The HMI Leaders Award 2015 was won by Dr. Alison Dougall, Clinical and Academic Consultant Special Care Dentistry at the Dublin Dental Hospital, for a project promoting better access to dental care and a culture of oral health promotion within the haemophilia care pathway, Maureen Browne reports.
Dr. Dougall was responsible for the transformation of dental services to people with haemophilia in Ireland. She has spearheaded not only a reconfiguration of services but also a shift in mind-set among patients, dentists and medics alike regarding the importance of good oral health for people with complex medical conditions.
The result has been that people with haemophilia who previously either did not receive dental treatment or had to queue for long periods to access it in a national centre can now receive it quickly and safely close to their home.
She has spearheaded not only a reconfiguration of services but also a shift in mind-set among patients, dentists and medics alike regarding the importance of good oral health for people with complex medical conditions.
She said that all patients with mild haemophilia in the Republic were now able to receive their routine dental treatment in primary care. Safe protocols based on use of up to date scientific evidence had been successfully implemented and waiting lists for more complex care had been reduced to one week for urgent cases, three months for routine cases and eight weeks for maxillo facial surgical cases. The cost savings over six years by using new low factor protocols were over €1 million. With safety always paramount, there had only been one significant dental bleed since the changeover was introduced five years ago and this was a patient who did not inform the surgeon that the patient had a bleeding disorder, further stressing the importance of educating patients regarding how to manage their mouths.
Presenting her award winning project to the Judging Panel at a function in the Pillar Room in the Rotunda Hospital, Dublin, Dr. Dougall said there were upwards of 7,000 people in Ireland with an inherited bleeding disorder, which at its most severe resulted in spontaneous haemorrhages into joints and organs or milder cases where bleeds occurred only following trauma or surgery. The incidence of haemophilia in Ireland was 1:10,000 live births and 1:1000 for von willebrands disease. There remained no cure but nowadays treatment was by modification of lifestyle and intra-venous infusion of missing clotting factor as required. Nowadays young people with haemophilia managed their own treatment at home and could live normal lives with participation in sports and recreational activities just like their able bodied peers.
A decade ago people with haemophilia all had to come to Dublin to get their dental treatment. It was a paternalistic model and had resulted in long waiting lists and a catalogue of difficulties for patients, and their oral health suffered. There was much untreated disease, more extractions required and poor access to preventive/restorative care and often competing priorities so that dental care was at the bottom of a long list.
“Haemophilia and dentistry had always had a tenuous connection and oral health had a huge impact on the health of people with haemophilia over the years, with some people diagnosed after a tooth was extracted in childhood.
We discovered that we could do most dental procedures without any factor at all and we started to transfer patients to primary care with individualised guidance for their own dentist.
“There was a fundamental problem to overcome in changing practice in that patients with haemophilia were scared of dentists and dentists were scared of people with haemophilia and doctors were terrified of the whole lot and catastrophised every dental intervention and insisted on factor replacement before every dental procedure. This imposed significant barriers to maintaining good oral health with high personal cost to people who were suffering from poor oral health and also impacted on the financial cost in sorting out the resulting dental problems with requirement for hospital in-patient stays and expensive factor replacement treatment.”
Dr. Dougall said that in Ireland, people with haemophilia were managed in comprehensive care centres with national adult and children’s centres in Dublin and smaller centres in Cork, Galway, Letterkenny, Waterford and Limerick. However, in the last ten years there had been a shift from hospital based care to self management and now patients with haemophilia were experts in their own care.
With improved medical treatment in countries such as Ireland, Australia and Canada we had now reached a situation where people with haemophilia were approaching the same life expectancy as the rest of the population. The medical teams needed training in oral health matters, patients needed specific pro-active advice to better self-manage their oral health and we needed to identify key areas where oral health promotion was required in their current care pathway.
“People with haemophilia knew how to manage their general healthcare and risk assess most activities in their lifestyle in most areas but not in dentistry. They thought they couldn’t brush their teeth in case they would start bleeding so we started by giving them proactive advice on how to manage their care taking a common risk approach to health along with heart disease, diabetes and obesity.
“I realised it was time to change our approach to oral health for people with haemophilia and join the mouth and teeth up to the rest of the body and I got together with the HSE, people with haemophilia and the Irish Haemophilia Society. My vision was to increase access to safe care in most appropriate setting closest to home and I could not have achieved this without patient involvement and trust from the haemophilia community and the teams that treat them.
“We developed focus groups to support leaflet and information for patients and dentists and produced information for a website. We also developed and published contemporary dental protocols using the appropriate skill mix. We integrated oral health promotion into the multi-disciplinary pathway. When we were developing dental protocols we discovered that we could do most dental procedures without any factor at all and we started to transfer patients to primary care with individualised guidance for their own dentist. Safety was the priority so we audited and re-audited as we changed practice. We needed to train our dentists and hygienists because they were scared.
“In the first wave transfer of patients to primary care settings, 400 patients with borderline disease were transferred and successfully treated outside of a hospital setting.
Where Are We Now
Preventive, restorative and cosmetic work is beings carried out by dentists, hygienists and oral surgeons and patients can choose where to receive that care supported by their local haematology teams. Dentists have access to a helpline to speak to Dr. Dougall personally once a week where they can receive guidance for individual patients that they are seeing in their own practices which has greatly increased their confidence and knowledge over time and the patients trust that their dentist have the information that they require to provide safe care.
This has increased access to timely care and reduced oral health inequalities and created an environment where every individual and sector of society could play their part in achieving a healthy Ireland. “Dental Caries and periodontal disease have been identified by the WHO as a modern epidemic which is linked to high sugar consumption and poor oral hygiene habits and this template could also transfer to an unlimited number of medical care pathways.”
Dr. Dougall has recently been elected onto the medical advisory board for the World Federation of Haemophilia, with responsibility for dentistry within the interdisciplinary care pathway. She has also been asked to be the expert for oral health in the interdisciplinary group formulating the European Haemophilia Principles of Care.
Seven finalists were selected to present their projects to the Judging Panel at a function in the Pillar Room in the Rotunda Hospital, Dublin on July 7, where the overall winner was selected.
The Judging Panel was chaired by Mr. Eamonn Fitzgerald, HMI Council Member and Chief Executive, Hermitage Clinic. The other members were Mr. Leo Kearns, National Lead for Transformation and Change, Office of the Director General, HSE, Ms. Suzanne Dempsey, Director of Nursing, Children’s Hospital Group, Ms. Eileen Dunne, Newscaster, Board Member, St. Vincent’s Hospital, Fairview, Dublin, Dr. Eva Lindgren, Medical Director/Chief Scientific Officer, Novartis Ireland Ltd and Mr. Ian Maguire, Head of Human Resources, St. Michael’s Hospital (part of the St. Vincent’s Healthcare Group).
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