Introduction

Special care dentistry is concerned with providing and enabling the delivery of oral care for people with an impairment or disability, where this terminology is defined in the broadest of terms. Thus, special care dentistry may be considered to be:

The improvement of oral health of individuals and groups in society, who have a physical, sensory, intellectual, mental, medical, emotional or social impairment or disability or, more often, a combination of a number of these factors.

(Gallagher and Fiske, 2007)

The World Health Organization defines disability as an umbrella term, covering impairments, activity limitations and participation restrictions:

An impairment is a problem in body function or structure; an activity limitation is a difficulty encountered by an individual in executing a task or action; while a participation restriction is a problem experienced by an individual in involvement in life situations … [Thus] disability is a complex phenomenon, reflecting the interaction between features of a person’s body and features of the society in which he or she lives.

(WHO, 2008)

In the United Kingdom there are an estimated 11 million adults and 770,000 children with a disability, using the widest survey definition. This equates to more than 1 in 5 adults, and around 1 in 20 children. However, many would not see themselves as disabled, and do not claim disability‐related benefits or use services aimed specifically at disabled people.

The population of disabled people includes those with a physical disability, wheelchair users, blind people, deaf people, those with mental health problems and those with medically compromising conditions. Although older people are more likely to be disabled than younger people, trends show an increasing number of children reported as having complex needs, autistic spectrum disorders or mental health issues.

The provision of oral care for disabled people is often complex and time‐consuming as a result of their impairment. Additionally, for some people, including those with mental illness and learning disabilities, the issues of informed consent present an added challenge. It is essential to take a holistic approach to oral care to address the complex needs of people in these situations.

Although people with learning disabilities and mental health problems have the same right to equal standards of health and care as the general population, there is evidence that they experience poorer general and oral health, have unmet health needs and have a lower uptake of screening services; the impact of oral conditions on an individual’s quality of life can be profound.

Treatment of oral disease is more likely to include extractions rather than fillings, crowns or bridges, particularly for people living in residential care. Physically accessing care for those with disabilities can be problematic. However, another significant barrier is some dentists’ attitudes, which can often be negative towards this group of people. There is a need to foster positive attitudes towards disability and to increase the knowledge of those in the dental profession towards disability and oral care.

This chapter will explore the use of conscious sedation in the management of those with disabilities requiring oral health care.

The Use of Conscious Sedation

Some of the frequently cited reasons for dental neglect in those with disabilities are: inability to locate a dentist willing to perform treatment, financial and transport difficulties, lack of motivation and, most importantly, fear and behavioural problems posed by these patients.

The difficulty in actually carrying out dental treatment may be due to:

• Reduced or a complete lack of co‐operation
• Anxiety/phobia
• Exacerbation of a medical condition
• Involuntary movements.

In many cases simple behaviour techniques will enable treatment to be carried out. Where this fails, however, conscious sedation may provide a useful alternative to patient care and avoid the need for general anaesthesia.

In considering management options, it is important to consider the following:

• Demand and need for care/long‐term plan
• Ease of carrying out treatment
• Different management options, for example sedation, general anaesthesia
• Best interests of the patient
• Patient’s level of capacity and consent.

The treatment planning process must be realistic and in the best interests of the patient. Management may involve:

• Monitoring and reviewing with no active treatment
• Simple treatment with or without local anaesthesia
• Treatment with conscious sedation and local anaesthesia
• Treatment under general anaesthetic.

The final decision to use conscious sedation must involve:

• Consultation with the patient and/or carer
• Assessment of medical and social history and fitness
• Consent process
• Most appropriate location for treatment.

The provision of conscious sedation in special care dentistry will be presented under the following headings:

1. Location for providing conscious sedation
2. Sedation techniques
3. Patient groups:
   • Neurological disorders
   • Musculoskeletal disorders
   • Learning disability
   • Sensory disability
   • Mental health problems
   • Systemic conditions (see Chapter 3).

Location for Providing Conscious Sedation

For conscious sedation to be safe, valuable and effective, it is essential that the most appropriate type of conscious sedation is chosen for each individual and administered in the correct environment by an appropriately trained practitioner. Conscious sedation for dental care may be provided in two different settings:

Out‐patient Setting

• General dental practice
• Community dental practice
• Dental hospital setting.

Day‐Stay Setting

• Anaesthetist led hospital unit.

The main criterion used to determine the most appropriate setting for patient care is the ASA grade. Patients classified as ASA I and II can generally be managed on an out‐patient basis under intravenous sedation or inhalation sedation. Some ASA III patients can also be managed with inhalation sedation in this setting.