APPROPRIATE ORAL HEALTH CARE

Provision of oral health care for individuals with special needs involves not only the delivery of safe and appropriate dental care but also focuses on the need to improve the oral health status of these populations by employing effective preventive measures. These objectives can be facilitated by the development of clinical guidelines and integrated care pathways to help overcome barriers to oral health care.

BARRIERS TO ORAL HEALTH CARE

The barriers to oral health care for people with special needs can be classified by illustrating the role of the dental profession and its interaction with individuals and society and government, as follows:

GOALS

Whilst perfect oral health is the ideal goal, five important objectives when providing oral health care are: enabling patients to care for their own oral health, with or without assistance keeping patients free from pain and acute disease maintaining effective oral function retaining aesthetics causing no harm.

THE PEOPLE INVOLVED IN PROVIDING CARE

Although the dentist may be the team leader, dental care professionals are essential to successful provision of care. Care may also involve the following groups: parents/carers social services/social work departments health visitors general medical practitioner paediatric consultant/other hospital specialists school teachers and assistants colleagues in paediatric dentistry, oral surgery, oral medicine, periodontics, endodontics, prosthodontics, orthodontics.

A multidisciplinary team approach to patient care leads to a more effective sharing of resources, generates more creative responses to problems involving patient care, heightens communication skills, produces new approaches to learning and clinical practice, and results in the formulation of a practical and appropriate treatment plan. Furthermore, involvement of other professionals ensures that they appreciate the importance of oral health care and its relationship to general health, and dispels the misconception that oral disease and tooth loss are unavoidable consequences of certain disabilities.

TREATMENT PLANNING

While patients from a specific special needs group may have several treatment needs in common with other members of that group, each patient should be considered and treated as an individual with a distinctive set of treatment needs. The development of individualised treatment plans may involve several members of the multidisciplinary team, as outlined above.

In order to facilitate appropriate oral health care, it is important to: obtain a careful medical, dental, family and social history determine the oral/dental needs of the patient obtain informed consent to any investigations that may be needed obtain informed consent to the resulting treatment plan.

The main objectives when formulating a treatment plan include: early assessment of oral health realistic methods of oral hygiene intervention – a dental hygienist can be particularly helpful in delivering advice and support dietary advice – liaise with a dietician where appropriate formulation of an oral health care plan – this should include preventative measures to minimise further oral disease management of current oral disease – this may include the management of dental emergencies, in addition to stabilisation of oral health status regular oral examination – the frequency of these examinations must be individually assessed in terms of the risk of further oral disease.

Medical history

An apparently fit patient attending for dental treatment may have a serious systemic disease and may be taking medication which may further compromise the provision of care. Many patients with life- threatening diseases now survive as a result of advances in surgical and medical care. Either or both can significantly affect the dental management or even the fate of the patient. These problems may be compounded by the fact that patients are seen briefly and medical support is lacking in most primary care dental surgeries. A detailed medical history is essential in order to: determine any effect on oral health assess the fitness of the patient for the procedure decide on the type of behaviour and pain control required decide how treatment may need to be modified warn of any possible emergencies that could arise determine any possible risk to staff or other patients/visitors.

The history must be reviewed before any surgical procedure, general anaesthetic, conscious sedation or local anaesthetic is given, and at each new course of dental treatment.

Preoperative assessment

An arbitrary guideline to assist in the selection of appropriate treatment modalities for a patient may be based on the Classification of Physical Status of the American Society of Anesthesiology (ASA) (Table 2.1).

Table 2.1

Classification of Physical Status of the American Society of Anesthesiology (ASA)

ASA	Definition	Dental treatment modifications
I	Normal, healthy patient	None
II	A patient with mild systemic disease, e.g. well controlled diabetes, anticoagulation, mild asthma, hypertension, epilepsy, pregnancy, anxiety	Medical advice may be helpful. Often few treatment modifications needed, unless GA or major surgery is needed.

III A patient with severe systemic disease limiting activity but not incapacitating, e.g. chronic renal failure, epilepsy with frequent seizures, uncontrolled hypertension, uncontrolled diabetes, severe asthma, stroke

Medical advice is helpful.

Dental care should focus on elimination of acute infection and chronic disease, prior to medical/surgical procedure (e.g. haemodialysis patients).

Patients are often best treated in a hospital-based clinic where expert medical support is available.

IV A patient with incapacitating disease that is a constant threat to life, e.g. cancer, unstable angina or recent myocardial infarct, arrhythmia, recent cerebrovascular accident, end-stage renal disease, liver failure

Medical advice is indicated.

All potential dental problems should be corrected prior to medical/surgical procedure to deal with basic problem (e.g. radiotherapy to head and neck, or organ transplant).

Patients are often best treated in a hospital-based clinic where expert medical support is available. Emergency dental care is usually indicated.

V Moribund patient not expected to live more than 24 hours with or without treatment

Medical advice is essential.

Patients are often best treated in a hospital-based clinic where expert medical support is available.

Emergency dental care is usually indicated.

According to the current guidelines, dental treatment must be significantly modified if the patient has an ASA score of III or IV. Of note, a relatively high percentage of the population aged between 65 and 74 years (23.9%) and 75 or over (34.9%) has an ASA score of III or IV.

Preoperative planning

Good preoperative assessment and organisation will assist in anticipating potential hazards when providing oral care, and also help to ensure measures are in place to manage emergencies quickly and efficiently. In most situations dentistry is safe, provided that the patient is healthy and the procedure is not dramatically invasive. Risks arise when these conditions do not apply and the dental team attempts anything over-ambitious in terms of their skill, knowledge or available facilities. It is helpful to formulate a checklist to ensure that factors such as transport, disabled parking and the need for accompanying carers are considered prior to the first treatment appointment. It may also be of benefit to devise a treatment plan consisting of a preoperative, operative and postoperative phase, to ensure that other factors (such as the provision of preoperative antibiotics for the prophylaxis of infective endocarditis) are also considered (Table 2.2).

Table 2.2

Example of clinic appointment schedule

Special care service
Patient	Last name
	First name
	Date of birth
	Unit number
	Telephone
	Mobile
	Fax
	E-mail
Systemic disease	Main problems
Communication difficulties	Main problems
Appointment		Date	Date	Date
		Hour	Hour	Hour
Treatment planned	Restorative
	Surgical
	Mixed
Support required	Transport
	Disabled parking
	Special seating
	Caregiver present
	Additional staff
	Other
Appropriate dental care	Antibiotic prophylaxis^*
	Blood tests (e.g. INR)
	BP monitoring
	Cardiac monitoring
	Medical assessment
	Others
Drugs to avoid	No restraints
	Drugs^*
	LA
Behaviour control	Relative analgesia
	IV sedation
	GA
	Others