Dr. Andrew Bolas:

My suspicion is that the incidence of oral cancer is increasing on a slow but steady basis. The confounding factors are alcohol consumption and smoking. I have noticed the patients referred to me are getting younger. The most recent case I saw a fortnight ago was a young girl 32 years of age. The beauty of oral cancer, so to speak, is that if it is caught early, the treatment can be done under local anaesthetic and is an excision of the area involved with dissolving stitches. However, once it gets to an advanced stage where one needs to borrow skin from other parts of the body or ribs or arms to replace bones, it becomes very disfiguring. When it gets to that stage, the first thing we examine is the patient's face. There is a social stigma almost attached to it.

People are presenting earlier with it. I have to give the credit for that to the Irish Dental Association and the Irish Cancer Society with its oral cancer awareness days. Also, with celebrities having it, some even dying of it, people have become more aware of it. Our biggest problem with the awareness day is that it is not supported by the Health Service Executive, HSE, or the Department of Health. It is purely down to the goodwill of the dentists doing it. We need to examine this because the incidence rates are comparable to other forms of cancer which get more air time.

School screening depends on the area. Geography dictates health care. In some areas, they attend the schools to examine the children in the class. Time wise that is probably the most effective way because then one knows who to call back to the clinic for treatment. The problem is that not everywhere has enough staff to go out to the schools so they have to call them to the clinics which takes longer. It means the children have to be brought out of school.

Parents often have to leave work to facilitate the appointment. The non-appearance rates also vary. In some weeks virtually nobody shows up and we are ringing around to find patients. I worked in County Leitrim for a period of time and if it happened to be a good week for cutting hay there was no point in sending out appointments. We also tend to avoid certain age groups during exam times.

In regard to the high cost of orthodontics, it is a modern reality in Ireland that the credit union treats many of the patients and even orthodontists will advertise that they allow instalment payments. However, it becomes a tough decision for parents when the choice is between paying an instalment for orthodontics or purchasing groceries.

There is a significant problem in getting theatre time in hospitals to treat patients with special needs. This is where many of the long waiting lists arise. There is a further failure in that insufficient people are trained in special care dentistry in order to proved the requisite treatments. The task is assigned to a senior dentist in a particular HSE area but he or she may not have formally trained in this area and is working on an experience basis rather than an academic basis. We found to our detriment that the packages handed out last year to encourage early retirement often removed the most senior people in dental departments. In many cases these individuals were the special needs dentists and they have not been replaced.

I will ask my colleague, Dr. Peter Gannon, to speak about models of best practice. As he works in general practice, he will be better positioned to comment on who we should resemble.