We have not received any apologies. In relation to presence in Leinster House, I advise members of the constitutional requirement that they must by physically present within the confines of the Leinster House complex in order to participate in meetings. I will not permit a member to participate where he or she is not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting. In this regard, I ask any members partaking on Microsoft Teams that, prior to making their contribution to the meeting, they confirm they are within the Leinster House complex.

The minutes of the committee's meeting of 17 December 2025 have been circulated to members. Are they agreed? Agreed.

Today, the committee will consider issues relating to dental services in the health service. In the first part of the meeting, we will hear from the Irish Dental Association and, in the second part, we will hear from the HSE and the Department of Health. To put this morning's meeting in context, in 2019 the national oral health policy, Smile agus Sláinte, was published. The overarching aim of the plan was to move away from an outdated curative care model to a preventative care and health promotion model. Almost seven years on from the publication of the national oral health policy, we are still waiting on an implementation plan. Unfortunately, there has been little noticeable improvement since 2019. It can be argued that the situation has deteriorated. The medical card scheme is haemorrhaging dentists.

Too many children are leaving primary school without ever having had a dental screening and dentists are still operating under legislation that is almost 40 years old. Urgent action is required. One of the reasons we are having this meeting this morning is to address these issues and tease them out further. In my view, our public dental services have been outdated and impoverished for far too long.

To commence the committee's consideration of these matters, I would like to welcome the chief executive of the Irish Dental Association, Mr. Fintan Hourihan, and his colleagues. Members and witnesses are reminded of the long-standing parliamentary practice to the effect that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable or otherwise engage in speech that may be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks and it is imperative that they comply with any such direction.

I now invite Mr. Hourihan to make his opening remarks on behalf of the Irish Dental Association.

I thank the chairperson and members of the committee. I am pleased, on behalf of the Irish Dental Association, to avail of the opportunity to address the committee on a number of topics concerning dental services and the ongoing staffing crisis in the sector. I am joined by my colleagues: Dr. Will Rymer, president of the association and general practice dentist in Roscrea, County Tipperary; Dr. Bridget Harrington-Barry, president-elect and senior dental surgeon with responsibility for school screening and special care patients in the HSE in Galway; and Dr. Sarah Edgar, general practice dentist from Letterkenny. We are also joined by Dr. Daniel Merrick, a general dental practitioner from Dublin; Dr. Daniel Linden from Monaghan, and Ms Roisin Farrelly, our director of advocacy and communications.

We welcome the continued interest of this committee in the concerns we have consistently raised around the provision of dental care in Ireland. We also welcome this first opportunity in the current Dáil to speak to members in this forum. Dentistry is a cornerstone of public health, yet oral health services in Ireland have been neglected over many decades. We have been invited to address four topics, namely the medical card scheme, dental assessments for children, training and workforce planning for dentists, and the role of dental hygienists in prevention and care. These tie in to broader issues across both the public and private dental sectors, not least the long overdue roll-out of the 2019 national oral health plan, Smile agus Sláinte. The Irish Dental Association is committed to reform and has published over half a dozen papers on reform proposals since 2018.

The medical card scheme, or the dental treatment services scheme, DTSS, provides care for medical card holders and is in a state of crisis. Active participation by dentists has collapsed and holders of medical cards struggle to receive dental care. Fewer than 600 dentists currently operate under the scheme, compared to over 1,400 in 2012 and over 1,600 in 2016. Between 2009 and 2023 the number of eligible patients increased by 130,000 to 1.61 million. Treatment volumes plummeted from almost 1.6 million treatments in 2009 to just over 970,000 in 2023 and this decline is certain to continue without meaningful reform. Why have dentists left the scheme? They have left due to State-imposed restrictions on the treatments they can provide compared to other patients, restrictions on the materials they can use, administrative red tape and the amount of paperwork required for very routine treatments, particularly where prior approval by the HSE is necessary, and also because fees offered are considerably below the costs incurred in providing the treatments.

Despite fee increases in 2022, the scheme has continued to haemorrhage dentists and remains restricted to emergency care and extractions, with limited preventative options. This perpetuates inequality and results in higher long-term costs for the State, as well as obviously negative consequences for patients. The Irish Dental Association has proposed a voucher-based model and interim measures such as evening clinics in HSE facilities, but formal negotiations on a new scheme were ended as far back as 2008 by the Department of Health. The Department walked out of talks with the association in that year and talks have not resumed since then.

I assure the committee that our members want to treat medical card holders but in many cases the amount they are reimbursed for a medical procedure is less than the cost of providing that care when the costs of materials, utilities, staff and other overheads are taken into account. Dentists want to treat patients in need but should not be expected to make a loss for doing so. The Department of Health, which walked out of talks in 2008, must sit down for comprehensive talks on a new, modernised and fit-for-purpose scheme at the earliest date possible.

Turning to dental assessments for children, the HSE school screening programme, once a flagship of preventive care, has deteriorated sharply. Official policy dating back to 1994 promises screening at three stages in primary school, usually in second, fourth and sixth classes, but many children are seen only once and there are parts of the country where they are not seen at all in primary school. In 2023, fewer than 104,000 children were screened, compared with 152,000 in 2018. There is an eligible cohort in the three classes of 200,000, so we can see that barely 50% of the children who should be screened in any year are screened. Screening is vital to ensure children can access preventive care, which dramatically reduces the need for future interventions. We have detailed regional data that shows that screening rates are as low as 19% in Limerick, while they are up to 87% in neighbouring Tipperary. The consequences of missing the school screening include rising decay, increased extractions and delayed orthodontic interventions.

We want to convey the very serious implications that poor oral health can have for people. It is only in recent years that we have begun to fully comprehend the strong links between poor oral health and broader serious health issues, such as cardiovascular disease, diabetes, stroke and respiratory issues. You cannot have good general health without good oral health. Despite these clear realities, the HSE dental workforce has fallen by 23% since 2006. I contrast this with the significant increase in the number of doctors, nurses and others in the health service. Uniquely, the number of dentists has fallen. However, in the same period, the number of eligible patients has increased by more than 20%. If this were another area of the health service, it would be considered totally unacceptable. We need a clear commitment from the HSE to rebuild the dental service on a phased basis and to increase the total complement by over 100 dentists in net terms on a phased basis.

Ireland also faces a severe shortage of dental professionals. We estimate that we need at least 500 additional dentists across the public and private sectors to meet demand. We welcome the opening of the new RCSI dental school in Dublin, which will provide a very welcome increase in graduate capacity. The two dental schools in UCC and Trinity College graduate about 90 dentists annually but 50% are non-EEA students, most of whom return home, typically to Canada and the Far East and do not begin practice here in Ireland. We have concerns as to the plans for the Cork dental school. It may be known there were plans to build an entirely new dental school in Cork. In fact, it was supposed to be completed in 2023, but this appears to have been abandoned. We believe that the number of places for non-EEA students in all dental schools should be capped at 20% but this would also require significant extra State funds to cover the shortfall in funding for dental schools that would follow with the loss of the significantly greater fees paid by overseas students.

Additionally, there is no foundation training year for new graduates, unlike the schemes that apply for doctors. The Irish Dental Association supports the reintroduction of a one- to two-year vocational training programme for new dentists to move from competence to confidence and to develop the skills and capacity of new graduates in the workforce. This would be vital in ensuring new dentists are given the skills to cope with high-pressure work environments and to help ensure that graduates remain practising as dentists. We welcome the announcement over Christmas of Cabinet approval for legislation to place professional competence or continuing professional development, CPD, for dentists on a mandatory basis. This is something on which we have presented to the committee and we welcome this news. At present only two specialties are recognised in Ireland and these are orthodontics and oral surgery. In the UK, up to 13 are recognised. This has an impact in hampering recruitment and service development here. We have presented proposals for the recognition of nine extra specialties to the Irish committee for specialist training in dentistry and to the Dental Council. We believe they are supportive of this change.

As an association, we have also advocated for the addition of dentists and dental nurses to the critical skills list to attract talent from the wider world. We believe this would aid significantly in alleviating skill shortages across the sector.

The creation of a national dental workforce database, which does not currently exist, would also be vital to enable strategic planning across the sector.

I will address the role of dental hygienists. Dental hygienists are critical for prevention and periodontal or gum care. Half of dental practices in Ireland currently report to the association that they have significant difficulty in recruiting hygienists and that visa restrictions limit overseas recruitment. We support expanding the number of places to train hygienists and integrating hygienists into public health programmes as this will reduce the disease burden and free dentists for more complex care. We also support direct referral to hygienists within dental practices. However, we are clear that patients should remain under the care and supervision of a dentist. There is an important public health rationale for this. While hygienists are experts in preventive gum health, they are not trained to diagnose oral cancer, complex decay or underlying systemic issues that present in the mouth. A dentist-led examination ensures that serious pathologies are not missed while the patient is simply getting a cleaning. The expanded role for hygienists will require careful examination and planning. We are aware that the Netherlands conducted a five-year trial and concluded last year that direct referral within independent hygienist practices was not desirable. We await proposals from the Department of Health regarding the scope of practice for dental hygienists and other skills-mix initiatives. We will be ready to engage positively to ensure patient care is enhanced and that access to care is made easier.

Oral health is integral to general health. Today, 80% of the costs of dental care are paid for by patients. Access for vulnerable groups is collapsing. Ireland is a signatory to the WHO global oral health strategy, which calls for universal access without undue hardship. Meeting this goal requires immediate talks on a new DTSS, restoration and rebuilding of the HSE school screening service, investment in workforce and training reforms and legislative updates for patient safety, CPD and other important patient safety issues. We welcome the stated commitment of the Minister for Health, Deputy Carroll MacNeill, to publish a three-year implementation plan to begin the roll-out of the 2019 oral health plan, known as Smile agus Sláinte. I assure members of the committee that the association stands ready to work with it and the Government to deliver a system that is fair, modern and focused on prevention and patient needs. We look forward to engaging with the committee here today on these matters and wider issues of concern. Thank you very much.

We will now move to questions from members and we will conclude this first part around 10.30 a.m.

I thank the witnesses for coming in today. I am baffled at how poor our system is at the moment with dental health given how the knock-on effect is so widely known. Cardiovascular disease, diabetes and respiratory infections were mentioned. I would also highlight the importance of dentists identifying mouth cancer and stuff like that. I am happy to work on anything that will improve dental health. As somebody who has had cancer, during my chemotherapy treatment, one of my teeth fell out. I think there is a need for greater education. Do the witnesses see an opportunity to identify areas where education around dental health might be improved? A lot of people do not actually understand how nearly everything starts in the mouth and dental health is so important. I think there are studies on poor dental hygiene that even show links to dementia and so on.

There was a reference to students coming to and then leaving Ireland. What would the witnesses propose about the caps for dealing with that? Regarding dental hygienists, why is there such an issue with recruitment at the moment?

I will take the first part of that question in terms of the importance of dentists in a range of issues. We probably are a little misunderstood as to what role the dentist has in the maintenance of health.

There is this perception that it is just about teeth but there is an awful lot more to the role. A great example would be when we lost a number of dental attendances during the Covid pandemic. We started to run into issues. We were treating emergencies only and started to lose regular contact and regular check-ups, the health screenings we do. We are not just dealing with the crisis the patient presents with. We are trying to intercept things that are coming down the line. The Senator is right; oral cancer screenings are probably the least well-known part of the dental examination but they are probably the most important. A significant number of oral cancers are detected early because of contact with a general dental practitioner, GDP. There is a volume of work to be done to emphasise to the public how important that dental check-up is. It is sometimes about public perception or the perception of the various departments of how critical we are. It is not just a small part of the mouth but it contributes to the wider picture of one's general health. It is very important that we are recognised as a vital part.

With regard to the school and student places, people obviously cannot be compelled as to where they work but there is obvious evidence that students who come from, for example, Canada then return to Canada. We are suggesting a limit on the number of places available to such students. We suggest that 80% of places be taken up by Irish or EEA students. While they cannot be compelled as things stand, they are far more likely to work here. That is why we are advocating it. The country needs it. The dental schools were encouraged to take in more overseas students to generate funds because those overseas students pay fees of about €50,000 a year. We would hope that restricting the number of overseas students would ultimately mean more graduates choose to live and work here.

With regard to hygienists, there are again very limited numbers of places available to train hygienists here. There is great interest in working as a hygienist but, again, there is not sufficient capacity to train them. We do not get very many hygienists coming to work in Ireland from overseas, unlike with dentists. That is the explanation.

I do think people want good oral health. If you look at the number of people going to Turkey to get their teeth done, it seems obvious that cost is a barrier. As a single parent, I know that if you bring your child to the dentist and he needs a few fillings, it will cost a fortune. Dentists are bound by regulation and standards. That is what is driving their costs so high.

People might wonder why it costs so much. They compare us with their medical GPs. Medical GPs are paid over €200 million a year towards their running costs before they see a patient and get paid their fee for doing so. Dentists' costs have to be covered by the money that comes in. It is more expensive to provide dentistry. You are talking about what are essentially mini operating theatres.

I welcome our witnesses. I will start with dental assessments and screening. We dealt with this in the lifetime of the previous Dáil and health committee but we have not seen any significant improvement. I am looking at the figures Mr. Hourihan gave us. He says that in 2023, fewer than 114,000 children were screened. That is out of an eligible cohort of 200,000. We know there are also geographical differences. It is really bad in some regions and counties while it is a bit better in some others, but a lot of children are falling through the cracks. Is it the case that some children are not getting any screening at all? In some instances, are they getting it but not as often as they should be? What is the optimum level of screening for a child going through primary school? What should be in place?

I can safely say that no child in any part of the country is being seen three times in primary school, which has been official policy for 30 years. My colleague Dr. Harrington-Barry works in Galway and does a lot of work in school screening. I asked her to explain what it involves and how many children could be seen. Where it works, it is really effective. Dr. Harrington-Barry might speak to that point for the Deputy but, to answer the specific question he asked, there are parts of the country where children are not seen in primary school at all. There is no part of the country where children are seen on three occasions. The most anyone would be seen is on two occasions.

Usually, the advice would be to be seen as young and as early as possible. I might ask Dr. Harrington-Barry-----

Sorry but I just want to follow on from that because I know how important and effective it is. I thank Dr. Harrington-Barry and others who were involved in it. I know it works very well where it does work but I just want to move on because we are short on time. Obviously, we are not doing as well as we should. There is a huge amount of improvement needed in screening, so we can start from there. We also know there are consequences, particularly for children, if screening does not happen. One of the issues I have been raising for a long time is orthodontics, and it is frustrating that we have not seen or are not seeing any improvements in it. That can be on the extreme side of it where people need urgent treatment. When we hear about people waiting on grade 4 or grade 5 waiting lists, are they the most urgent cases?

They are the most severe cases. There is what they call an "index of need". It is a five-point scale. If a person is a grade 4 or 5, they have the most severe overbites or severe orthodontic problems.

I am looking at the waiting list for quarter 2 of 2025. There were 7,247 people, mostly children, waiting for orthodontic treatment. A total of 751 of those had been waiting over four years. Mr. Hourican gave the example of some children having waited over six years, but it is a staggering figure. In the south east, where I come from - again there are geographical inequalities - there were 1,555, mainly children, waiting. Four hundred of those are waiting over four years. It is staggering to think about that many children waiting so long. Four years is a huge length of time in a young child's life to go without the treatment they need. Bear in mind, these are the most urgent, severe cases we are talking about. For grade 4, the figure was 4,724, and again, 422 had been waiting over four months. Why is that the case? Is it purely down to workforce?

In short, the answer is "Yes" because children are not being seen at an early stage as part of the screening due to what we have just explained. That is part of the problem. When they are examined and prescribed for treatment, the specialists are not available to see them. It is a classic case of where there is not a screening service, the orthodontist does not get to see the child at an early stage, which has an impact on their orthodontic development, but then there is also a shortage of specialists to provide the care.

I have one final set of questions. Mr. Hourihan talked about workforce planning. We know we need to increase the workforce. The workforce has gone down proportionately, and demand has gone up. That is a real problem. When we talk about a reliance or overreliance on non-EEA fees - people from outside of the country coming in and being trained here - Mr. Hourican said that in some cases it can be 50%. What is the evidence relating to how many of those stay in Ireland and practise here? I am assuming it is low. Is the concern Mr. Hourihan has that we are essentially not funding the training colleges? The training colleges have to subsidise themselves by taking in more non-EEA graduates. We are not getting enough domestic graduates. The people we are training are basically going home to work elsewhere. Is that the issue?

I ask Mr. Hourihan to give a brief answer because we are out of time.

Yes, that is correct.

I thank the witnesses for their presentation and their supply of information to us over the past 12 months in particular. In relation to the number of dentists employed in the public sector at the moment, in 2012 it was 283. We have had a huge increase in population since 2012, of 25% or 30%. I understand, however. from the last figures I received from the association that the number of people in the public service as dentists was something like 253. Has there been any change on that?

There has been negligible change in recent times. There have been commitments to hire extra dentists. The HSE will have current figures, but I cannot imagine that it is much more than 253.

Even though we have had a substantial increase in population, we have not had an increase in the number of dentists working in the public sector.

That is correct. I will contrast it with the expansion of the number of doctors, nurses-----

That is the point I was making. In the meantime, the number of medical consultants working in public hospitals has gone from around 2,000 to 4,500.

Instead, with the dental service, we have remained static and, if anything, we have gone down, despite the increase in population.

That is very much the case, yes.

In relation to children in particular, every week I have different parents come to me who have a child with an intellectual disability and they are trying to get access to dental care. There seems to be a huge problem in that area because in a lot of cases the child needs to get an anaesthetic for a proper examination and treatment. What is the witnesses' understanding of what is now being provided, in particular for children with intellectual disability as regards any kind of planned approach to dealing with that type of patient?

My colleague, Dr. Harrington-Barry, deals with special needs patients so I might ask her to address the question.

I thank Deputy Burke for that question. I am quite happy to speak on that. From a screening point of view for special care patients - I treat both special care adults and children - in an ideal situation these patients would not need any treatment if we had a proper screening procedure and proper preventative treatments in place. That can be something as basic as basic oral health instruction. When we get to the time when we have to have treatment, general anaesthetic is usually the place we need to go. I run two general anaesthetic services in University College Hospital in Galway. I have an adult service and a paediatric service. A year ago it came to a crisis as I was not getting access at all. There is always a knock-on effect on a health service or in a department. The emergency department in UCHG is full. Therefore, those patients are then admitted into the surgical day ward and a lot of elective surgeries are cancelled, which would include special care patients.

Is Dr. Harrington-Barry saying that, basically dental care is not compartmentalised like other areas and as a result, you fall in under the general scheme as regards trying to get access?

Yes. I work in UCHG to treat patients - children and adults with additional needs.

Is one of the problems in the dental service that dentists like Dr. Harrington-Barry get frustrated with the system as they find that they have not got any change in the last five to ten years?

We can get particularly frustrated but when it works it works. We had a crisis this time last year so we sat down and ring-fenced a service for my paediatric special care patients. I have ring-fenced beds in the paediatric ward in UCHG and I have not been cancelled at all. The other body of work that we need to do is to ring-fence those same beds for my adult patients.

Just coming back to the number of people we need to come out every year to fill the gaps, because obviously dentists will be retiring over the next five to ten years as well, what kinds of numbers do we need to come out of college every year in order to fill the gaps that are there now? We currently have between 50 and 55 what we would call Irish-European students coming out. If we add on the Royal College of Surgeons, in four years' time we will have another 25 coming out, but that is still only 75 in real terms. What should we be bringing out?

We should be graduating at least 100 dentists every year. It is important to understand that with the dental register, two thirds of the dentists who are joining the register in any given year are coming from outside Ireland. Graduates will contribute to the increase in the workforce but, to answer Deputy Burke's question, we would need at least 100 graduates a year who are willing to work and practise in Ireland.

I have a number of questions at this point. I want to start with the national oral health policy, Smile agus Sláinte. It is quite extraordinary that seven years after the policy was published, we do not have an implementation plan. Many of the failures we are talking about this morning go back to that lack of action and the lack of implementation of the plan. Why does Mr. Hourihan think we are still waiting on the implementation plan? Does he think it reflects the level of priority given to oral health by the Department of Health and the HSE? Could he point to any major changes in oral health since the 2019 plan was published?

Yes. All of what the committee has heard today reflects the fact that oral health is not given any priority.

This is true of successive administrations over the past three decades. The oral health plan was published in 2019. We certainly would have expected to see the roll-out of the first phase of the reforms long before now. We were told we were invited into a consultative exercise in the summer of 2024. We were provided with a draft of the plan and we expected it to be published long before now. We are constantly told it is "imminent", which is the most common word we hear to convey to the profession and to patients as to when change will come. All of what the committee has heard reflects the fact that oral health has never received the priority it deserves, and we are now seeing the consequences.

Absolutely. I wish to touch on the medical card scheme, and the dental treatment services scheme. In 2016, there were 1,644 dentists participating in the medical card scheme. By 2024, that number had more than halved, with just 810 dentists taking medical card patients. What are Mr. Hourihan's thoughts on the reason for this mass exodus? One of the things that struck me was around the criteria of the scheme, which allows for only two fillings a year, but an unlimited number of extractions. What are Mr. Hourihan's thoughts on the restrictions around the scheme? Are they a barrier for dentists participating? Is the gap between the fees and the actual costs a bigger issue? Does Mr. Hourihan think the scheme can be improved and be made fit for purpose, or is he in favour of an entirely new model?

To answer the latter question, we do not believe the current scheme can be tweaked in any way that will make it viable. My two colleagues to my right, one of whom left the scheme and the other of whom works in the scheme in Donegal, where the medical card scheme is particularly important, will give the Cathaoirleach their sense of why we have arrived at the impasse we have. I ask Dr. Rymer to speak first.

I graduated from the UK. The idea of a health service is something that is in my genetics. It is a fabulous concept. I worked under the medical card scheme for a number of years, and when I transitioned from an associate - I was a dentist who worked for another dentist - into a practice owner, I made the decision, unfortunately, and it was not based on costs. The Department will say it has given us a fee increase with no impact at all on workforce. The real issue for me relates to patients who came to me after years of self-neglect. I can think of 1,000 patients but two in particular really stand out. One patient was anxious about going to the dentist and never wanted to go, but she decided to take the opportunity to turn the situation around. She came in to me, but all I could offer was very minimal intervention. We cast such people back out into the world without really having had the problem addressed. This is a very young patient who is going to lose a lot of her teeth through gum disease. Another young gentleman who had got some work done abroad came back wondering why his dental work was loose. Essentially, over the course of two years, I converted him from a mouth of crowns and bridges to two very ill-fitting dentures. He is 35. I was 35 at the time, and I have sent him out into the world knowing that the dentures and work I am able to provide under the medical card scheme are woefully inadequate for his function and for his abilities to eat and talk. His self-confidence is shot. It is just not an adequate level of care. I cannot understand why we have a health service that facilitates implants for hips and knees, but when it comes to teeth, we are happy to leave people with inadequate care.

There are huge issues. Some of it goes back to the children's dental services, starting early, and the number of public dentists. In 2012, there were 283 whole-time equivalents in public dentists. That has fallen to 241, a decrease of 43 dentists. That is a concerning drop in the number of public dentists. I am also very concerned about the drop in training places, and the decision not to proceed with the UCC dental school in Cork. We need to be training more dentists. There should be investment in that area. I thank our witnesses. Our next slot is for the Labour Party. I call Deputy Sherlock.

I thank the witnesses. This is a very important session today because dental services have been the forgotten part of the health service. Certainly, in my view, it beggars believe that we have an oral health plan that is now waiting seven years for implementation. The reality is that the lowest income and hardest pressed families are those who are suffering most. With regard to screening, a senior dentist in the public service told me that in his area, the children are now coming in in sixth class.

In fact, one of the children drove themselves to what should have been their primary school screening. Again, this beggars belief regarding the public screening service. The view of the Irish Dental Association is that the DTSS is certainly on the point of collapse. We have seen a 38% drop in the number of participating dentists over the last number of years, and yet in the second session today the HSE will tell us there has been a significant increase over the last number of years and everything is looking very rosy.

The Irish Dental Association has said that the Department of Health walked out of negotiations on the scheme in 2008. There was obviously a series of changes to the fees in 2022. What has happened since then? Are negotiations taking place now? Has there been a proposal for negotiations? Is it expected that negotiations will take place this year?

No negotiations are taking place. A fee increase was introduced in 2022. There should have been a fees review in 2025, but that did not happen. We have consistently sought negotiations. In 2008, talks started, and then the Department left those talks. It said it was for legal reasons. There is no good reason it will not and cannot speak to us. We are available to speak to the Department. We want to see an entirely new scheme. The Department would say it increased the fees for some of the treatments by between 40% and 60% in 2022. At the time, I told the Department it would have no impact because the fees are only part of it. It is also about the restrictions on the scheme, its operation, its limitations and the associated bureaucracy. An entirely new scheme is required.

If the Department is saying there has been an increase in the number of treatments provided, it is obviously about where you choose to start your analysis from. There might have been a small increase in treatments if we were to look at the last five years, but if we were to look at where we were in 2009 and the fact we now have 130,000 extra eligible patients, then the number of treatments should be significantly greater. We are nowhere near where we were even in 2009, and we have 130,000 extra eligible patients. Nobody, therefore, can persuade me that the scheme is suddenly on its way back. It is not. The evidence is there. We have a record number of dentists in practice, but fewer than 600 are actively participating. The committee will be told there are 800 contracts, or whatever number is given, but there are contracts that are dormant and duplicate contracts. If we were to look and ask how many dentists are actually claiming payments for seeing patients, it is fewer than 600 or thereabouts. This is when we have four times as many dentists in practice. Barely one in four private dentists is participating in the scheme right now. There is a reason for that and we have explained it.

We are available. We are frustrated. We want to see an entirely new scheme. We are not interested in an interim scheme or in tweaking a scheme - we want an entirely new scheme. There is no good reason we have not been at the talks table, other than that, as I consistently say, oral health is not a priority. If it was a priority, we would not be here asking why we have been left outside the door and why there have not been talks in the last two decades.

As I see it, there is growing inequality in the country right now. There are lots of people who can pay and who choose to pay for dental care and also lots of people who cannot do so. If negotiations were to restart, is the Irish Dental Association confident it would be able to bring the 75% of dentists not currently participating into a new scheme? I am very clear as to what is needed. Obviously, we see that the Department of Health is in a completely different head space in this regard, but does the Irish Dental Association believe there would be a significant response from dentists out there to a new scheme if one were to be agreed?

What I can say with certainty is that we will bring a lot of new ideas to talks with the Department and the HSE. Ultimately, the extent to which dentists sign up to the scheme will reflect the viability of what emerges. I believe it is possible, but I would not underestimate the level of distrust in the State on the part of the profession for obvious enough reasons or the challenges posed because of recent experience.

I just have one thing to say. On the special care, I understand kids are going from Kildare to Dundalk for general anaesthetic, and from Waterford to Cork. Galway was also mentioned. Are there examples in other parts of the country where children are having to travel significant distances for general anaesthetic? I ask this because I think it would be really useful for us to understand the huge gaps in special care.

I thank the Deputy. We will get a very brief answer.

Very quickly, yes there are. There was a clinic in Dublin, in St. James's Hospital, that closed over ten years ago.

There is supposed to be a facility opening in James Connolly Hospital. It has not happened so children must travel from half the way across the country and further.

I thank Mr. Hourihan and his team for coming in today. My first question is on the dental treatment services scheme, which has been alluded to by Mr. Hourihan. It beggars belief that with a growth in population of 1.2 million over the last 20 years we now have fewer dentists providing a service to the State. I am not blaming the dentists for this. The plans that have been mentioned for having a comprehensive dental scheme for the State are really important and I wanted to note that we have fewer dentists.

The number of dentists being trained has been mentioned and it seems really low. Between 50 and 55 people are being trained as dentists but that seems like a really low figure. An additional 25 dentists will come from the Royal College of Surgeons in Ireland but it still seems like a really low figure. What would Mr. Hourihan say to that?

To be clear, in any year over 90 people graduate. When we say there are 50 or 55 graduates, that is how many are EU graduates and are likely to practice in Ireland. We now have a third dental school which is operated by the Royal College of Surgeons. In time it will become the biggest of the three dental schools. It takes five years to train a dentist. Yes, the number of dentists is woefully inadequate in terms of training places.

The number of medical general practitioners in Ireland is about 3,500 and 450 people are trained each year. Therefore, it is difficult not to believe that we are not addressing the capacity issue for dentists. Would that be a fair summation?

Absolutely. There are challenges in medicine and there are even greater challenges in dentistry. Yes, where you have that many medical graduates every year and that number of medical doctors in general practice, you would say we are completely undertraining the number of dentists. We are now relying on and are very grateful for dentists arriving into Ireland from Britain, the rest of Europe and further afield. If we did not have that option, we would be in an unthinkable situation. We have to become more self-sufficient.

I do not mean to interrupt but there are considerable barriers to getting on the dental register here. I am aware of a Pakistani doctor who has lived here for 15 years. He worked in surgery but came to general practice and was training in my practice. His wife is a dentist. They are moving to Enniskillen because they have told me, and Mr. Hourihan can correct me, that it is less onerous to get on the UK dental register than the Irish dental register. Please explain that. On the face of it you would sense protectionism. Is that the case?

As the Deputy will know, the Dental Council of Ireland is a separate body.

Yes.

It is the licensing regulatory body. On the face of it, the requirements are very similar in Ireland and Britain. The administration and how applications are processed may be the explanation in that the Dental Council-----

I think the couple said that the dentist's wife will have to do less years in practice to qualify to get on the UK register. I stand to be corrected and I am happy with what has been said by Mr. Hourihan but it is something that struck me.

On the proposal to have intern years for new dentists, in my own profession one does six years. I was ill equipped after six years. I was not a great student. There were other students who were a lot better than me but after six years I was ill equipped to go into practice. In solo practice, certainly I would say it would have been dangerous to do that. My intern year in James Connolly Hospital in Blanchardstown certainly sorted me out in the real world and put me on the right track. It beggars belief that there is not the same intern position for dentists.

My colleague Dr. Harrington-Barry is one of the last people who was involved. There was a vocational training programme for a short period that was somewhat analogous. Maybe Dr. Harrington-Barry can outline her experience.

I was in the pilot scheme when it was withdrawn. When I qualified, it was an optional scheme whereby someone would do a year post graduation during which they worked two days per week in private practice, two days in the public scheme and had a day of lectures. The scheme was withdrawn around 20 years ago.

We are out of time. Time is quite tight because we have another session coming up.

Regarding the information the witnesses gave earlier about ring-fenced resources, am I correct in saying that those relate to Galway?

Yes.

On particular children with special needs, I want to read out details of the experience of one of my constituents and I would like to hear Dr. Harrington-Barry's opinion as to whether this situation is sadly unique or is desperately sad and a reflection of the current system. This young lad is five and has additional needs. Since February 2025, he has had multiple tooth infections requiring repeated antibiotics. He requires dental extraction of his milk teeth under anaesthetic and is in ongoing pain. Is that how bad this service is for children with additional needs?

Unfortunately, the truth is that this is how bad it is across the country. I am lucky. A year or two years ago, that would have been the situation I would have had. Luckily enough, I have ring-fenced resources. That has reduced my waiting list for paediatric special care patients.

By how much?

By about 70%. I have frequent access because I have ring-fenced resources. Where we have ring-fenced resources or resources in the public dental service, things work. Unfortunately, however-----

I have one eye on the clock, and I really want to get a bit more information. Before Dr. Harrington-Barry had those ring-fenced resources, how long could a child expect to wait to receive the treatment he or she needed in comparison with now?

Over a year. Within the hospital workforce I work with, we can sometimes get a maxillofacial surgeon to see a child as an emergency case, but, again, seeing that patient on an emergency basis when he or she should be seen by the likes of me pushes somebody on a waiting list for maxillofacial work back. Everything has a knock-on effect. Ideally, we would not have a five-year-old patient with that level of dental decay. That is where early intervention really matters. Resources need to be put into early intervention.

in the context of basic school screening, I told Mr. Hourihan earlier that-----

I will come to that in a moment. How common is Dr. Harrington-Barry's experience of having those ring-fenced resources?

I would say that it is not common enough.

By how much?

I would not have the figures on that but it is not common at all.

Should it be the standard?

Absolutely. When I was thinking about coming up here today, I was thinking about how I would explain what we do in the public dental service. We work within the community and also within hospitals but we are not hospital staff. We straddle both. We are quite different in community service. That is where we are a bit different because we do have that surgical access.

Are the patients availing of and benefiting from that surgical access all within a close geographic area or do they come from much further afield?

My main referrals would be from Galway county and city, but I would also get referrals from Mayo and Roscommon. Patients who may be too high-risk to be seen in a smaller hospital would be seen in Galway. I know how lucky I am. That has only happened this year. The ring fencing of resources should happen nationally and-----

Luck should not be a part of it.

Absolutely, and a nod and a wink should not be part of it. It should be part of our structure. We are very lucky that we have that outreach and care pathway in the public dental service. It is developed, but the resources are not there. We have the infrastructure; we just need more resources to make-----

And a definitive plan.

Absolutely.

On those missed assessments for school-age children, is it even possible at this stage, given the resources and pressure on resources in the public system, to clear that backlog? Are those missed appointments gone forever and that inequality embedded for those children?

Unfortunately, and I think it was Deputy Sherlock who said this, some students, usually in transition year, drive themselves to their first dental assessment in some areas that are poorly served or have no staff at all. That is where that happens. There is a direct link between having no staff and those patients who are driving themselves to their appointments. Ideally, we should be serving first, fourth and sixth class, but as Mr. Hourihan said, it is not happening.

I thank the witnesses for attending. From their opening statement, it appears that the facts are quite negative and worrying with regard to the whole scheme of things. We read and hear, and this sounds negative about the Government, about how the Government is committed to doing X, Y and Z. I am flabbergasted that things are as critical as they are presented in this report. It behoves the committee to demand or ensure follow-up to this and, whatever is promised, that we are assertive enough to ensure that investment and that progress are met. I would not like it to be that we come back here in a year's time and find that the status quo remains. It is quite worrying.

I will not go back over any questions that were asked by previous speakers, but the one thing that strikes me about this is the lack of detection for children in primary schools. Mother of God, that is the place where you intercept those dental problems. That is where correction and all that process begins. If that is not happening, or is happening on a poor scale, that should be an immediate priority for any government or any Department. I would hate to be the parent of a young student who needs dental correction or examination. If I got this report, I would throw my hat at it and say, "Let us go to Spain and get this done where we can expedite the process". I have to express my genuine concerns over everything I have heard this morning. Every paragraph in that report is peppered with negative and worrying facts. I look forward to what is coming in the next session by way of understanding exactly how these people can come together, with recommendations from the witnesses and all of government ensuring that there is investment where issues exist.

It was suggested that Ireland requires an additional 500 dentists. Even with expanded training places, how long do the witnesses believe it would realistically take to close the gap? What interim measures are essential or are being considered?

It will probably take a full decade to see a real, noticeable improvement because there is that level of unmet and undiagnosed need currently, and that level of undersupply in the public service. When we say 500, we are saying that we would need 100 net extra working in the public service to get the school screening programme back to where it is. We anticipate there are not enough dentists to meet the rise in the population that continues.

On what needs to be done, there needs to be a focus on those most in need. We see those as being children and medical card patients. There are clearly lots of other changes that need to be made in terms of the legislation. There are many good ideas in the 2019 Smile agus Sláinte plan.

There are some that we do not agree with but that we are happy to talk about. We would say that in order to make the biggest difference, the focus should be on the most vulnerable patients. Those are the ones the committee has heard about already. They are the children who are not being seen in the schools. When Dr. Harrington-Barry goes into a school to carry out screening, she can see 100 schoolchildren in a day. What is being proposed is that some services will be put out to tender in the private sector. That will not work. We need more dentists in order to have children seen at an early stage. The latter works, and we can give countless examples. We do not want to be constantly highlighting the negative. We would be more than happy to talk about the things that work, but, unfortunately, those things only work when they are properly resourced. The things that used to work well no longer do so because there are not enough dentists. I referenced the school screening programme.

On what should be prioritised, it should be the replacement of a completely unworkable scheme relating to 1.6 million adult patients who are medical card holders and a focus on hiring more dentists in order that children are seen. If we do the latter, instead of 100,000 being seen every year, 200,000 would be seen and there would be a noticeable improvement in oral health.

Apologies, I was at another meeting. The Cork-Kerry region gets an annual briefing. The Chair would have been at the most recent briefing just before Christmas. I want to hear the witnesses' opinion on one of the proposals that jumped off the page at me - it was obviously put forward with the right intention - namely tackling waiting lists. The proposal is to provide a €3,000 subvention or grant to parents. This is only under consideration; it is not a formal proposal yet. What is the witnesses' view on allowing parents to seek private treatment for their children from dentists rather than keeping them on never-never that is the public waiting list?

I am not familiar with the proposal, but it is somewhat similar to the voucher idea we have proposed for medical card patients who are adults. The idea of investing and giving money to parents to spend on dental care is something we would welcome. Obviously, it would have to be properly policed and the money would have to be spent on dental care. That applies to the dentists as much as to the patients. Anything that will allow people to access dental care has to be good. We welcome and are well aware of the review that is taking place in Cork and Kerry, specifically in respect of oral health services. We would certainly like to discuss that idea and others.

Would anybody else like to comment on that or is there general agreement on it?

Any scheme that addresses the backlog is good. There is a tsunami of dental needs. We would obviously have to look at any proposed scheme. We would broadly welcome the proposal. The difficulty is that a huge amount of money has to be put in to fix the problem. It needs to be stopped and, simultaneously, the school screening crisis has to be fixed. Any dentist here will be able to come up with 100 patients they see on a private basis regarding problems that are expensive to fix and that were either entirely preventable or preventable at a low cost have and that have now become much bigger problems. A €3,000 grant could potentially solve issues early on.

On the number of students from abroad who are here studying, it was stated that the likelihood of them returning home is quite high. There are talks in the health service about areas where there is a deficit of employees. The students in question might be tied into the system here for five years, three years or whatever after they qualify. What is the witnesses' opinion on that in the context of retaining newly qualified staff?

Anything that keeps dentists here has to be a good thing. I would rather incentivise people than penalise them. The majority of Irish students will choose to work and live here. Anything that keeps dentists working here has to be good. If it is approached on the basis of encouraging rather than penalising people, that could be workable.

I would just add that having the foundation training is beneficial, either a year or two years. I was part of that programme in the UK and did a year's vocational training. It took me to an area of the country that was less well resourced with dentists. I ended up staying there. It really encourages students. They develop a peer network around them. As well as making them more confident in their actual clinical skills, it really helps to keep people in the dental service in this country if there is a foundation training programme available.

This is an issue that is of concern to all of us. Many people say to me that their children cannot get an appointment and so on. I am from Limerick, which was highlighted in the report as a place where the number of people who were seen was quite low. There is an imbalance around the country as to how many people are seen in different counties. Is that due to the shortage of staff? Would the HSE consider bringing back retired dentists to oversee the schools programme? They still have their qualification and some of them may have kept of their training. Was that ever considered?

The variation in the number of children screened is entirely reflective of the number of dentists available to do it. Overall, the average is that 50% of children are seen and 50% are not seen. There are regional variations and Limerick is particularly bad, or it was in 2023. As to retired dentists coming back, the HSE has rules around bringing people back once they pass a certain age. There would possibly be some dentists past retirement age who would be willing to consider doing occasional work but it is not something that has been discussed. I know from discussions I am in with other health service unions that the HSE has strict rules about bringing people back once they pass a certain age. Subject to that, there may be some scope for bringing back retired dentists.

Because of the shortage, some people have resorted to going online for their dental advice. Others may have gone abroad. Have the witnesses any comments on that? I have seen people going abroad and having to come back here to get it rectified.

It is even more complicated than that. A patient who has a dental issue may do a google search, looking for an Irish dentist. They consult the Irish dentist and may be told they need to do X, Y and Z to get it fixed. The way social media and the Internet work is that they will then be bombarded with ads from clinics abroad. It is very tempting to opt for that when they are offered similar treatments at a much lower price. There is not necessarily a level of awareness of the problems they may run into. I have a significant number of patients who sought treatment abroad and now either have to come back and have reparative work done at much more significant cost than the original plan provided by a local dentist, or leave themselves in a much worse state from an oral health perspective as they have lost a lot of what they started with. It is a huge problem, which goes to highlight the systems failure. If we had the system failures corrected, it would not be as much of an issue.

There was reference to having it put on the critical skills list. Has there been any update on that? Is the Department open to it?

We have made submissions to the Department of industry unit. We will continue to make submissions. There are lots of other people making similar submissions. We have not received a positive result yet. We are in no doubt that there is a shortage and that there are dentists, hygienists and nurses outside of the EEA who would be interested in working here.

I was a member of the old Southern Health Board and was chair of it for two years back in the 1990s. The public dental service has gone from very poor to absolutely shocking. It is appalling, to be honest about it.

There is a severe lack of public dentists and the numbers employed by the HSE have declined over the past 15 to 20 years. There is a workforce crisis, of that there is no doubt, and rural areas are being affected the most as a result of this. There is a limited number of places in the Irish dental schools and many students who come here to train as dentists return to their own countries after graduation. Is anything being done about that? That is not the way to do business. They are here for a reason and we should be keeping them here. There were plans for a new dental school in Cork. Are they gone completely off the radar? The school was supposed to be completed by 2023 but it has not even commenced.

There are extremely long waiting lists for children, older people and those with special needs who require essential, specialist care. How many years are they waiting? Can the witnesses give us a feel for that? I have come across unbelievable stories over the years and the situation is not improving.

Regarding the school dental scheme, there has been a huge decrease in the number of practices taking clients. Can anything be done in this regard? The witnesses said that an additional 500 dentists are needed immediately. What can be done to address that shortfall? The DTSS is a complete waste of time because it only covers extractions. It does not cover preventative measures such as fillings and so on. The public scheme has been underfunded and it is children and medical card holders who are suffering the most. We need to get our act in order. That is the bottom line. It is shocking.

On the question about the dental school in Cork, we believe that it has effectively been decided not to proceed with that plan. A school was to be built on a new site in Cork, which would mean that the existing school on the CUH campus would be given over and developed for medical purposes. We believe that because of decisions made within UCC itself, a decision has been made not to proceed with that, which is extremely disappointing. The existing dental school in Cork is barely fit for purpose. It requires significant funds to bring it up to appropriate and acceptable standards. The staff and students there are doing incredible work, given what they are provided with. It seems that the thinking now is to invest in the existing school rather than building a new one, which was promised and which should have been built by now. We would welcome some certainty on the future of dental education as it relates to Cork and the Munster region more generally.

Regarding incentives-----

I ask Mr. Hourihan to be brief because we are over time.

We have covered the fact that the foundation training scheme would be pivotal in keeping people working in Ireland, particularly in rural Ireland. Addressing all of the problems with the medical card scheme and addressing all of the other issues we have raised will help to attract dentists to Ireland and keep them here.

I thank the witnesses for coming in. I must say, for somebody like me who is fielding phone calls about dental care for children, the news here today and the reports we are hearing are really damning. It is great to get feedback from the witnesses. I come from Donegal, a very rural county. The school was always the first start for every child and they were taken up through the school system. Recently we lost our school dentist in Killybegs. The service was moved to Donegal town but we had no prior notice that it was going to be moved. The screening needs to start at school. That is where it was previously and it was working.

I cannot understand. Is it cutbacks? It beggars belief as my colleague said. We are only hearing this today. It is good to hear it from the witnesses and it will be good to have the HSE before us. At the end of the day, the school screening service worked and I do not know why it is not being kept going.

There is also a serious lack of dental hygienists. Are the dental hygienists also trained in Cork and Dublin or can they go some place else? I know two people who applied to get into Cork and did not get in for some reason. Other people from other countries got in. That is wrong. According to the dentists I talk to, there is a serious lack of dental hygienists in Donegal. It is great to have a friend here from Donegal. I have never met her, but it is lovely to see Dr. Edgar here. Where can we start to get the dental hygienists trained and moved on quicker?

Dental hygienist places are limited in Ireland and that is one message that comes from the IDA and general dental practitioners. We need more dental hygienists. Surrounding that we need the framework of dentists because dental hygienists must work under the prescription of a dentist because of their scope of practice as defined by the Dental Council. Just trying to train more dental hygienists is a sticking plaster on the problem. We need that framework beyond them. The message comes that we should be finding ways to try to find training places for people who want to stay and work in dental hygiene. The failure of the whole dental service can be encapsulated in a child missing their screenings. I see it. They will then get decay and need to be referred to the general anaesthetic service. They then get crowding because they have lost teeth early. They end up in the orthodontic service. If we can get them in at the screening stage and with the preventive message with dental hygienists working in the public service, that will save resources down the line.

The Senator hit on an important point about school screenings in his area. While we welcome that we have a health policy in Ireland now, a real problem for us is that any oral health policy should not only be about driving an improvement in oral health in the country, but it should also be about reducing health inequalities. I throw up the red flag that proposals the committee will hear about later will talk about moving the school screening service effectively into private practice. The scheme, as it is supposed to operate right now, will ensure that every child gets seen. It works really successfully when funded correctly. The new system will drive health inequality. Those most vulnerable are not going to seek treatment from private practitioners, and private practitioners do have the capacity or the training to be able to deal with that. It will be detrimental to oral health.

As Dr. Rymer said, the HSE runs a targeted approach and the proposals out there say it would be up to a parent to bring their child to the dentist. We run a targeted approach. As Mr. Hourihan said, I can go to a school and screen between approximately 80 and 100 kids, prioritise those, bring them in as they need to be brought in and refer them to the hygienist as needed. Our going to a school has a halo effect. The whole school is talking about it.

I thank the Irish Dental Association for its engagement, the detailed briefing and coming before the committee and for all of its work and advocacy in this area.

I welcome representatives from the HSE and the Department of Health to continue the committee's consideration of dental issues in the healthcare system. As they will know, we had an engagement with the Irish Dental Association earlier. We will continue those engagements. The witnesses joining us here today are all very welcome. We are quite tight on time this morning so I ask that they keep their opening statements to five minutes.

I will cut the witnesses off at that point in the interest of time.

We will start with the HSE and Mr. Canavan.

I thank the Chairman and the committee for their invitation to meet with them and to discuss matters relating to the dental service in the HSE. I am joined by my colleagues Mr. Pat Healy, the national director for national services and schemes, Dr. Anne O' Neill, our assistant national director for oral health, and Mr. T.J. Dunford, an assistant national director for primary care access and integration. I am also supported by my colleague Ms Caroline Crawford, who works with me in my office.

In recent days, we have provided the committee with a detailed briefing on progress that has been made and activity that has been delivered over recent years, including the reforms under way in line with the national oral health policy. The HSE delivers oral health services through three main channels: the dental treatment services scheme, which enables medical card holders over 16 to access care through contracted dentists; the community dental service, which provides care for children under 16 and patients with additional needs and emergency treatment; and orthodontic services for children who meet defined clinical criteria.

The national oral health policy, Smile agus Sláinte, launched in 2019, sets out a transformative vision, moving from a targeted school programme to a life-course approach, embedding prevention and integration within broader health strategies.

Following the introduction of a number of changes and fee adjustment in May 2022, there has been a significant increase in activity under the DTSS. In 2025, over 307,000 adults received care under the DTSS. This is up 20% on 2022. More than 1.05 million treatments were delivered last year, a 30% increase over the same period. Investment has grown by 43%, with €69.9 million paid to contractors in 2025.

Dental services for children under 16 years are delivered through 17 dental areas nationwide. In the period to November 2025, over 138,000 new patients were assessed, including 94,800 under the targeted programmes in respect of school and special care programmes, with over 40,000 others assessed in the non-target groups, including emergencies.

The HSE provides orthodontic treatment free of charge to children who meet defined clinical criteria under the HSE orthodontic guidelines waiting list initiatives. These initiatives have delivered a significant impact over recent years. Over €20 million has been invested in contracted orthodontic care, resulting in more than 5,200 removals from our waiting lists. A dedicated orthognathic surgery programme has supported 206 patients to date, addressing complex needs that cannot be met through orthodontics alone.

Access to dental services remains a significant challenge for some groups of patients. In addition, access to services in some parts of the country is particularly challenging. We acknowledge the impact this has on patients and we are committed to making every effort within the resources available to us to improve access to all dental services.

The HSE budget for oral health was €182.1 million at the end of 2025. It has increased steadily over recent years, reflecting growing demand and strategic investment in dental and orthodontic care.

Chairman, I want to bring your attention and that of the members to an error in my opening statement as it was circulated to the committee. It is in the next sentence. There are currently 773 whole-time equivalents working across the HSE services, including consultant orthodontists, dental surgeons, dental nurses and hygienists. I will repeat that because there was an error in my note. There are 773 whole-time equivalents working across the HSE services.

While progress is evident, challenges remain. Recruitment and retention of dental professionals continue to impact service delivery, particularly in the public dental service. Persistent waiting times for orthodontic and complex care require sustained investment and innovative solutions. Access to sedation and general anaesthetic facilities for patients with additional needs remains a critical issue, given the demand for hospital-based resources. In this context the HSE is committed to the implementation of the national oral health policy, including continued investment over the coming years. Fifteen additional posts were approved in 2025 and, in line with the new policy, a review of staffing levels and skill mix will be undertaken as part of the implementation process.

The HSE, through the national oral health office, is working with the Department of Health and wider stakeholders, including the Irish Dental Association, to implement the national oral health policy, Smile agus Sláinte, aligned with Sláintecare and the WHO global oral health action plan. Phase 1 of a three-year implementation plan is under development with the Department of Health and will prioritise prevention-focused oral healthcare packages for children, reform of the adult medical card scheme, enhanced workforce planning and education, including expanded roles for dental hygienists and nurses, and investment in sedation facilities and specialist training to support patients with additional needs.

I thank Mr. Canavan. I now invite Mr. Redmond to read the opening statement on behalf of the Department of Health.

I am grateful for the opportunity to address the committee today. I am responsible for primary care oversight and performance in the Department of Health and I am joined by Mr. Simon Fahey, principal officer for oral health policy, Dr. Dympna Kavanagh, chief dental officer, and Ms Hilary Lovejoy from the oral health policy unit.

Oral health is not just about teeth; it is integral to overall health, well-being and quality of life. Government policy aims to ensure that every person has the support to enable them to achieve their best oral health. At a population level, sugar and alcohol taxes, reformulation and labelling of foods, tobacco cessation, HPV vaccination and water fluoridation are core elements in how we support oral health overall, while access to timely, affordable and quality dental care, with an emphasis on disease prevention, is also necessary.

The State invests about €240 million annually in oral health services. Mr. Canavan will have touched on some of the HSE side in his opening statement. In addition to the HSE schemes, the dental treatment benefit scheme supports insured workers and retirees and is overseen by the Department of Social Protection. All of these schemes combined are essential for maintaining access for those who rely on State assistance, particularly the more vulnerable groups.

Turning to the dental treatment services scheme, DTSS, we know that targeted investment and policy reform can deliver measurable improvements in access. Following changes introduced to the scheme in 2022, including a renewed focus on preventive care and significant fee increases of 40% to 60%, we have seen continued improvement in access to care. In 2025, over 307,000 patients received over 1 million episodes of care under the scheme. In the past four years, 50,000 additional patients per annum received care and the number of treatments funded has risen by 240,000 per annum. However, there is more work to do, and we need to build on these reforms with innovative approaches to further improve access.

In relation to the HSE public dental services, Mr. Canavan will have highlighted the various patient groups services provide for. The number of children and adults supported by those services in 2025 was well over 122,000. It is important to reflect that the current service model, including for children’s care, derives from the 1994 dental health action plan and the evidence of that time. Today, international best practice indicates that the population, and particularly the children's population, should be supported much earlier, with continued seamless care right across that life course. As such, we acknowledge that reform of the public and private dental service is required alongside capacity development.

In the context of that reform, the Department is committed to implementing the national oral health policy, which sets out a vision for modern, evidence-based oral healthcare. The policy provides a framework for comprehensive reform, legislative change, strategic workforce planning and enhanced education and training. These reforms prioritise essential oral healthcare, delivered through a reoriented, primary care-focused model to ensure the most vulnerable can access the care they need. This fully aligns with the WHO Global Oral Health Action Plan 2024. The trends show that a future challenge will be to maintain oral health into old age, supported by regular periodontal or gum care, as poor gum health is not only linked with loss of teeth but also poor cardiac and diabetic outcomes. To support this, with the HSE, we are developing a phase 1, three-year implementation plan to bring all strands of strategic reform together, supported by appropriate governance structures. Priorities in this plan include reviewing and reforming the adult medical card scheme, developing prevention-focused oral healthcare packages for children, regulatory reforms such as the recently announced statutory basis for continuing professional development for dentists, and enhanced workforce planning capability. In line with best practice, we are designing and delivering services that represent a move from the traditional curative approach to care towards a more preventive care and health promotion model of service.

In the context of capacity and workforce planning, we can see positive upward trends in the number of registered dentists. There are currently 3,945 registered dentists in Ireland, up 167 since January 2025. For context, this is an increase of 27% since the policy was published in 2019. Last September, the Minister launched a new undergraduate dental programme at the RCSI, which will have an initial intake of 20 EU students per year, rising to 35 at full roll-out in 2027. We also aim to optimise the workforce capacity across all dental professions on the dental team. Reform of oral health services clearly requires substantial change in training and education and an enhanced role for the wider range of professionals on the dental team, including nurses and hygienists, in the provision of oral healthcare.

For example, enabling dental hygienists to work to the top of their scope of practice will expand our capacity and reach. This will help address many emerging demographic and epidemiology oral disease trends. This year we aim to commence a proof-of-concept mobile dental clinic for children, one of the aims of which will be to thoroughly evaluate direct access to preventive elements of the scope of practice of dental hygienists with a view to safely expanding access to preventive care.

I thank Mr. Redmond very much. We will now move to questions from members.

As I mentioned earlier, the public dental service is probably one of the worst sections of the entire health service. I was a member of the former Southern Health Board back in the 1990s. The service was quite poor in those days but it has gone from poor to bad to worse to shocking. It is absolutely appalling. There is a total lack of public dentists. The number of those employed by the HSE has significantly dropped over the last 15 to 20 years. Sadly, rural areas are suffering most due to the difficulties in filling posts. It is a workforce crisis. There is only a limited number of places in the Irish dental schools and many students who come here to train return home to their own countries after graduation. We need to address that issue and keep them here to work for us in the Irish health system. I mentioned earlier that there are plans for a dental school in Cork but that has gone completely off the radar. That was supposed to be completed by 2023, yet it has not even started. There are extraordinarily long waiting lists for children, older people and those with special needs for essential and specialist treatment. They are waiting years for treatment. There has been a huge decrease in the number of practices taking clients for the dental school scheme. That needs to be addressed. We have an underfunded public scheme and, sadly, those who are suffering most are our children, the less well-off and medical card holders. The dental services scheme is a complete waste of time because it only covers extractions. There are no preventive measures or proper treatment such as fillings, etc.

I thank the Chair for the opportunity to speak. The very last point is that the Dental Council has already stated that 500 dentists are required immediately. We need to get cracking on this because it is appalling and shocking. There is no other way of describing it. It is a poor reflection on us as a Government and society.

As I touched on in the opening statement, we do have a challenge with capacity. There are a number of challenges in relation to that. We have a record number of dentists - more than we have ever had before. One of the challenges we face is in terms of strategic workforce planning and understanding what those dentists are doing, how many of them are active and how many are in patient-facing roles. At the moment, one of the key elements that we are looking at - hopefully in the next couple of months we will have a report on this - is the development of a dental census, which will explore exactly what is happening in terms of the dental register, what dentists are actually doing, how much of their time is spent doing dental care, how much is patient-facing and a full mix of education and skills. That is a critical piece in matching up what is required in the pipeline of dentistry, whether that is domestic or international in the future, and how we match skills in relation to that.

The development of the RCSI school, which opened in September, is positive. Once that is operating at full tilt over the next couple of years, it will increase our graduate output by about 25% per annum. There are really significant developments but a lot more needs to be done in terms of training places. We are working closely with our colleagues in the Department of further and higher education, the Higher Education Authority and the existing dental schools, including UCC, as the Deputy mentioned, in trying to look at how we might expand the current footprint and training places that are available there. Active work is ongoing in relation to that.

Mr. Redmond said in his opening speech that the policy of the Department is to ensure that everybody has the support to achieve good oral health. I will start by discussing access for children and the issue of screening and assessments for children in schools. Would Mr. Redmond accept we are not doing as well in that area as we should be?

Absolutely. We have a capacity challenge, of which there are two elements.

First, does Mr. Redmond accept we are not doing as well as we should?

Yes, we clearly have a capacity challenge.

It is more than a capacity challenge. Children are not getting access to screening and they should be getting it. While it might be an aspiration of the Department to ensure that everything is done and that everybody has the support they need, clearly it is not happening in this area.

Representatives from the IDA were here earlier. They said that 104,000 children in 2024 did not get access to screening and the eligible cohort was about 208,000. Is that figure accurate?

My colleagues in the HSE will comment on the specific data.

The figure is closer to 70,000. In the 2024-25 school year, we should have seen about 216,000 children, including special classes, but we saw 147,000 children.

How many children last year should have received screening or an assessment but did not?

About 70,000 in the 2024-25 school year.

That is a huge number, 70,000 children.

Yes, it is a significant number. While we recognise that there are deficits, the important point is that we try to see all children by sixth class, and if we do not, we follow through such that they do get seen, but it is taking longer than it should, absolutely.

For nearly six years I have heard about deficits and challenges. The problems stay the same and screening is one part.

Earlier, I raised the issue of orthodontic treatment. I will cite the figures because they really are bad, and they are worse for the part of the country in which I live. As the witnesses will know, orthodontic patients are graded using a scale of 1 to 5, with grades 4 and 5 deemed the most urgent due to being assessed as chronic cases. The most urgent case is grade 5 and 7,247 patients at the end of quarter 2 of last year were waiting, of whom 751 had been waiting over four months and 400 of those patients were in the south east. That is incredible. Of the 1,555 patients who were deemed the most urgent for orthodontic treatment, 400 of them were waiting over four years, and in some cases waiting six or seven years. Is that acceptable?

We have put in a number of initiatives over the last number of years to try to address that-----

Never mind the initiatives. I am asking about the figures and the fact that people are waiting. We will get to what the Department did and did not do in a moment. The figures do not lie. I quoted figures from responses to parliamentary questions that were supplied by the Department. A total of 7,247 people, mainly children, were awaiting orthodontic treatment, with 751 of those having waited over four years. Is that acceptable?

No. Those figures are not where we would want them to be. That is why we are taking steps to try to address that and remove patients from that list. Mr. Canavan, in his opening statement, outlined some of that. We have had 5,300 removals over the last number of years through investment in waiting list initiatives, in particular to deal with the longer waiters, across both grade 4 and, more recently, grade 5 and the orthognathic surgeries.

Can Mr. Redmond tell me why the situation is so bad in the south east? The grade 5 figures are bad. The grade 4 figures are also bad and it is the same situation for the south east. A total of 7,247 people were waiting fo orthodontic treatment, with 751 or about 10% of those waiting over four years. Yet, of the 1,555 people waiting, in the south east that figure was 400, which is multiples of 10%. Clearly, there is a bigger problem in the south east. Why is that the case?

My understanding is that there is a capacity constraint both in the public service and also in the private sector.

I made this exact same point five years ago. I do not think it was Mr. Redmond who was here before the committee then. It was probably somebody else, and somebody else from the HSE, but on that occasion we heard about the same figures, the same problem and the same challenges. We were given the same response. Why is it that the situation has not improved? How is it that there are so many children in the south east, and I would argue that the problem is across the State when you look at the numbers, who need urgent orthodontic treatment, yet they still are waiting, in some cases over four years, and as we heard from the IDA representatives, in other cases waiting six or seven years? This situation is not acceptable. It is really problematic to hear the same conversations every couple of years, like Groundhog Day. We bring in representatives of the Department and the IDA and talk about the problems, and the representatives of the Department and the HSE will talk about processes, improvements and all the rest. In fact, even on the DTSS, the true figures have not been given to us because they go back to only 2024. I suggest that Mr. Canavan look at the figures for 2020, 2019 and 2018 showing the number of dentists who were on that scheme providing a service.

It was three times what is being done now. The scheme has collapsed. That has been the case for some time. There is no recognition of that from the HSE in the opening statement. I just get really frustrated when it is Groundhog Day and we are having the same conversation but I do not see the improvements that are needed.

I thank everyone for coming in and making their presentations. I accept fully that people are doing their best but I think the HSE and the Department have their heads buried in the sand on this issue. The figures given here are not real. For instance, the number of dentists working in the HSE in 2012 was 283. In 2024 it was 254. We are being given a figure of 700 but that figure is about a whole lot of staff other than dentists. We now have fewer dentists working in the HSE than we had in 2012, yet we have had an increase in population of 25% to 30% in that period. We need to take employing people seriously. The HSE might outline to me the role in respect of recruitment of additional staff to replace the people who have retired. What is the plan for the next 12 months?

There are a number of recruitment processes under way. In terms of replacement of people who have retired, since 1 January 2024 those are being approved by the regional executive officers, that is myself and five colleagues around the country. In general, all of those replacement posts are----

My figure is 253 dentists in 2024. Has that increased since then?

The number of dentists we have currently working within the system is 286 whole-time equivalents as of November 2025.

If we look at the medical consultant situation in hospitals, we have increased the number of medical consultants from over 2,000 to 2011 to over 4,500 now. We have increased by over 100%. We should have been doing the same thing in the dental area but we have not. How long now is it? There is the schools programme and a whole lot of programmes where there are fewer people being seen. We were given some figures there about more people being seen. In 2012 there were 394,000 people seen under the scheme being operated by the private dentists. By 2023, it was down to 283,000. There were 100,000 fewer people seen. We have a collapse of the public service as regards the dental care sector. What plan of action is there? It will not be done overnight, but is the Department putting in place a clear plan for the next five years? We were given figures today but that is not the real world. Every week I have a parent on to me who has a child with intellectual disability who cannot get access to services. They are told the earliest they can be seen is in 12 months' time. What plan of action is the Department going to put in place now?

We did see a decrease in the number of contracts in the scheme. There are a couple of reasons for that. Some of it is people leaving the scheme, which is fair enough. It is also probably fair to say that the list of contractors who were there in the early 2020s probably had not been updated for a while and needed a cleansing. There is certainly a data piece in that, trying to get to the true number. That is why we see a very significant----

In 2012 there were 1,425 private dentists providing public care, and there are now less than 600. The Irish Dental Association gave us that figure this morning.

There are almost 850.

Some of those may be on the system but are not providing care. What plan of action is the Department taking not just for this year but for the next five years? We have a major challenge. The numbers being seen have gone down every year since 2012.

In terms of DTSS, since we made the changes in 2022, which included a significant fee increase and also the introduction of preventative care back into the scheme, we have seen the numbers go up year on year in terms of both the number of patients seen and the number of treatments. We have seen that change happening over the last three or four years.

Is that enough? No, it is not. In the context of the development of our three-year implementation plan for the oral health policy, one of the key priorities in relation to that, which will commence this year, is a fundamental review of the DTSS itself, so we are looking at-----

I want to ask one final question on the training of dentists. We are having the same number of Irish dentists and EU dentists being trained in our colleges. Yes, I know the Royal College of Surgeons in Ireland, RCSI, has increased its numbers having started its new programme. Why have we increased in all other areas in healthcare except dental training? What engagement is there with the Department of higher education on this problem?

Can we just get a brief answer on that because we are out of time?

The RCSI was a particular success but we are engaging very extensively with all the other schools and with the Department of higher education and the HSE in relation to plans around expansion of other schools and opportunities, so that is an ongoing, very active set of engagements.

Will we get the same answer in 12 months' time?

We have to work through the processes involved.

Thanks very much. I have a number of questions to ask. What we heard this morning in particular and again now are real concerns around dental services, which are in crisis in many places. There are real struggles with access to the public dental system, particularly the medical card scheme. There are issues with children's dental services and shortages of staff and training places. It seems to me to be a service facing many different crises.

I started with the Irish Dental Association on the policy. I think that is where I want to start with you as well. In the bigger picture, this State suffers from implementation deficit disorder when it comes to national policy. I think that is true of this area and many others. In 2019 the national oral health policy, Smile agus Sláinte, was published. Since 2019 how many of the 41 actions have been fully completed?

I will have to let the committee know later. I just cannot put my hand on that information at the moment.

The fact that you do not even know how many of the 41 actions of the policy have been implemented, almost seven years later, is extraordinary.

Sorry, I would like to just take some of that. Many of the actions are split between the Department of Health and the HSE and other colleagues. Our own actions very much centre on policy, legislative development, surveillance and fluoridation. In all of these areas we have progressed hugely. For instance, in workforce, one of the key areas was about opening a dental school, looking at a dental census and looking at workforce development. Those two publications, as Mr. Redmond alluded to, are coming out in the very near future. In addition, in relation to fluoridation and surveillance, which are key parts of our actions, we have progressed enormously, going forward over the next five years, to put in €12 million to increase it up to optimal levels. This will have a huge impact on our children's health going into the future. What I am trying to put across is that we have been working concretely in the background on our actions in relation to the Department of Health and they have progressed enormously in the key policy areas for legislation in that regard.

Can we get a detailed note on each action and where we are at on them?

Yes, we can do that.

The other key question is why, almost seven years after the policy was published, we are still waiting for an implementation plan. Why is that the case?

There are a couple of elements in that. Unfortunately, the plan was published a couple of months before the pandemic, which put a pause on meaningful progress in relation to it. Since then, as Dr. Kavanagh has set out, we have worked our way through a number of the actions. A significant number of foundational actions are required to create the environment and the enablers to progress, particularly around the services piece. We are at a very advanced stage in bringing all of that together into a coherent three-year plan, which we will publish this year. It is really important to say that progress is going on and is happening in the background in terms of delivering the staging posts for a lot of that action.

I am quite tired, and I think many citizens are quite tired, of Covid being blamed continuously for failures in our public services and being used as a reason for not doing things. That excuse needs to stop. We are now many years post pandemic, and those excuses need to stop. I welcome that the report is going to be published this year, but I would press that it does happen this year, and that we are not back here this time next year with the same questions.

In the HSE's briefing document, it states that 16 of the 41 actions in the 2019 plan will be prioritised for implementation. I take it these are the same 16 actions that were identified in 2019 in the implementation plan to be done within three years. Is that correct? Will the witnesses explain why that is? In 2019, 16 actions were identified that would be done within three years and we are still here in 2026 with the same actions, still a priority and still not done.

For the same reasons Mr. Redmond has set out, it has taken a while to put the implementation plan together. I think what we are concretely doing is that where we can invest and where we have resources from the Department to employ more people, we are doing that. Fifteen additional dental surgeons are being appointed at the moment. We are expanding the orthodontic service. There are posts at the CAAC at the moment. We hope to roll out more consultants. There is a recruitment challenge for us. As the REO has said, we are filling posts as they come up and we are adding additional posts. There is a challenge. We will have to work with the Department and the Irish Dental Association to look at how we can get the contractor service to become more involved. In the national policy and in this implementation plan, there will be proposals for packages of care for children's services to provide support in addition to what is currently being done.

It is extraordinary that it was said in 2019 that 16 actions would be done by 2022 and now it is being said they will be done by 2029. I really think we need urgency around here in respect of the implementation of these national policies.

Next, we turn to a Fianna Fáil slot. I call Deputy Martin Daly.

I thank the witnesses from the Department and the HSE for coming in today. They have drawn the short straw because, to be honest, I do not have any questions. I am going to share some reflections on what is in the document. I think what is in this document, and what we have heard from the Irish Dental Association, is indefensible. We are talking about a dental service that is a poor law service. We are going backwards. We are going back before 1972. We are going back to a poor law situation, where it is almost a charity to get decent dental services if people do not have their own personal resources.

It is interesting to reflect on which three services are the Cinderella services of the health service. I refer to the mental health services; to community services, even though some investment is going in there, but it is not proportionate to what is happening in the hospitals as was pointed out by one of the previous Deputies; and to the dental service, which is by far the worst. Capacity planning is a basic function of the Department of Health. How could we not plan for a growth in population of 90,000 annually, year on year, and 1.2 million overall in the last 20 years?

We are not training enough dentists. Reference was made to 100 dentists coming out a year, but when we compare this to the medical schools and veterinary colleges we see that it is just not enough. I think there are 2,400 dentists in the country. Many of them are in private practice, and this leads us on to the next thing. They dropped out of giving public service because under FEMPI there were very significant cuts right across all sectors. It had to be done because the country had to be saved. There is no doubt that there was a targeting of professions. That might have been popular at the time because dentists and doctors were seen as well-paid professions, but we are now reaping the harvest of pandering to the lowest-hanging fruit. We then come to another point. I know someone in GP training here who is originally from Pakistan and is now naturalised. His wife is a dentist. They are moving to Enniskillen. He is a really good general practitioner. They are moving because of the barriers to getting onto the dental register here in the South compared with the Six Counties and the UK. That is a personal story. This situation needs to be addressed.

Then there is the idea that there has not been reform of the role of dentist hygienists and their scope of practice in a time of famine in dental services. It does not make any sense. Turning to the schools screening programme, my God, we were doing better in the school screening programme when I was a child. I do not want to tell everyone how long ago that was, but I will. It was 50 years ago when the dentists came to the school. Now, it was not always the most humane service, but it was a service in screening children. To give excuses involving the fluoridation of water in this day and age is a joke. Preventative medicine and dental care is the most cost-effective care we can give.

It closes off problems in the future for developing children.

I am going to come to the service for disability and, in particular, for children with additional and special needs. I had a meeting in my office in Roscommon last Friday. I met six families who have children with complex additional and special needs. They are being let down by the health service. There is an absence of simple things such as having protected spaces in emergency rooms for children with neurosensory disorders, protected spaces for children and plans in local hospitals to get admissions through so they do not have to go to the emergency room, when everyone knows what needs to be done because these are repeated admissions. There is a lack of planning, common sense and communication, and we then get the situation we have for the service for children with additional and special needs. Those six families were sitting in my office. Roscommon town is 10 miles from the county border. It is, as Mr. Canavan knows, a narrow county. People who are 10 miles from a service in Roscommon town, with children who have complex special and additional needs, are being asked to go to Galway, which is 45 miles away. As the witnesses know, 30 miles of that journey comprise the easy part and it then takes an hour to get across the city. It is a postcode service for the care of children with special and additional needs. It is simply unacceptable.

I thank the representatives of the Department and the HSE for coming here. I am going to be honest and say that this is one of the most frustrating sessions I have had as a member of the health committee. I am shocked and appalled, quite frankly. Sláintecare promised delivery and not delay. That is a fact. The fact that it has taken years for policies even to be met with an implementation plan is shameful in the extreme. We hear of aspirations for resources but do not hear of any definitive plans. While this is going on, the witnesses seem to be going for the full bingo card of excuses and deflections, between fluoride, Covid-19, recruitment challenges, the fact that people are leaving and the need to update contractor lists. What on earth has been allowed to happen to our dental services?

With all due respect to Mr. Healy, he may dispute the figure that the dentists gave this morning. They said that that 104,000 children missed their assessment last year. Mr. Healy put forward a figure of 70,000. That is still more people than can sit in Croke Park. These are children for a dental service. I read out the following example this morning, but a five-year-old in my constituency has been waiting over a year to have teeth extracted. The child has had multiple infections and repeated antibiotics. A dentist tells me this is the norm. That is not normal. It should never be considered normal. In a country that has a population entitled to a medical card of approximately 1.6 million people, to have 600 dentists active in that scheme is not normal, nor should it ever be considered normal.

I want to ask whether the Department and the HSE recognise that the DTSS is entirely dysfunctional. Do they recognise the level of urgency? Will they act on it?

In relation to the DTSS, in 2022 we introduced preventative measures and other expansion of care means in relation to the scheme. We also increased the fees-----

In Mr. Redmond's opinion, is it working? The figures would indicate it is not.

The figures over the past four years have shown significant improvement, following that.

Define "significant". I do not like wishy-washy terminology. I ask Mr. Redmond to define "significant".

Last year, an extra 50,000 patients were seen compared with 2022.

What percentage of that figure are people who are medical card holders who sought care?

I will get that figure and come back to the Deputy. Those are 50,000 extra people and an extra 250,000 treatments per annum. That also includes an extra €20 million in investment compared with 2022, before those changes were made. That is a significant improvement. Is it enough? Absolutely not. The next step in the DTSS is the more fundamental reform of the scheme itself.

I would say fundamental would be delivering services to the people who need them.

You have to do that with a reformed model of care and a reformed model of service.

We have to deliver the services. We are talking about recruitment but we know that not enough dentists are being trained to recruit the number of dentists required to meet the level of need that exists.

People are entitled to this service because they are medical card holders. On the other hand, the State is handing people an entitlement to a service in a system that simply does not have the resources to meet the need. This is not new. Let us be honest; it has been going on for a significant number of years.

We can see, in terms of international and domestic trends, which is particularly relevant to the DTSS, what the disease profile and interventions look like. We can see a growing need for preventative care interventions. One of our opportunities here relates to our dental workforce, which needs to be used to its maximum. There is an opportunity for hygienists to come in and provide a much more significant level of care. That has a real opportunity for us in terms of-----

Where are you getting them from?

There are 700 registered hygienists in the country at the moment.

Where are you getting the additional that are going to be needed from? Where are they coming from, physically?

There is capacity already. From Healthy Ireland surveys, we already know that 40% of children, for example, are being seeing in private practice. We know there is a significant amount.

Why are 40% of children being seen by those in private practice when we have a scheme paid for by the State whereby they should be seen in school? Whether it is 104,000 or 70,000, any number in this regard is simply inexcusable.

On the screening programme, and, again, our policy is very clear in this regard, we know from the WHO and internationally that we need to change the model of episodic screening. We need to be seeing children much earlier in course of their lives, namely in the period from birth to two-----

Mr. Redmond is not going to get any disagreement here. I strongly suggest, however that the Department start with the policy that is already in place to the effect that children in primary school be seen three times before moving to secondary school. This would mean that a child who should have been seen in sixth class will not later be obliged to driving themselves to an appointment when they are eventually offered it four or five years later.

It is not one or the other; it is both in terms of building our capacity in public dental services-----

Will every child who did not get an assessment screening be offered one before they reach junior cert year?

I ask for a brief answer on that.

This is on the catch-up process in relation to that.

As I said, those 70,000 who have not been dealt with are picked up. It takes longer-----

Is that before they reach junior cert?

Generally, it is before they reach junior cert. It is even before that. I fully accept that it should be within the school year. That is what we want to try and do, but we need to recruit more dentists. There is a challenge with recruitment and retention.

At least do a better job, with all due respect.

The witnesses are most welcome. We had a very robust engagement with the Irish Dental Association earlier. I forensically looked at the report that was presented to us along with the report we have been given by the officials. If I were Judge Judy and were assessing what I believe, I would honestly fall down on the side of the Irish Dental Association because it very eloquently demonstrated or explained where the issues lie and where it would be able to make recommendations in respect of improvement and investment.

I reiterate one of the things I references earlier, namely that there seems to be a massive shift away from school intervention where children in national school, particularly in the past, were examined and any dental issues were intercepted. That was a great system but now we have situation where people have to find their way to a private practice. That clearly is not working. I recall the commentary from one of the witnesses earlier that the school visitation and dental examination had a halo effect, which was a very good way to describe it. We seem to be moving away from that, which is not a good plan because, quite honestly, if we rely on private practice, a lot of that cohort will not get the attention. They will be missed.

I read the report. Terms like "crisis", "striving for better" and "more investment" are used. The thing that strikes me - and I do not want to cast aspersions - is that it is quite easy to dress up a report and for officials to come in here and make it look like everything is going well, instead of striving for and demanding change, form and capacity planning.

That is where we need to get to. It would be a disservice to every one of us, including the witnesses, if we were to come back here in a year's time to get a repeat dose. I am really concerned and disappointed that we are having this very meaningful discussion around the clear deficits in dental treatment. There is no other way to describe it. It has been calamitous to say the least. More and more people are leaving the system.

Given the scale of the reform under Smile and Sláinte, do regions have sufficient management and clinical leadership capacity to implement change alongside existing services pressures? The witnesses acknowledged that challenges remain in some regions. Can they identify which regions are most affected and what immediate measures are in place to address the deficits that exist?

As a general comment on the overall position of the HSE, I do not think we are saying that everything is okay with the service. We said clearly in our opening statement that there are deficits. Those deficits are largely associated with access to care and the various points at which it is provided. We are saying that there is significant room for improvement across the breadth of the services we provide.

We are also saying that there have been improvements in recent years. Some of the reasons why there have been improvements have been outlined as well. They form the basis on which we should be building and trying to develop further improvements but we are clear in saying that significant improvement is required.

It is fair to say that there is insufficient resourcing within the regions. That relates partly to our capacity issue. We see that in particular in terms of the school services provided. There is a need for additional resources. Such resources will have to come through the implementation of the strategy. A total of 15 additional posts were approved in 2025. The funding associated with those posts was provided, and we are in the process of recruiting for all 15. The majority of them are recruited while a small number are in processing and three are in recruitment so we are adding to the overall resource that is there. Further resources will be required as we implement the strategy. The dental strategy-----

Apologies, but we are out of time.

We had two very distinct presentations this morning. Mr. Canavan clarified that the HSE has identified that there are serious concerns and challenges. As was intimated earlier, however, the language used seems to shroud things. This is a full-blown crisis. Any TD will tell you about the number of contacts we get in our constituency offices from people regarding difficulties they face in sourcing adequate oral healthcare. I put a question to the Irish Dental Association earlier in order to gauge its view on one proposal that is being considered by Cork and Kerry. I will put the same question to the witnesses from the Department of Health and the HSE. One of the proposals being considered is the provision of a €3,000 subvention or grant to each child awaiting orthodontic care. Is that in line with national policy? Is it something the Department is comfortable with? While I am not necessarily against it, I had significant difficulty a number of years ago in terms of disability services. I accept that the latter was a totally different situation. We tried to privately procure somebody to come to a special school - with the help of the HSE - to provide speech and language therapy and physiotherapy. The amount involved was €40,000. We were told "No" categorically and that we would not be facilitated because the proposal was contrary to the system that was in place.

Eventually, after political intervention and 18 months of battling, the school was allowed to take on a private therapist.

It is not that I am against what is proposed in this regard; I have campaigned for it in the past with regard to disability services, but it is a washing of the hands and a raising of the white flag in terms of the provision of a national healthcare service. What are the Department's thoughts on the proposal being considered by CHO 4 for Cork and Kerry in terms of the provision of a €3,000 subsidy? Will this proposal be considered more widely in future?

Similar to what Mr. Canavan said, the Department acknowledges that there are challenges across the board. We are certainly not attempting to suggest otherwise. There have been improvements, but a lot more needs to be done. I will leave it at that.

I am not aware of the proposal Deputy O'Sullivan has spoken about. To the best of my knowledge, I do not think it has come to the Department. We have a waiting list action plan or initiative in place regarding orthodontic treatment. My concern is about it going off in the direction being suggested, even though I have not seen the detail of the proposal. It is about being able to control pathways of care and ensure the clinical governance required and that the resources available are being prioritised towards those with the most need. I certainly have concerns about this. Dr. Kavanagh might give her views on the service. Clinical governance would be a concern also. I have not seen the detail. It certainly seems to be something that would have to be considered in appropriate detail.

It is about looking at the detail of it in the context of clinical governance. We have spoken about complexity of care, and it would depend on whether surgery is involved. It is very difficult to comment without being aware of the detail involved. Perhaps it is a matter for our colleagues in the HSE.

We have made investment in private capacity in recent years to support removals from the orthodontic waiting list regarding grades 4 and 5.

I apologise for cutting across Mr. Redmond, but the proposal we were given for Cork at the recent briefing would be entirely dependent on private services. There is very little ambition to do anything on the public side from what I could see from the presentation that was made. This is something that worries me as a public representative. We are completely abandoning the responsibility the HSE and the Department of Health have for these patients.

There are two strands to this. We are investing in the workforce again this year in terms of 15 whole-time equivalents coming in. That includes the orthodontic service. I do not have a breakdown in terms of where they are located geographically, but we are also using the available private capacity. There is a mix. We spoke about some of the challenges in the south east, where even private capacity is challenged. We do have initiatives in place to try to tap into as much as possible of the totality of the available capacity to remove patients from waiting lists.

I would like one or two sentences from the HSE regarding it being a national programme.

Very quickly, because we are over time.

It is not national. It is an idea that has been floated as something that might be looked at, but it would require legislative change if it were to be introduced nationally. It is probably grounded in the initiative we have with orthodontics. This is where the idea came from. We have not received it as national proposal from the HSE.

It is great to have the witnesses before the committee, but what we have heard this morning is very disturbing. This is my first time on the health committee. What we heard from the Irish Dental Association was very disturbing. Why has the school scheme not been promoted in the way it was 30 years ago when I was in school? It worked well. A dentist came in and saw 70 to 100 pupils in a school and prioritised them and move things on. Why has that stopped? It is not happening in the schools I know in Donegal.

There is no question of it being stopped or changed. We are absolutely trying to maximise the use of the public dental service to reach the children. In the year 2024-25, we went through 147,000 children, including in special classes. We are short 70,000 children.

The challenge at the minute is having sufficient dental teams to meet the demand that is there. We have a range of initiatives we have been trying to implement, but we are not moving away from the scheme. Dr. O'Neill may wish to comment on that.

The description of school screening we have heard refers to a time when the dentist went into the school and did a quick assessment of the children in the school. We have moved that into the dental clinics because the parents can now attend. We have access to X-rays and a whole range of additional equipment, so the examination is a full dental examination rather than a brief assessment in the school. While we call it school screening, it is now actually a dental examination being provided in the clinic.

I get what Dr. O'Neill is saying but the other system was working. The new system is definitely not working. One of the things I would like an answer to is why the dentist was taken out of Killybegs. This is a parish matter for me because that was working perfectly. I never had one complaint about that service. Since it has left Killybegs the question I am asked every day is why that service was taken away. It was taken away in the middle of the night. Nobody heard it was going. Why did it leave the town? We got a letter back saying it was because of the building. Why did the HSE not make it clear what was happening and tell the local politicians what was going on? We could have tried to source a building. We now have people travelling from Gleann Cholm Cille to Donegal town. I have no problem with Donegal town. It is a great service and anybody who has used it is more than happy with it. However, it is 47 km from Gleann Cholm Cille. Fathers and mothers have to take a day off work to take their children to Donegal town. If they have to go to Ballyshannon it is an extra 12 km up the road. There was no thought process put into this. This seemed to be that it was an easy one to take, so it was taken out of Killybegs. I would like somebody to give me a straight answer as to why it was taken out of Killybegs. They can blame the building if they want but there are plenty more people with buildings in Killybegs and I know they would have been happy to rent.

Killybegs is one of the areas that comes within my region. If I focus not on Killybegs but in general, we have seen that the physical infrastructure through which services are delivered, including dental services, at times falls short of what is required. What might have been acceptable 30 years ago is not acceptable in many cases now. It is important that we move on in terms of infection prevention and control and other standards that are helping to protect patients across a whole range of services, including dental services. That is relevant in the case of Killybegs and in the decision making associated with that. It also coincided with the retirement of one of the key clinicians in the service. While we would like to be able to provide services as close as possible to where people are living so they do not have to travel significant distances, that always has to be balanced against the need to provide them in an appropriate setting that can ensure appropriate standards are being met on a consistent basis. That really is probably at the heart of the decision in relation to Killybegs.

In fairness there are plenty of other buildings around Killybegs that could be utilised for this and those involved would have been more than happy to facilitate this. There are buildings lying empty. There was no thought put into what the children or parents have to give up to do this. It was just taken away and was gone in the middle of the night before any public representative knew about it. I can show a list of probably 200 names of parents who got on to me since this service was taken out of Killybegs. It is unacceptable. It is something that needs to be looked at again. Donegal is a big county and a rural county. What suits in Dublin does not suit in Donegal. There needs to be practical thinking about the people in Donegal. There really does.

I agree with the Senator's point about infrastructure and buildings needing to be invested in. If people are retiring, there needs to be plans about staff replacement. People retire all the time, and these staff need to be replaced.

I have found this whole session totally frustrating. My first point is about the school visits. Everybody seems to be shouting about how positive and beneficial they were.

It is like the witnesses are not hearing what is being said. I do not understand, from a preventative point of view, why the school visits have been pared back. On going to the community appointment, I think that lady - I do not know her name - mentioned about having everything. As a parent, I would rather it happened in the school. I remember that when I was younger - I am giving away my age like the witness did earlier on - it was much better. I have been thinking about this in advance of this meeting. Sometimes we just have to hold up our hands and say that something is not working. With the way things are happening at the moment, it is not working. The school is the first line of defence. Even it being taken out of school has made education and awareness around dental health drop. So many other illnesses are associated with poor dental hygiene and we are totally mismanaging our young people and the opportunity for preventative healthcare. I do not know whether the amount of money being allocated is not enough to service it.

I want to speak about the disability dental services provided on a county and community health organisation, CHO, basis. It seems to me, and I would like to ask why, that the service provided is to suit the needs of the provider rather than the patient. Is there vision to change this? The witnesses have spoken about how service users have been affected. Then it goes back to the school thing where parents did not have to bring the children. It was targeted and all children were included. Are the witnesses open to improving on this and holding their hands up and acknowledging how everyone here has said how important the school service is for children? Are they listening? Can they hear what we are saying, including about the improvements in the services suiting the needs of patients and families rather than suiting the needs of the service providers?

In relation to the schools programme, as Mr. Healy touched on a little while ago, we are not pulling back from the schools programme. It is a capacity and resource challenge in regard to the staffing to close that gap.

I feel it has been pulled back on because, as that lady said, it is in a different setting and the parents can come.

In regard to the model of service, best practice and evidence, the model has changed internationally and domestically in terms of providing the best possible care to people. That sometimes requires a different and more clinical setting, I suppose, and Dr. O'Neill would have touched on that in regard to some of the equipment and supports that are required to support the best possible service.

What is important is that school services obviously focus on a particular age range. Certainly from a policy perspective, we are very clear, and the evidence shows very clearly as well, that we need to see children much earlier in their lives and, of course, effectively in the first couple of years of life. A significant part of that is around public health and health promotion, and the elements the Senator touched on in regard to a better understanding of oral health and how to protect and manage oral health. We can see the downstream effects of that because it means you are dealing with preventative issues much earlier and earlier intervention obviously reduces the complexity of care and the need for more complex interventions later on. There is a full end-to-end piece to this-----

I am sorry for cutting across Mr. Redmond but I am conscious of time. He is talking about best practice but examination numbers have gone down, so best practice would be to examine children-----

A screening programme.

-----screen them and have a proper screening programme. The way it has changed is not best practice.

To build on that point, the Senator is absolutely correct in that there is a real value in it, as she rightly says, at certain points of a child's life, like we do with vaccinations and other public health and population health interventions. To cut to the chase, Mr. Redmond mentioned in the opening statement that we are looking at the mobile dental clinic concept, not necessarily in a mobile dental clinic but, as has been pointed out by HSE colleagues, there is an opportunity now with changes in technology where we can actually bring a mobile-type clinic to the school setting.

That is something we are investigating, particularly for schools in vulnerable areas, because it is, as the Senator said, very challenging to travel and there is an opportunity, particularly for vulnerable communities, that we would investigate that process.

I thank the witnesses for coming here today to discuss this important issue. I think everyone is in agreement here that dental health is certainly something that is very important from the young to the not so young.

I note that staff shortages have been highlighted quite a bit. It is something I put earlier to the Dental Health Association. Is there any room for retired dentists to be used in terms of examining children's teeth in a dental setting or in a school setting? They have their qualification. Many of them have kept up their professional qualifications. Some of them are not long retired and would still have all the experience. Is that something that should be looked at?

The critical skills list was highlighted earlier to deal with the shortage of dentists. Is that something the Department has looked at? For example, dentists could be brought into the country or maybe dentists from other countries who trained here could be given jobs. There is a shortage of hygienists. Is there anything the Department has looked at in terms of filling those places?

I will address the employment permits aspect and then our HSE colleagues can respond on the use of retired HSE dentists.

Regarding the critical skills list, that is obviously managed by the Department of Enterprise, Tourism and Employment. Through its twice yearly assessments of the workforce in its totality, it has looked at dental services on foot of submissions from the Irish Dental Association. Some of the challenges are around the evidence of the shortage because we know about one third of all dentists on the register are coming from overseas, predominantly from across the EU. There are a number of parts of the EU where there is an oversupply and we have been an beneficiary of that, which is really good.

As I mentioned earlier, we do actually have a record number of dentists on the register. Some of our challenge is trying to understand what they are doing in terms of their patient-facing focus in particular. We have spent quite a bit of time developing a workforce census, which we are going to publish this year. That will give us an opportunity to work with the Dental Council in trying to identify what the skill mix is for dentistry, where the real gaps are in terms of skill mix and geographic capacity, and what evidence there is for looking further afield. There is a very significant supply-----

Has the Department made a submission to the critical skills list?

I do not think we have. What happens generally is a Department to Department engagement on proposals that are received. We certainly would have engaged with the Department of enterprise at various points on this.

Regarding the retired dentists, that is something we have looked at. There are a couple of things in it. One is that, no different to GPs and other professionals, the tendency has been that they have retired much later than the normal age. The tendency then is that, when they have retired, they have not necessarily wanted to come back in a broad way. More recently, there are pension issues related to those who come back. That has also limited the interest in that aspect of it, but it is something we have looked at.

The Dental Health Foundation provides services to people who are less well off and visit nursing homes and DEIS schools. Is there consistency regarding funding relating to that or is it considered each year? Is there any hope of it being given consistent funding for these services?

The Dental Health Foundation is a charity with a focus on the provision of oral health promotion.

It is supported by the HSE through a grant-in-aid under sections 38 and 39 of the Health Act. We meet with it regularly on that basis. It has been advised that if it has new projects or new developments, they go through the Estimates process and it submits business plans to us, so it has the opportunity to provide us with additional requests for finance and funding.

I thank the Cathaoirleach for letting me into this committee meeting. I have submitted several parliamentary questions about Monaghan and the non-existence of dental screening for children there. I want to alert the witnesses to this. I heard a lady on the radio earlier discussing children of seven years of age having to get seven extractions done because there is no dental screening going on in our schools. This is what we are up against. There are greater problems being created down the line. I brought this issue up on the Dáil floor as well recently with the Minister of State, Jennifer Murnane O'Connor, and she said she would look into the service in Monaghan. I went back and asked more parliamentary questions about the service in Monaghan. I have been told that two dental surgeons are on maternity leave, I was told back in November 2024 that a dental hygienist is being recruited, I was told in July 2025 that a dental nurse position is vacant and being recruited for and I have been told of another dental nurse on maternity leave from January 2025. It is just not good enough for the people of County Monaghan. The children are not getting any dental screening. What are the witnesses doing about recruitment? The Minister of State said during that intervention on the Dáil floor that this would be sorted out. I want to know today whether it has been sorted out. Has the HSE started doing dental screening in Monaghan Hospital? I want to know, for the people of Monaghan, what is happening there and whether there has been any improvement since I brought this to the Dáil floor. That was probably two or three months ago.

A number of the posts the Deputy referred to are in the process of being filled and many others have been filled. There are-----

But some of these vacancies are from 2023 or 2024 and they are still not filled.

Yes, that is correct, but the majority of posts are currently filled or almost completed through the recruitment process. There are a number maternity leaves within the service, and that is inevitable in any service. While it might be desirable to try to fill them, it is often difficult to get somebody on a temporary basis to do so. The majority of posts in the Cavan-Monaghan area are currently filled.

They are not currently filled because I have here a list of positions and none of them are filled. This relates to children in the schools in Monaghan specifically. I put in questions about Cavan and Monaghan. There were 188 screenings, I think, in 2024-25 but zero screenings of children in Monaghan Hospital for the people of Monaghan. It is not good enough. I do not know. We are not at the races in relation to dental screening for children in national school. They are not getting it. I know that myself. I had children in national school right through. They were not getting the screening. The screening is not happening in Monaghan Hospital. Since I brought that up on the Dáil floor, has anything changed?

I am slightly confused because the Deputy is referring to Monaghan Hospital.

Yes, Monaghan Hospital. We have dental screening in Monaghan Hospital. Maybe the HSE is not aware of where it is supposed to have services?

I might ask Dr. O'Neill to respond.

If I am not mistaken, the dental clinic is on the grounds of Monaghan Hospital.

Yes, that is correct.

I do not have the detailed numbers for staffing, etc., and I do not have a detailed response specifically for Monaghan. From my recall, I think there is a delay in school screening for Monaghan.

A big delay. A year.

I would have to go back and ask the principal for specifics on the actual positions filled because I do not have them here. I can do that for the Deputy.

I thank Dr. O'Neill. I would appreciate that and I would appreciate that there would be some urgency in replacing these positions because children are losing out in Monaghan. Why are we not being looked after in Monaghan? I would appreciate it if Dr. O'Neill could look into that as urgently as possible.

I will absolutely follow up on that for the Deputy.

I thank Dr. O'Neill.

The point was made about maternity leave and it is an important one. People who go on maternity leave should have cover for their posts and they should be filled. There was a briefing yesterday done by Fórsa trade union about staff morale, the real issues for women who go on maternity leave, the worry and stress that are caused to them by their going on leave, knowing that there will be a post vacant, their patients or the people they work with and the strain that puts on other colleagues.

In other sectors and other public services, such as education, maternity cover is provided. That is not the case in some of our health services. The majority of those working in our health services are women. There is a real gender issue there that needs to be considered and addressed. I have heard real concerns about this issue from all members and all groups this morning. I propose that, as our next step, we write up a report based on our findings this morning and lay it before the Dáil and the Seanad. There are real concerns that have been ongoing for some time now. That could be the next step in progressing things. With the members' agreement, we will progress that piece of work.

That concludes this meeting. I thank the HSE, the Department of Health and our earlier witnesses from the Irish Dental Association for their engagement. I have no doubt that we will be coming back to these issues. I will now adjourn the committee until Tuesday, 20 January, at 3.30 p.m., when we will meet in private session.