Chapter 4

Communicating in Special Dental Situations

Aim

The aim of this chapter is to provide the reader with an understanding of how communication skills may be modified to match the requirements of patients with special dental needs. The communication skills described in Chapters 2 and 3 are the basis for this chapter. Practical suggestions will be described and how alterations of the basic concepts of communication can assist the dentist in the care of patients with special dental needs.

Outcome

At the end of this chapter the dentist should know the meaning of the terms impairment, disability and handicap, special needs and social exclusion. The dentist should have an awareness of the need to provide accessible information in both verbal and written form for patients with communication difficulties. The need for the use of interpreters for those with hearing impairment and/or children and adults with a learning disability is examined, together with the acknowledgement that the inclusion of a third person alters the dynamics of communicating with the patient. Mention is made of the communication programmes ‘Writing with Symbols’, Wigit^© and Makaton^©, and their usefulness when interacting with people with communication difficulties in the dental surgery.

Defining Special Needs

The term ‘special needs’ is difficult to define, as it has become associated with various different meanings. In 1980 the World Health Organization attempted to define special needs in terms of the terms impairment, disability and handicap:

• Impairment was defined as a loss or abnormality of bodily function and/or structure.

• Disability was defined as any restriction or lack of ability to execute an action considered to be within the normal range of human activity.

• Handicap was defined as a disadvantage as a result of the impairment or disability, which limited or prevented the individual experiencing and fulfilling all aspects of their lives as considered to be normal for that individual.

A result of the WHO definitions was to group all people with special needs together in accordance with the medical diagnosis of their impairment, disability, or handicap (Table 4-1). Furthermore, as these definitions relied heavily on the medical model they promoted the tendency to perceive special needs patients as ‘ill’. An alternative definition existed, however. If disability was perceived within a social framework, special needs could be understood as a label society had provided for those who were impaired. Thinking in this way allowed the realisation that the label ‘special need’ belonged not with the disabled person but with society. It was society that branded individuals as having a special need and consequently excluded them from society, all types of services, social production and goods, resulting in economic exclusion.

Therefore people who are socially excluded may or may not be disabled but they may be unemployed, impoverished, homeless and may misuse alcohol and drugs. Social exclusion is a major factor in the increased prevalence of ill health found in these individuals. Therefore, while treating people with special needs may require a medical classification with regard to infection control or antibiotic cover, in order to reduce barriers and improve access to dental services dentists should perceive special needs within the parameters of social exclusion and societal demands. Thinking in this way improves access to care and communication for people with special dental needs.

The acknowledgement of the requirement for specialist training for dentists caring for patients with special dental needs has been recognised by the Royal College of Surgeons of England. The proposed new speciality of ‘special care dentistry’ has allowed the role of communication, behavioural sciences and health promotion to be seen as central in the oral health care of these patients. Information about the Diploma in Spe found at http://www.rcseng.ac.uk/dental/fds/examinations/pdf/regs_dscd.pdf

Are Patients with Special Dental Needs Treated in General Practice?

Evidence from work with general dental practitioners suggests that a variety of patients with special dental needs are treated in general dental practice. The majority of patients with hearing or sight impairment are readily accepted, as are older people and those with physical and learning disability. If the disability is regarded as too severe or the older person is too cognitively compromised the patient is referred to salaried primary dental or secondary dental services. The situation with regard to HIV-seropositive patients was different. One general practitioner stated: ‘A patient of mine has just been diagnosed with HIV and asked if I would still treat him. There is no question about it – of course I will. I’m not taking on any new patients at the moment – and so I won’t be taking on anyone, so it’s not an issue of whether they are HIV-positive or not.’

The role of decision-making in general practice is discussed in Chapter 6 and how decisions may be made with regard to treatment and management. For the purposes of this chapter the assumption is made that the choice has been made to include the individual as a practice patient and necessitates a delivery of appropriate and effective communication skills.

Communicating with Older People

Life expectancy of people in the developed countries is increasing. This means that the proportion of older adults within communities is greater. The likelihood that these people will require continued dental care well into their eighth decade is now recognised. Improved oral health of people in their sixth decade has been shown to have an impact on service provision, since they expect high-quality dental care. Referred to as the ‘young old’, patients aged 65 to 74 will have experienced restorative dental care and expect more high-tech solutions than partial dentures for the replacement of missing teeth. The myth that older people will naturally loose teeth is being dispelled. Greater efforts are being made by patients themselves and their dentists to retain their natural dentition (rather than resort to partial or full dentures).

Dental practitioners and their staff will need to be encouraged and trained to prevent and counter-act long standing attitudes that may be prejudicial to the provision of holistic care for older people. Unfortunately, without awareness among some members of the dental team of negative behaviours towards older people (over the age of 64 years) it will be difficult to maintain a sensitive and competent caring regime for this group. Regrettably, it is common, for healthcare providers to hold negative views about older people. It is important that the principal practitioner and practice manager set good examples to others in the dental team to improve the chances that ageist attitudes are not revealed or acted upon.

The first signs of disability may be observed in patients aged over 50 years, and after the age of 70 years they rise steeply. According to statistics, almost 70% of disabled adults are aged 60 and over. Commonly reported disabilities in this age group are impaired mobility and hearing loss. Although the most severely affected older people tend to live in residential care, for others fears about living alone have resulted in she/>

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