REGLAS GENERALES QUE OPERAN EN EL PROCEDIMIENTO ESPECIAL SANCIONADOR

The guideline for FV application published by the Chilean Ministry of Health (MINSAL) in 2012 established that the application of FV can be performed by a dentist, dental nurse (Técnico en Odontología de Nivel Superior), or dental hygienist; also, according to decree 1704 of MINSAL (2013b), it can be performed by a dental assistant (Auxiliar Paramédico de Odontología) under the direct supervision of a dentist. This variation in responsibilities is reflected in a difference in wage between both technicians; a dental nurse earned a mean salary 5.6% higher than dental assistants in the Chilean public health sector in 2012.

Dental hygienists are the rarest form of dental auxiliary personnel in Chile, with few of them working in the public health system. Therefore, though it is clinically plausible that they could be involved in the provision of FV due to their training and experience, in practice the lack of personnel demonstrates that it is not viable that they can routinely be used as part of the FV application process in the foreseeable future. As a consequence, they will not be considered in the modelling process.

The requirement for direct supervision is a legal limiting factor but, as with all legal aspects, requirements can be modified. Chile has some recent experience with changes in its laws related to the health workforce. For example, in 2010, the lack of ophthalmologists led to a modification that allowed medical technologist specialists in ophthalmology to prescribe spectacles (National Congress, 2010). However, changing the requirement for direct supervision could be even easier than the example of medical technologists. The legal normative that contains such limiting factors is a decree issued by MINSAL (2013b), this means

that a possible modification is within the domain of the Ministry of Health and would not need to pass through the National Congress to be approved.

A second argument that supports the elimination of this limiting factor is related to the simplicity of FV application. The procedure requires “painting” teeth surfaces with FV using a special brush. The complete procedure usually takes less than five minutes and the training for applications is short. Therefore, there is no necessity for highly trained personnel to perform it. Finally, a third strong argument in favour of eliminating direct supervision is the fact that there is almost no evidence about side effects (Marinho et al., 2013) and, as described in the literature (Milgrom et al., 2014), FV is safe even for young children (see Chapter 3).

Conclusion: Although modifying a Chilean decree could be laborious, it can be done. Therefore, elimination of this limiting factor (LF) was considered possible.

Prescriptions

Although dental nurses are entitled to work without a dentist’s direct supervision, they cannot do the entire procedure of application due to the Chilean guideline (MINSAL, 2012c) that specifies that a dentist must perform a clinical diagnosis first; therefore, the dentist must indicate (prescribe) the FV application. Under Chilean law, the only professionals allowed to prescribe a medication are physicians, dentists, and midwives. This means, for example, that a dental nurse cannot be sent on their own to perform FV application because FV requires a prescription, which requires a dentist. However, as in the case of direct supervision, the legal normative that contains this limiting factors is a decree issued by MINSAL; consequently, it is a political decision.

Other studies wherein the application was performed by non-dental personnel, such as in Lawrence et al. (2008) where the application was performed by dental hygienists, support the participation of non-dental personnel in a possible health programme of FV application. A similar point of view about task delegation was shared by Vermaire et al. (2014) who considered the use of auxiliary dental personnel in the application of FV in a study of caries prevention programmes in the Netherlands.

Within Chile, the main point is not about the capability of non-dental personnel to carry out FV applications, but about their inability to provide a diagnosis. Nevertheless, the need to make a

diagnosis of caries in low SES children is redundant when almost 80% of low SES children experience caries by age six (Chapter 6). Therefore, this raises the question as to why all low SES populations should not be considered as a high-risk population. In this case, there would be no need for a diagnosis, and hence prescription.

Chile has had some experience in targeting the entire population for a preventive programme. For example, a national sub-programme of fluoridated mouthwash was focused on children attending public schools in locations without natural or artificial fluoridated water. This programme also did not require a diagnosis or prescription to be applied, suggesting that a prescription for FV can be eliminated provided that FV can be incorporated as part of a national programme.

Conclusion: Prescriptions as a limiting factor was considered feasible to be corrected, because it depends on a political decision that should made by MINSAL.

Second visit to school

A second visit to the school is difficult and expensive to correct due to the low attendance rates at preschools by Chilean children, estimated at 78% by Arbour et al. (2014). If the intention is to get access to the maximum number of possible children, a second trip, at least, would be required. This logic means that costs associated with the transport of the health team would double.

An important argument against a second visit to the school is the time consumed by the health team for each visit. The opportunity cost of being in the dental practice working with patients rather than trying to “capture” the non-attending children, could be high and questioned by society. As Monsalves (2012) commented, dentists in the public health system are few compared to private sector; this is in agreement with Goic (2015), who estimated that just 22% of dentists work in the public sector. Also, as was commented on in Chapter 4, dentists in the public sector provide dental care to about 82% of the Chilean population; hence, they are under a high demand for dental care.

Conclusion: Second school visits as a limiting factor was not considered modifiable, because of the high demand for dental care in the public sector.

Parental attendance

This point is related to the concept of oral health education (OHE). This point is difficult to correct due to the low participation of parents in activities related to schools in large urban areas (Kain et al., 2010).

An important reason for low participation in school activities is that such activities coincide with the working hours of parents’ jobs (Cáceres and Alegría, 2008); this implies difficulties in getting permission to leave their job and the possibility that absence from work will reduce the income of an already poor group.

Conclusion: Parental attendance was not considered readily modifiable, so it was not planned to evaluate education in oral health (OHE) in the PSS setting in a further decision analytic model (DAM) study.

Risk of cross infection

Theoretically, different health interventions carry different cross infection risks, and therefore different adjustments might be required, some of which would be feasible and some of which would not. The risk of cross infection increases when the procedure requires more than one person.

The risk of cross infection could be reduced by the adherence to guidelines that clearly indicate what the risk of cross infection is, and how to reduce it. It would be anticipated that adhering to these guidelines would entail the use of more consumables. Specifically, the guideline should highlight the avoidance of re-using gloves (and other consumables) by the dentist and auxiliary personnel.

Conclusion: The elimination of the risk of cross infection as a limiting factor was judged feasible.

Over demand on health system

When a dentist completes an oral examination, and makes a diagnosis, she or he has the ethical and legal obligation to share this information with the parents. Once the parents have this information, they could demand dental attention. This means that a FV application programme could increase the demand of services. Unfortunately, the Chilean health system is not able to absorb anything other than the most modest increases in demand. To avoid this possible rise

of dental demand, the examination should be just a screening and not a complete oral examination.

Something similar happened with the referral of children for further treatment. Given the prevalence of caries in preschool population (MINSAL, 2012a), the risk of overloading the current health system is high. Consequently, referral of all children with caries is not recommended. An intermediate solution could be a referral or suggested action, just for those children with pain or oral infection.

Conclusion: Given that solving this limitation would require excessive amounts of money, this limiting point was judged as not modifiable. Thus, the DAM will not consider the variable of referral.

8.2.4 Primary care setting