Special care dentistry

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‘For special care patients, a visit to the dentist may be one of the most overwhelming and anticipated trips out of their usual environment’

Jignesh Panchal highlights the importance of special care dentistry.

As the 13th addition to the GDC’s specialist list, special care dentistry (SCD) is the branch of our profession that looks after some of the most vulnerable patients.

Specialists in this area act to improve and treat the oral health of those patients who are affected by physical, emotional, medical, intellectual, sensory, mental or social impairments, and are therefore unable to accept routine dental care.

Although disabilities affect people of all ages, SCD mainly addresses adolescents and adults, as the care of special needs children is usually undertaken by the branch of paediatric dentistry. Young dentists can often lack confidence when dealing with such patients, but these skills can certainly be developed with the right education and experiences.

Indeed a survey by the British Dental Association (BDA) showed that young dentists feel the least confident in their ability to carry out clinical work in SCD, followed by molar endodontics and minor oral surgery.

However, given that 18% of the world’s population have some form of disability, we as young dentists are very likely to come into contact with these groups of people during our practising lives. Of these, 90% can be seen in primary care dental services.

Understanding patient needs

Unfortunately people with disabilities can feel ostracised from society. SCD patients should not be classified as, for example, an ‘asthmatic patient’ or an ‘epileptic patient’ but rather, they should be thought of as a patient with a condition – and that condition should not define them nor categorise them in a discriminatory fashion.

As a profession we can act to tackle this by making our services more accessible and not let the patients feel marginalised. For the majority of patients, dentistry makes up a small, but important, part of their lives. For special care patients, a visit to the dentist may be one of the most overwhelming and anticipated trips out of their usual environment. It is important that all members of the dental team are all able to understand the needs of this group of patients.

Aside from the clinical dentistry being challenging, the patient’s ability to consent is often another difficult aspect of working with special care patients, and as always, acting in the patient’s best interests is imperative. Young dentists should also be aware of the various support services that exist, and these will depend on the local authority that you are in. Overall, a multidisciplinary, specialist-led, holistic approach is required for the successful management of these patients.

Giving the best possible care

Previous generations of dentists may not have been as aware of SCD during their years of dental training. Now, there is more of an emphasis on recognising this group of patients with certain impairments and there are lots of resources available on how to give them the best possible care.

How willing a young dentist is in managing these patients can depend on their confidence. General dentistry can be difficult at the best of times and adding an extra layer of complexity in terms of a medical condition can make things all the more challenging. Therefore, treating their dental problems and maintaining their oral health may need more tactful communication.

Ultimately the core clinical principles learnt throughout dental school are essentially the same when it comes to SCD, but these patients will require a greater degree of care, compassion and communication.

As one of the newest specialities in modern dentistry, SCD is a challenging yet rewarding aspect of dentistry that provides care for those patients who are unable to receive traditional dentistry due to some form of impairment. It is envisaged that access to dentistry for these patients continues to improve and we as young dentists and healthcare professionals are equipped with the necessary skills to provide the best possible dental care we can.

Advice from a speciality trainee in special care dentistry

I had a Q&A interview with Suzanne Burke, a speciality trainee in special care dentistry at the Liverpool University Dental Hospital. She offers some advice for young dentists who may be apprehensive about SCD.

Jignesh Panchal (JP): What attracted you to a career in SCD?

Suzanne Burke (SB): I was fortunate to work in a very supportive and caring general dental practice for four years after I qualified. I had the opportunity there to provide care for vulnerable groups, including on a domiciliary basis. This encouraged me to seek a role in the Community Dental Service (CDS), and I have worked in the CDS in one form or another for the last 15 years.

It sounds very cliché; however I love special care dentistry because I believe that we really make a difference to quality of life for vulnerable and excluded groups in our population. Special care dentistry takes a holistic view, and considers that wider picture of how we can help – treating the person, not just the teeth.

The satisfaction of providing care for a patient group with so many other challenges in their lives is very important to me. Teeth and dental health can impact day-to-day living in so many ways, and we need to ensure that access to oral healthcare is not compromised due to medical or social issues. There are so many inequalities in society that often those with the greatest need are neglected, in preference of treating the most demanding.

JP: What are the most challenging aspects?

SB: It can be emotionally demanding to deal with a patient group with so many complex issues. Provision of care for a dying patient, or those undergoing chemotherapy or other cancer treatment can be exhausting. We often need to obtain information from a wide group of healthcare professionals, family members, and coordinating a wider group of people can be frustrating.

As in any service, there are decisions to be made on a daily basis that involve a careful balance of risk and benefit to the patient. It is really important to have a close peer support network to discuss those challenging cases, where there is often no right or wrong answer. I am very lucky in my training post currently to have so much support, advice and experience available from my consultants, fellow trainees, nurses and the wider dental team.

Sometimes the dentistry itself is challenging due to physical access – factors that increase disease or reduce the chances of ‘success’ of our treatment can be outside of our control. The role can be physically demanding, with us ending up in strange and varied operating positions!

JP: What are the most enjoyable aspects of being a speciality trainee in SCD?

SB: Feeling like you have done the right thing. It is very satisfying to achieve care for a patient where it has not been possible in any other way. Whether we have used our behaviour management skills, IV sedation or general anaesthetic, achieving oral health so that the patient can get on with their life is immensely satisfying.

Being part of the SCD team is also enjoyable, as is having a shared purpose, with each and every member of the team contributing to the care of the patient gives a great sense of camaraderie. There is a lot of humour in special care dentistry, and as staff we are much richer from the experiences our patients have. The glimpse into their daily challenges makes us put our own lives in perspective and realise how lucky we are.

JP: Which skills in particular are the most important for people working within this area of dentistry?

SB: Well, where to start? Compassion is very important, as is a sense of empathy for our patients and the difficult situations they may be in.

Communication skills (with patients, their families and carers, other healthcare staff), verbally and non-verbally are something that comes with time, but SCD does demand an insight into how we come across, how our behaviours and attitudes can affect our patients, and the people we need to work with as a team to achieve the best outcomes for them.

There is a level of academic demand, as we need to have a good deal of theoretical knowledge around medical conditions, physiology and psychology. We need to know up-to-date legal frameworks and guidelines, just the same as other aspects of dentistry.

We need patience and perseverance to be able to set and achieve realistic goals within the context of that patient’s wider life, and the determination to provide the best possible care for those we have the privilege to be involved with.

JP: What tips do you have for young dentists who may be anxious about working in SCD?

SB: This is such a rewarding specialty. Our patients are people who happen to have additional complexity – but don’t we all in one way or another? We do need to be thorough to identify all issues, but with a ‘can do’ attitude. Some skills such as communication, empathy and building rapport with patients takes experience to build – so there’s no time like the present to start!

Having said that, every professional has their own particular strengths, and SCD may not suit some people’s personalities or priorities, just as other specialities don’t suit mine. Deciding on a career path only begins after graduation, and I have been lucky in choosing a pathway that I feel is right for me. As a group, SCD teams are enthusiastic, supportive and truly have the best interests of their patients at heart. The skills you build in SCD will be invaluable in other areas of dentistry, and in life in general.

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