Titelblatt
Copyright-Seite
Foreword
Chapter 1 Understanding Special Care Dentistry
Aim
Outcome
Introduction
What is Special Care Dentistry?
The Ethos of Special Care Dentistry
Definition of Disability
Demography of Disability – One in Four of Us
The Disability Discrimination Act (DDA) 1995
The Disability Discrimination Act (DDA) 2005
The Mental Capacity Act 2007
Current Health and Social Policy
Oral Health and Disability
Dealing with Disabled People
Conclusions
Further Reading
Chapter 2 Managing the Oral Health of Patients With Physical Disabilities
Aim
Outcome
Introduction
Barriers to Oral Healthcare
Improving Access
Clinical Service Provision
Manual Handling Issues
Oral Hygiene Aids
Adapting Toothbrush Handles
Domiciliary Dentistry
Advantages and Disadvantages
The Scope of Domiciliary Dentistry
Planning
Health and Safety
Infection Control
Medical Emergencies
Mobile Dental Units
Conclusions
Further Reading
Chapter 3 Managing the Patient With a Sensory Disability
Aim
Outcome
Introduction
Visual Impairments
Auditory Impairments
Deafblindness
Conclusions
Useful Contacts:
Chapter 4 Managing the Patient With a Learning Disability
Aim
Outcome
Introduction
Demography
Additional Disabilities
Causes
Epilepsy and Learning Disability
Oral Health
Consent
Patient Management
Communication
Restraint and Physical Intervention
Conclusions
Further Reading
Chapter 5 Managing the Patient With Mental Illness
Aim
Outcome
Introduction
1. Schizophrenia
Cause
Signs and Symptoms
Management
Nicotine
Violence
Oral Health
Dental Management
2. Endogenous Depression
Symptoms
Management
Oral Health
Dental Management
3. Dementia
Aetiology of AD
Onset of AD
Diagnosis
Clinical Features and Symptoms
Management
Oral Health
Oral Health Assessment
Expression of Oral Symptoms
General Principles for Oral Healthcare
Dental Treatment
Consent
Conclusions
Further Reading
Chapter 6 Managing Patients Who Require Antibiotic Cover
Aim
Outcome
Introduction
Infective Endocarditis
Risk of Infective Endocarditis from Dental Treatment
Risks from Using Antibiotics
Antibiotic Cover and Dental Treatment
Treatment Planning
Local Anaesthesia
Restorative Dentistry
Endodontic Treatment
Paediatric Dentistry
Dental Treatment and Heart Surgery
Dental Treatment and Prosthetic Implants
Dental Treatment and Joint Replacements
Medicolegal Considerations
Conclusions
Further Reading
Chapter 7 Managing Immunocompromised Patients
Aim
Outcome
Introduction
Conditions Leading to Immunodeficiency
Innate (Primary) Immunodeficiency States
Acquired (Secondary) Immunodeficiency States
White Blood Cell Count
Assessing Immunodeficiency in Relation to Oral Healthcare
What Do You Do When Faced with an Immunocompromised Patient?
Liaison
Check Patient Factors
Oral Hygiene and Risk
Infection Control
Treat the Symptoms
Prophylaxis for Dental Treatment
Plan the Dental Treatment around the Condition
Follow-up
Conclusions
Further Reading
Chapter 8 Managing the Patient Having Radiotherapy
Aim
Outcome
Introduction
Facts about oral cancer include:
Radiotherapy
Effects of Radiotherapy in the Head and Neck Region
Oral Assessment Prior to Radiotherapy
Treatment Prior to Radiotherapy
Oral Management During Radiotherapy
1. Dry Mouth
2. Mucositis
3. Loss of taste
4. Oral flora changes
5. Trismus
6. General oral hygiene
7. Diet
Oral Review
Oral Rehabilitation
Maintenance
Osteoradionecrosis
Post-radiotherapy Extraction of Teeth
Conclusions
Further Reading
Useful Web Sites
Chapter 9 Management of Patients With Bleeding Disorders
Aim
Outcome
Introduction
Haemostasis
Identifying Bleeding Disorders
1. Anticoagulant Therapy
a. Anti-platelet therapy
b. Coumarin therapy
2. Platelet Disorders
a. Thrombocytopenia
b. HIV infection
3. Congenital Clotting Disorders
a. Haemophilia A (Factor VIII deficiency)
Other Barriers/Challenges
b. Haemophilia B (Christmas Disease)
c. Von Willebrand’s Disease
4. Vitamin K Deficiency and Malabsorption
Conclusions
Further Reading
Chapter 10 Managing Pronounced Gag Reflexes
Aim
Outcome
Introduction
What is Gagging?
The Classification of Gagging
The Aetiology of Gagging
Contributing Factors
Assessment of the Nature and Severity of the Gagging Problem
Clinical Examination
Initial Treatment
Gagging Reduction Strategies for Examination and Treatment
1. Relaxation, Distraction and Desensitisation Techniques
2. Psychological and Behavioural Therapies
3. Pharmacological Agents – Local Anaesthesia, Sedation and General Anaesthesia
4. Complementary Therapies
5. Other Techniques
Recording Success
Conclusions
Further Reading
Chapter 11 Patient Management Through Non-invasive Treatment
Aim
Outcome
Introduction
Alternative Operative Techniques
1. Atraumatic Restorative Technique (ART)
2. Air Abrasion
Advantages of air abrasion
Disadvantages of air abrasion
Main indications for use
Cost
3. CarisolvTM Gel
Advantages of CarisolvTM gel
Disadvantages of CarisolvTM gel
Main indication for use
4. Combination of Air Abrasion and CarisolvTM Gel
5. Oraqix
6. Ozone
Main indications for use
Conclusions
Further Reading
Chapter 12 Sedation and General Anaesthesia in Special Care Dentistry
Aim
Outcome
Introduction
Intravenous Sedation (IV)
Inhalational Sedation (IS)
Oral Sedation
Transmucosal Sedation
General Anaesthesia
Patient Assessment for Anaesthesia
The General Anaesthetic Setting
Making the Decision Between Sedation or General Anaesthesia
Conclusions
Further Reading
Quintessentials of Dental Practice – 42
Clinical Practice – 5
British Library Cataloguing in Publication Data
Special care dentistry. - (Quintessentials of dental practice; v. 42)
1. People with disabilities - Dental care 2. Dentistry - Practice
I. Fiske, Janice II. Wilson, Nairn H. F.
617.6 ′0087
ISBN: 185097313x
Copyright © 2007 Quintessence Publishing Co. Ltd., London
All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without the written permission of the publisher.
ISBN: 1-85097-313-x
Special Care Dentistry is special on many counts. Patients requiring Special Care Dentistry pose special challenges; special skills and knowledge are integral to successful clinical outcomes, and special care and attention is fundamental to the planning and effective delivery of care.
This book is timely, given the growing need and demand for Special Care Dentistry around the world. Advances in healthcare, people living longer, and attitudinal changes in society are but three of the many, varied reasons for the growth and increasing practice of Special Care Dentistry.
In the provision of oral healthcare to individuals with disabilities, disorders and other conditions falling within the scope of Special Care Dentistry, the most appropriate and effective treatment may be relatively straightforward and minimally interventive – indeed, often the simpler the better, but the management of the patient tends to be complex and challenging. Understanding and dealing with these complexities and challenges is the focus of this excellent addition to the highly successful, wide-ranging Quintessentials of Dental Practice series: comprehensive, yet succinct; authoritative, but pragmatic; and of immediate clinical relevance, rather than theoretical. To add to these qualities, this book is most engaging and easy to read, given the carefully crafted text, supported by numerous high-quality illustrations.
Practitioners, let alone students, and even those with special interests in the field will extend and enhance their understanding and appreciation of Special Care Dentistry in the few hours it takes to read this book from cover to cover – an enjoyable, thought-provoking and informative experience. And once read, this book will become a trusted reference text to turn to for practical guidance and situation-saving clinical tips. All in all, another gem in the bejewelled Quintessentials crown.
Nairn Wilson
Editor-in-Chief
The aim of this chapter is to explain what is meant by Special Care Dentistry, who requires it, why he or she requires it and who can provide it.
After reading this chapter you should have an understanding of what is meant by Special Care Dentistry and the part that you can play in its delivery.
The main purpose of this book is twofold:
Firstly to remove the stereotypes and myths that can surround people who require Special Care Dentistry, and
Secondly to provide the dental team with knowledge, information and practical tips that will encourage them to undertake Special Care Dentistry.
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 is concerned with: 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.
It is defined by a diverse client group with a range of disabilities and complex additional needs and includes people living at home, in long-stay residential care and secure units, as well as homeless people. Clearly, not every individual encompassed by this definition requires specialist care and the majority of people can, and should, be treated by the primary dental care network of general, personal and salaried dental services.
The ethos of Special Care Dentistry is its broad-based philosophy of provision of care. It achieves the greatest benefit for patients by taking a holistic view of oral health, and liaising and working with all those members of an individual’s care team (be they dental, medical or social) to achieve the most appropriate care plan and treatment for that person through an integrated care pathway.
Special Care Dentistry is proactive to the needs of people with disabilities rather than solely reactive. Recognising that some groups of people are unable to access oral healthcare unaided, to express a desire or need for oral healthcare or to make an informed decision about its benefits to them, Special Care Dentistry includes screening, preventive, and treatment programmes tailored to meet the specific needs of groups or individuals.
Its guiding principles are that:
All individuals have a right to equal standards of health and care.
All individuals have a right to autonomy, as far as possible, in relation to decisions made about them.
Good oral health has positive benefits for health, dignity and self-esteem, social integration, and general nutrition and the impact of poor oral health can be profound.
Disability is difficult to define. Words mean different things to different people. While some people prefer to be referred to as “disabled people” (as it clarifies that their disability is related to society’s barriers), others prefer to be called “people with disabilities” (emphasising that they are people first and disabled second). However, there are also cultural differences in the use of terminology. For example, as Nunn points out, in African languages there are words to describe observable impairments like lameness but no overarching generic terms. Some cultures consider names as stigmatising, and in the UK the terminology “mental retardation” is considered to be stigmatising and unacceptable, whereas in the USA it is considered acceptable and is a currently used term.
The language of disability can be confusing. It is continually changing, reflecting developments in legislation and understanding of the complex issues surrounding it. Whilst there are different causes and different types of disability it is important to remember that everyone with a disability is an individual with their own set of needs and wants.
In the UK, terms in general use are impairment and disability, where:
Impairment refers to a medical condition or malfunction
Disability refers to the restrictions caused by society through discrimination, ignorance or prejudice.
Within this book, the term disability will be used to refer to all those people who require Special Care Dentistry, including those with complex medical conditions.
It is estimated that between 8.6 and 10.8 million people in Great Britain are disabled (see Table 1-1) and that the life of one in every four adults in the UK will be affected by disability, either through experiencing a disability or caring for someone close to them who has a disability.
| Types of impairment | Estimated numbers affected |
| Visual impairments | 2 million |
| Hearing impairments | 8.7 million |
| Mobility impairments (wheelchair users) | 500,000 |
| Learning difficulties | 1 million |
| Invisible or "hidden" impairments | 250,000 |
| Arthritis | 8 million |
| Mental health impairments | 1 in 4 of the population |
The number of people with a long-term illness, health problem, or disability which limits their daily activities or work increased significantly between the 1991 and 2001 surveys. Census data for England and Wales indicate that almost 9.5 million people (18.2% of the population) self-report a long-term illness, health problem, or disability which limits their daily activities or work. Disability tends to increase with age and multiple disabilities are more likely to occur in old age with approximately two-thirds of all people with a disability being over 65 years of age. The prevalence and common causes of disability for the different age groups are shown in Table 1-2.
| Age group | Prevalence of disability | Common causes of disability |
| < 16 years | 4.3% |
|
| 16–49 years | 9.65% |
|
| 50–64 years | 26.6% |
|
| 65+ years | 51.5% |
There is no single register for disability, and a proportion of people with disability have multiple impairments and/or medical conditions so that the categories of disability and impairment may overlap. For example, people with learning impairments have an increased prevalence of associated disabilities such as physical or sensory impairments, behavioural differences and epilepsy. Furthermore, with ageing, people with learning disabilities also have a higher rate of dementia than the general population.
Within the terms of the UK DDA 1995, a disabled person is defined as someone who has a physical or mental impairment that has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities. The DDA 1995, together with related Codes of Practice, introduced measures aimed at ending discrimination and giving rights to disabled people. It was introduced in phases (see Table 1-3).
| Phase | Requirement |
| 1. December 1996 | It became unlawful for service providers to treat disabled people less favourably for a reason related to their disability |
| 2. October 1999 | Providers were required to make reasonable adjustments for disabled people such as providing extra help or making changes to the way they provide their services |
| 3. October 2004 | Required service providers to assess obstacles and make reasonable adjustments to the physical features of their premises to overcome physical barriers to access |
Essentially it requires that providers must:
Take reasonable steps to change policies, practices and procedures which make it unreasonably difficult or impossible for disabled people to use their services.
Take reasonable steps to remove or alter physical features which could be a barrier to disabled people using their services.
Provide the service in an alternative way if the removal of such barriers is impossible, for example, where planning consent to adapt a listed building is withheld. In the case of services to people confined to their home, this could mean providing domiciliary dental care.
Consider access to a service in broad terms that includes access to information about a service. This means that information should be available in alternative formats such as audio, large print formats, etc.
The UK DDA 2005 is designed to extend the rights for disabled people, and clarify and extend the provisions of the DDA 1995. It extends the definition of disability; gives protection against discrimination for people in public service; and creates new legal responsibilities on local authorities, primary care trusts, health authorities and other public bodies to:
develop and deliver disability equality plans
demonstrate how they intend to eliminate discrimination and harassment
promote equal opportunities
encourage positive attitudes towards disabled people.
The UK Mental Capacity Act will be implemented in 2007. It aims to protect people with learning disabilities and mental health conditions, such as Alzheimer’s disease. It will provide clear guidelines for carers and professionals about who can take decisions in which situations. The Act states that everyone should be treated as able to take their own decisions until it is shown that they are unable to do so. It aims to enable people to make their own decisions for as long as they are able and a person’s ability to make a decision will be established at the time that a decision needs to be made. Additionally, there will be a new criminal offence of neglect or ill-treatment of a person that lacks the capacity.
Current health and social policy is focused on the reduction of health inequalities. It recognises that this will not be easy, and that inequalities in health are widening and will continue to do so unless things are done differently through better coordinated activities that cross traditional boundaries so that agencies work in partnership. It particularly refers to improving the quality of life, access to services and addressing healthcare needs for older people, people with mental illness, people with a learning disability, and asylum seekers and refugees. The ethos of Special Care Dentistry echoes this philosophy.
Disabled people want teeth for the same reasons as other people. They want to look good, feel good about themselves and to be socially acceptable. Additionally, they want their mouths to be comfortable and to be able to enjoy their food. To achieve this end, people increasingly wish to retain their natural teeth.
People with disabilities and complex additional needs should have equal access to oral healthcare services and equitable oral health outcomes in terms of self-esteem, appearance, social interaction, function, and comfort. However, this is not the case. Indeed, whilst people with disability and complex additional needs (particularly those with a learning disability or mental health problems) have similar patterns of oral disease as the general population, they have poorer oral health and poorer health outcomes from care. Lower levels of oral health have been demonstrated in a range of patient groups, including people with cerebral palsy, epilepsy, multiple sclerosis, and psychiatric illness. This situation has also been identified amongst young disabled people, people with learning disabilities, and older people, particularly those in residential care. Furthermore, when oral diseases are treated they are more likely to result in extractions than fillings, crowns and bridges. The British Society for Disability and Oral Health has produced guidelines for oral healthcare and the development of integrated oral healthcare pathways to encourage the move towards equitable access, care and outcomes.
Generally, people requiring Special Care Dentistry have needs which are wider than oral health. For example, providing oral care for persons with a learning disability may involve dealing with their inability to consent for care; the use of tools such as “Makaton” and “Easy Read”; working with advocates; organising, attending and informing “Best Interest Meetings”; and taking responsibility for informed consent.
A current, comprehensive medical and social history that is constantly updated is imperative to understanding the needs of all patients including those with disability and complex medical conditions. Not all disabilities are visible and many are “hidden”, for example epilepsy, diabetes, positive HIV status and ischaemic heart disease. There is some evidence to show that it is more difficult for people with hidden, than visible, disabilities to ask for the help they need. Also because of the stigma attached to a disability they may not disclose their disability or may even go as far as disguising one disability by pretending that they have another less stigmatising disability; for example, people who cannot read have been known to feign impaired vision.
When meeting a patient with a disability for the first time:
don’t make assumptions – always ask
be patient – allow time for questions to be answered
listen – use an active non-judgemental technique
believe what they tell you
respect the person for who they are
gather additional information if required (e.g. from a carer or a healthcare professional)
when talking to a carer, include the person with the disability in the conversation. Never talk across them, over their heads or about them as if they are not present.
The majority of people with a disability have disabilities that are mild or moderate and do not require specialist dental care.
Most people with mild or moderate disability could, and should, receive dental care in mainstream primary dental services.
This book seeks to encourage you to treat people with disability by providing you and your team with knowledge and information related to Special Care Dentistry.
British Society for Disability and Oral Health’s Oral Healthcare Guidelines for various groups of people can be accessed at www.bsdh.org.uk
Nunn J. Disability and Oral Care. London: FDI World Dental Press Ltd, 2000.
The Disability Partnership. One in Four of Us: The Experience of Disability. Accessible at www.disability.org.uk/dp
The aim of this chapter is to discuss the treatment of those patients who may have difficulties with access to dental care or complying with dental treatment due to physical disability.