Special care dentistry: time for action
For decades special care dentistry has been the preserve of committed dental professionals in the public dental services who have much experience but little education and training. For some, training in paediatric dentistry was a starting point for a working life devoted to children and then adults with special needs. Likewise, specialists in oral medicine often provide care for medically compromised patients. Both these disciplines have provided such services – mainly because no-one else was available to look after the special needs of these adult patients.
So what is special care dentistry?
Special care dentistry is concerned with providing and enabling the delivery of oral care for people with an impairment or disability. It aims to improve the 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 (Joint Advisory Committee for Special Care Dentistry, 2003a).
Why do we need to know about this now?
In 2005 the Disability Act entered the statute books; this legislation has an impact on people with disabilities in relation to their housing, education, social welfare and, of course, health.
The Department of Health and Children has, along with other interested government departments, published its Sectoral Plan in response to the Act. The most immediate result is the requirement to have in place, by the summer of 2007, an assessment of educational and health needs of children and young people. Something similar will follow for adults. While this does not guarantee the provision of services to match identified needs, inevitably the very process of ascertaining this need will heighten awareness among patients, families and carers. Is the dental profession in a position to respond to that demand?
We know from national epidemiological monitoring programmes commissioned by the Department of Health and Children that the oral health of many children and adolescents who are designated as having ‘special needs’ is poor. The National oral health survey of adults with an intellectual disability in residential care in Ireland 2003 has been published and results indicate that:
• Fifty per cent of adults require oral/dental care
• Fifty-two per cent had moderate to severe periodontal disease, with 11% experiencing a painful gum condition
• Twenty per cent had suspect oral lesions, 3% of which were suspect pre-cancerous lesions
• Twenty per cent of residents would require sedation or general anaesthesia (GA) for dental treatment
• Eighty per cent of the residential units reported a need for training in oral hygiene management for carers.
The 2002-3 National oral health survey of children with special needs is as yet unpublished but preliminary data (Crowley, 2005) indicate the following:
• Treatment need is high for these children, ranging from 16% of 5-year-olds to 76% of 15-year-olds
• Special needs children have more extractions, need more extractions and have less prevention, for example the use of fissure sealants
• The need for general anaesthesia for dental care is high: 42% of 5-year-olds, 19% of 12-year-olds and 15% of 15-year-olds
• Forty-five per cent of 12-year-olds have had two or more general anaesthetics for dental care.
For many people, figures such as these do not convey the real picture of the impact on patients and their carers, especially the impact on quality of life from poor oral health.
What does this mean in terms of real patients?
Case 1: Muscular dystrophy
This patient is a 33-year-old man with muscular dystrophy (Figures 1 to 3). He was referred for hospital care because he was in a wheelchair and there was some doubt about clotting capacity. Routine investigations revealed no coagulation defect.
The patient was able to transfer satisfactorily from his wheelchair to the dental chair. He had undergone restorative and periodontal care in the past but had not been followed up.
He does not need to be seen in secondary/tertiary care. This patient needs the same considerations as any person who has restricted mobility and uses a wheelchair – competence in manual handling skills and an effective tracking system so that regular reviews and treatment are in place. The only significant caution surrounding clinical dental care in some patients with muscular dystrophy is in their reduced tolerance to local anaesthetic solution.
Case 2: Down’s syndrome
Oral healthcare services for children with disabilities are often better developed than those for adults. This patient’s parents felt that although he had had dental checks at school, once he was working part-time, nobody seemed to bother about him.
Again, his needs are routine and there are no behavioural problems to compromise the provision of dental treatment in a primary care setting. However, the absence of dental attention in the years since leaving school has resulted in moderate to severe periodontal disease, the effects of which are not reversible (Figures 4 and 5). Whose responsibility is this?
Case 3: Epilepsy and learning disability
These patients have two conditions in common – and at least one dental consequence (Figures 6 and 7). Both boys have epilepsy and both have experienced dental trauma as a consequence of a malocclusion and their seizure disorder. Because of their accompanying learning disability they were not offered orthodontic care.
In addition, it was suggested to the parents that nothing should be done about the traumatised (and non-vital incisors) until they were adults and could have crowns placed on these teeth. For one of these boys, who also has cerebral palsy, the crowding present may well be a contributory factor to the poor oral hygiene and related periodontal signs.
Yet orthodontic treatment can be a reality for many children and even adults with disabilities, and, indeed, many within the HSE orthodontic services here in Ireland undertake such care.
Case 4: Head and neck cancers
Increasingly, we will be asked to treat more and more patients who are survivors of cancer. The maxim nowadays has moved from survival at any cost to survival at least cost in terms of the impact of the disease and its treatment on the body. This includes oral and dental structures.
This young man had a rhabdomyosarcoma of his nasopharynx at three years of age. This was successfully treated with radiotherapy and chemotherapy but both these treatment modalities left their hallmark. The early treatment has affected his facial growth centres and he now feels his face is so disproportionate that he wants orthognathic surgery. However, his virtually rootless teeth presented a challenge to the orthodontist (Figures 8 and 9). In addition, as happens with seriously ill children, he was prescribed sweetened liquid oral medicines and lost teeth early as a consequence of rampant dental caries (Figure 10). He now has a very dry mouth and is at risk from dental caries (Figure 11).
The stark reality
These patients illustrate the oral health data presented earlier in this article and are a stark reminder of the way in which vulnerable sections of the population can lose out in a so-called modern, affluent society.
What do we do to change this? And yes, it is we who must make the changes. This should be the concern and business of all dental professionals, not only the public dental services but all those in the dental profession who have the knowledge and skills to provide what is often basic dental care.
In 2005 a collaboration between the National Disability Authority, the Dental Health Foundation and the Dental School and Hospital of the University of Dublin Trinity College hosted a round table forum of stakeholders. In attendance were patients, parents, public service dentists, the Irish Dental Association, charities, support groups, representatives of health departments both north and south of the border, and academics. The outcome was a plan of action called Disability and oral health: the way forward (Elliott et al, 2005). This plan is now with the Department of Health and Children and its aims are contained in Table 1. Its agenda is ambitious but patients, parents, carers and other advocates have long demanded, at the very least, the same quality and access to care that non-disabled people receive.
The Disability Act 2005 has given the mandate for a needs assessment; the rest is up to us. So much of what people with disabilities need and demand requires the skills of a dentist, but maintaining that work is the remit of the dental hygienist. Arguably, this is as, if not more, important in some circumstances than dental interventions; without skilled home oral care, dental care will fail. One of the overwhelming findings in most oral health surveys of people with disabilities is the over-riding need for oral hygiene intervention, hence the reference to a multi-professional response, as well as a ‘training the trainers’ programme in the action plan.
Data from current research projects, in collaboration with the HSE dental services around the country, will help to answer some of the questions posed by oral health findings from national surveys. How do we ensure that people with disabilities access dental care and how do we address the high non-attendance rate for appointments by some people with special needs?
We acknowledge from the national surveys that the oral health of young and older people with disabilities is often poor. A Health Research Board funded study seeks to investigate ways of preventing oral and dental disease in young children with disabilities, so that the clinical data presented in this article is not an inevitable outcome for special needs children growing up in Ireland today. More specifically, innovative ways to contain and prevent the seemingly inevitable progression of periodontal disease in people with Down’s syndrome is underway at the Dublin Dental School and Hospital.
The Dental Council of Ireland has endorsed the need for recognition of a specialty in special care dentistry. This is in line with many other countries world-wide, not all of which are so-called developed countries.
Will the efforts of those who are prepared to provide the much needed level of service receive the level of support this requires from the rest of the dental profession, to ensure that one of the richest nations in the world provides comprehensively for its most vulnerable citizens?
Crowley E, Whelton H, Murphy A, Cronin M, Flannery E, Nunn JH (2003) The national oral health survey of adults with an intellectual disability in residential care in Ireland 2003. http://www.dohc.ie/ publications/pdf/oral_health_ residential_care.pdf?direct=1
Crowley E (2005) The oral health of adults and children with special needs in Ireland. http://www.dohc.ie/issues/dental_research/presentation8.ppt
Elliott I, Nunn JH, Sadlier D (2005) Disability and oral health: the way forward. National Disability Authority. http://www.nda.ie/ cntmgmtnew.nsf/0/4739AF522B1865EC8025707B004C4015?OpenDocument
Joint Advisory Committee for Special Care Dentistry (2003a) Training in special care dentistry. http://www.bsdh.org.uk/misc/ACase4Need.pdf
The Disability Act 2005 http://www.oireachtas.ie/documents/bills28/acts/2005/ a1405.pdf