2: APPROPRIATE ORAL HEALTH CARE

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:

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: image parents/carers image social services/social work departments image health visitors image general medical practitioner image paediatric consultant/other hospital specialists image school teachers and assistants image 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: image obtain a careful medical, dental, family and social history image determine the oral/dental needs of the patient image obtain informed consent to any investigations that may be needed image obtain informed consent to the resulting treatment plan.

The main objectives when formulating a treatment plan include: image early assessment of oral health image realistic methods of oral hygiene intervention – a dental hygienist can be particularly helpful in delivering advice and support image dietary advice – liaise with a dietician where appropriate image formulation of an oral health care plan – this should include preventative measures to minimise further oral disease image management of current oral disease – this may include the management of dental emergencies, in addition to stabilisation of oral health status image 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: image determine any effect on oral health image assess the fitness of the patient for the procedure image decide on the type of behaviour and pain control required image decide how treatment may need to be modified image warn of any possible emergencies that could arise image 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

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

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

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

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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      

image

*Specify drugs, doses and time of administration.

CONSENT

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:

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.

In the UK, competent adults, namely a person aged 18 and over who has the capacity to make />

Jan 5, 2015 | Posted by in General Dentistry | Comments Off on 2: APPROPRIATE ORAL HEALTH CARE
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