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.
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:
The key to removing these barriers and improving oral health care provision for people with special needs is education of the individual, the dental profession, society and government as to the importance of oral health and its positive effects on general health.
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.
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.
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.
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.
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).
|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|
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.
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).
|Special care service|
|Date of birth|
|Systemic disease||Main problems|
|Communication difficulties||Main problems|
|Appropriate dental care||Antibiotic prophylaxis*|
|Blood tests (e.g. INR)|
|Drugs to avoid||No restraints|
|Behaviour control||Relative analgesia|
Morbidity is minimal when local anaesthesia (LA) is used. Sedation is more hazardous than local anaesthesia; it must be carried out by adequately trained personnel and with due consideration of the possible risks. General anaesthesia (GA), whether intravenous or inhalational, leads to impaired control of vital functions and is thus only carried out by a qualified anaesthetist, and permitted only in a hospital with appropriate facilities.
Consent in relation to dentistry is the expressed or implied agreement of the patient to undergo a dental examination, investigation or treatment. The law in relation to consent is evolving and there are significant variations between countries. However, the principles remain essentially the same:
Adults are always assumed to be competent unless demonstrated otherwise. If you have doubts about their competence, the question to ask is: ‘can this patient understand and weigh up the information needed to make this decision?’ Unexpected decisions do not prove the patient is incompetent, but may indicate a need for further information or explanation.
To give valid consent, patients must receive sufficient information about their condition and proposed treatment. It is the dentist’s responsibility to explain all the relevant facts to the patient, and to ascertain that they understand them. The information given to patients must, as a minimum, include:
If the patient is not offered as much information as they reasonably need to make their decision, and in a form they can understand, their consent may not be valid. For example, information for those with visual impairment may be provided in the form of audio tapes, braille, or large print.
Consent can be written, oral or non-verbal. A signature on a consent form does not itself prove the consent is valid; the point of the form is to record the patient’s decision, and also increasingly the discussions that have taken place. Your Trust or organisation may have a policy setting out when you need to obtain written consent.
There are several legal tests that have been described in relation to consent. The Bolam test states that a doctor who: ‘acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art is not negligent if he is acting in accordance with such a practice, merely because there is a body of opinion which takes a contrary view.’ However a judge may on certain rare occasions choose between two bodies of medical opinion, if one is to be regarded as ‘logically indefensible’ (Bolitho principle). The main alternative to the Bolam test is the ‘prudent-patient test’ widely used in North America. According to this test, doctors should provide the amount of information that a ‘prudent patient’ would want.