainers or space maintainers, which are removable appliances that allow the patient to manage his or her own situation. We do not have the manpower to do that now. We are too busy filling and extracting teeth to do the tasks that represent an investment in the future. It is a further argument for the moratorium to be lifted for dental staff. When it was initiated, an exception was applied to front-line speech and occupational therapists and physiotherapists. We are therapists also, but of teeth. That was forgotten.

My colleagues have mentioned the voucher system for orthodontics. Many consultants also have private practices. They work under the new consultant contracts. A voucher would go a long way for the category 4 patient or someone on a waiting list or who qualifies and needs but cannot afford private treatment. They are the ones who are bullied at school and have aesthetic issues. Many category 5 patients have teeth buried in their jaws, but their teeth look fine. No one knows they are badly off from an orthodontic point of view. No one will pick on Johnny at school because his canine tooth is impacted in the roof of his mouth. The treatment for an impacted tooth is to leave it and to avoid surgery where that will not improve the outlook or dental health of the patient. However, that category 5 patient takes a place on the waiting list before someone whose canine tooth is coming out sideways and at whom everybody points in the classroom. There is a great deal of peer pressure on category 4 patients. If one flicks on the television, every American child one sees has a fixed appliance. It is actually abnormal not to have one. That is what our kids are thinking about. I have had mothers ask me to put a fixed appliance on even though it will not do anything. It is just so that the child can appear in school with a fixed appliance and not be the only child without one. One would not do that, however, because there are oral health issues.

One of our problems is that we do not catch kids young enough. The European norm, including in the United Kingdom, is that children are encouraged to attend the dentist from the first sign of any baby teeth, particularly from the age of three or four. Even if the child is not sitting in the chair but is there to see a brother or sister get work done, it helps him or her to see that a dentist is not someone to be scared of. It gives the dentist the opportunity to tell the mother not to send a child to bed with a bottle of Ribena and to watch his or her diet. We have the highest consumption of sweets of any country in Europe. We want to catch children young enough and reinforce the message between the first and last visit. Children are covered to age 16, which will be when the last visit happens. We really only provide emergency treatment after age 14. Those children will become parents one day. What they learn as children becomes a habit and habits are learned from parents.