Special needs dentistry

This academy is a group of specialists who are registered as Special Needs Dental practitioners in both Australia and New Zealand. This organisation was developed with the intent to establish a network for those involved in Special Needs Dentistry in Australia and New Zealand. With the advancement of the speciality they intend to enhance the dental experience for those patients with special needs and through developments in research and advocacy their objective is to enrich these patients' overall quality of life.[6]

The Australian Society of Special Care in Dentistry was formed in 1997 and currently has 65 representative members within each state and territory of Australia. The objectives of ASSCID include an oral health and special needs educational role for dental professionals and other allied health workers. They act as a resource hub for professionals to obtain information on the special needs patient and how best to formulate care plans. ASSCID supports the need for oral health services for those with special needs and aligns with health promotion programs that focus on people with special needs.[7]

The Australian and New Zealand Society of Paediatric Dentistry was established in 1988. It is a collaboration of two associations, the Australian Society of Dentistry for Children and the New Zealand Society of Dentistry for Children. The society aims to remain dedicated to the research and development of Paediatric Dentistry. The society also has a large focus on dental care for special needs children and avidly support oral health promotion.[8]

The Australasian Academy of Paediatric Dentistry was developed in 1990. Striving for the best possible oral health conditions for babies, children and adolescents, including those who have special needs, is one of their main objectives.[9]

The principal public oral health organisation in Victoria, Australia, is Dental Health Services Victoria (DHSV). It was founded in 1996 and is a State Government funded initiative that delivers oral health care to Victorian citizens who fit the eligibility criteria. Regarding special needs, the DHSV provides clinical care to patients from the Special Care Unit at the Royal Dental Hospital of Melbourne, via two special dental vans and also through a domiciliary service.

All children enrolled in special or special developmental schools both in urban and rural areas are presented with the opportunity for oral health care at no cost at one or two year intervals.[10]

The IADH is an organisation that was developed by individuals in 1971 who have a passion for working within the community to endeavour to improve the overall health and wellbeing of a person with special needs, specifically through enhanced oral health care networks. The association was formerly known as the International Association of Dentistry for the Handicapped, but was altered to its current name to mirror present community ideology.

Every 2 years since the association was established, the IADH runs an international congress in various locations worldwide and has members in over 40 countries.[13]

SCDA was formed through an amalgamation of professionals from the Council of Hospital Dentistry, the Council of Dentistry for People with Disabilities and the Council of Geriatric Dentistry. These originally separate councils made the decision to collaborate due to their analogous objectives and devotion to advocating oral health for those with special needs.

The SCDA is an international association that allows its members the opportunities to expand their knowledge and skills in the area of special needs through educational services, access to resources and networking opportunities. The SCDA promotes for legislations, develops practice guidelines and protocols to enhance oral health professionals’ abilities to deliver quality healthcare to those who need it most.[14]

Special Care in Dentistry Association has an official journal titled Special Care in Dentistry. It is an online only publication that provides a comprehensive resource for dental professionals who are interested in learning more via education and interacting with other oral health care professionals. Access to oral healthcare is a key area this publication aims to enhance for patients with special needs.[15]

Published by the British Society for Disability and Oral Health, The Journal of Disability and Oral Health was founded by the International Association of Disability and Oral Health. The journal's mission is to publish innovative pieces relating to the holistic approach of oral care for a person with special needs. This quarterly journal is an effective modality for the distribution of information for all oral health and other allied health professionals who are concerned with the management and advocacy of oral health for the patient with special needs.[16]

Special Needs Dentists are practitioners that are concerned with the oral health of people severely affected by intellectual or physical disability, experience profound psychiatric or complex medical issues.[17] They provide treatment which includes assessment, diagnosis, treatment, management and preventative services for people of all ages.[18] The post-graduate training of three years exposes them to scenarios in which there are certain obstacles that must be over come to provide the treatment necessary.

A special needs dentists may find it typical to perform procedures under general anaesthetic to ensure that the treatment is adequate and optimal. Although the procedures will not change in steps to achieve final product, it may be more advantageous and safe to complete treatment depending on the individuals needs.

Oral health therapists (OHT) are dual qualified as a dental therapist and dental hygienist.[19] They provide oral health assessment, diagnosis, treatment, management and preventive services for children and adolescents and, if educated and trained in a program of study approved by the National Board, for adults of all ages.[19] Their scope may include restorative treatment, tooth removal, oral health promotion, periodontal treatment, and other oral care to promote healthy oral behaviours.[19] Oral health therapists may only work within a structured professional relationship with a dentist or dental specialist.[19] The education requirement for a graduate oral health therapist to be registered is a minimum three year full-time bachelor's degree education program approved by the National Board.[19]

An oral health therapist may aid in performing daily self-maintenance activities for patients who have substantial physical or cognitive limitations, which may hinder their success in major life activities. They have a strong preventive focus and are strongly committed to fostering positive attitudes to oral health.[20] Oral health therapy degrees have incorporated studies to allow their scope of practice to cover working with people with special needs. They may accompany a dentist within clinic or domiciliary environments to aid in education, disease control and maintenance of patients with special needs.

The role of an oral health therapist within any dental practice is multifactorial and involves the fundamentals of oral hygiene instruction, simple restorations, and hygiene treatment. When working with special needs patients the oral health therapists is able to work independently, however when working along a dentist they are able to complete more holistic treatment for the patient.

CVD is the most common cause of death in the developed world. It is important that the dental team have a thorough understanding of common cardiac conditions and they know how to best manage these patients in the dental setting, since many dental procedures and drugs used in dentistry may aggravate heart disease. Common cardiovascular conditions that are dealt with in special care dentistry include: hypertension, angina, myocardial infarction and inherited and acquired bleeding disorders. Cardiovascular disease is associated with the following oral implications:

• Periodontitis
• Caries
• Xerostomia

It is imperative that preventative advice is implicated early on in the treatment of these patients in order to avoid the need for extensive dental care later on.

The two most common respiratory diseases that may be encountered in dental practice are asthma and COPD (Chronic Obstructive Pulmonary Disease). Asthma affects almost 5.2 million people in the UK today and causes an airway obstruction resulting in coughing, wheezing and/or shortness of breath. There is no cure for asthma however the management includes use of preventer and reliever inhalers. COPD is a chronic condition that encompasses a collection of lung diseases. COPD can vary in severity ranging from mild to severe disease with some patients suffering from respiratory failure. The development of COPD is predominantly due to smoking and is irreversible.

Patients suffering from developmental disabilities such as autism, cerebral palsy, down syndrome and intellectual disability have a multitude of different oral health issues. They and their carers require regular oral care to maintain a healthy dentition.

• Autism:
  • People with autism have a higher risk of caries, bruxism, tongue thrusting and self-injurious behaviour such as picking at the gingiva or biting the lips. In addition, delayed tooth eruption can be seen in Autistic patients.[24]
• Cerebral Palsy:
  • Patients suffering from cerebral palsy not only struggle accessing dental services, their daily living is affected and therefore they often require additional support with activities including oral care.[25] As a result, these patients are often faced with higher levels of untreated disease and tooth loss.[26]
    • Poor oral hygiene
    • Periodontitis
    • Xerostomia resulting from mouth breathing and medications
    • Enamel hypoplasia
    • Caries
    • Drooling
    • Dysphagia
    • Bruxism
    • Fractured teeth
• Down's Syndrome:
  • Down's syndrome is a genetic condition that results in learning disability and a variety of physical and medical features. The majority of these patients should be able to be seen in primary dental care with appropriate behavioural management techniques. the degree to which this is successful is entirely dependent on the extent of the learning disability and the cooperation of the patient. Many procedures can be successfully carried out under local anaesthesia but attention should be paid to any pre-existing cardiovascular or neurological conditions. Should the patient be uncooperative or require sedation or general anaesthesia, care can be shared with specialist services. The following oral features are common:
    • Delayed dental development and eruption
    • Hypodontia
    • Microdontia
    • Hypocalcification
    • High incidence of severe early onset of periodontal disease
    • Protruded tongue
    • Strong gag reflex[27]

This area of special care dentistry is more common in young adults and adolescents and examples of conditions that are dealt with regularly in the special care setting include schizophrenia and bipolar disorder.

• Schizophrenia
  • Signs and symptoms of schizophrenia include hallucinations, delusions, social withdrawal and apathy. The management of schizophrenia is usually through drug therapies and psychosocial interventions and many patients are well controlled and present no issues with routine dental care. However some aspects of schizophrenia and the management can impact on oral health:
    • Poor self care including diet and oral hygiene
    • Xerostomia as a result of antipsychotic medication
    • Caries
    • Periodontal disease
    • Tardive dyskinesias characterised by involuntary muscle movements
• Bipolar Disorder
  • This disorder is thought to affect 1-3%[28] of the population and is characterised by manic episodes and depressive episodes. since this condition is relatively common, it is important that dentists understand the main features of the condition and know when to refer for specialist care in a secondary care setting. Bipolar disorder can have an effect on oral health through:
    • Poor oral hygiene
    • Increased levels of plaque and calculus
    • Increased risk of periodontal disease
    • Increased caries
    • Xerostomia
• Depression
  • 4-10% of people in England will be affected by depression.[29] Typically managed in the primary dental care setting, there are still adverse dental effects that we should be aware of:
    • Xerostomia (typically due to tricyclic antidepressant medication or due to an anxiety component to the disorder)
    • Poor self care including diet and oral hygiene
    • Caries (change in appetite/diet can be a factor in the disorder)
    • Periodontal disease
    • Oral dysaesthesia (generalised physical aches and pains)

Geriatric patients or ‘elderly’ are also an aspect of special needs dentistry, as sometimes they may be needed with a little extra care and support whilst in the dental environment. Often with ageing there comes the slow shut down of the human body and organs, this can lead to multiple medication conditions and some in particular that are seen more readily in the geriatric population such as:

• Cardiovascular disease
• Diabetes
• Hypertension
• Macular degeneration

Because of these particular medical conditions there are many treatment planning objectives that need to be taken into consideration such as ‘is antibiotic prophylaxis required’, ‘ is this within my scope of practice to treat and manage’. Such considerations to the dental environment for geriatric patients include the use of handrails and wheelchair access throughout and outside of the practice. Also when treating the geriatric age group it may not just be situated within the dental practice is can include; independent living, shared housing, assisted living, continuous care communities and nursing homes. The Oral Health Therapist and Dentist are readily needed in these areas to help treat and prevent the further progression of dental disease. Extra empathy must be used when treating geriatric patients as some of them that are being treated may be palliative care or suffering from a severe and enduring mental illness. One of the major obstacles when treating this group of patients is gaining informed consent. Many health care workers in the field consider that the geriatric group can make and assist in their own decision making. Ensuring that the patient is fully adequate in making the informed decision about treatment planning is vital for legality reasonings.[30]

The socially excluded patients such as institutionalised elderly people and substance or drug abused people are also considered as special need patients. These individuals suffer from various oral health conditions. The institutionalised elderly people show more number of caries and root caries than other elderly groups. In addition, the drug abused people consume large quantity of sugar (especially methadone users) which lead to caries. Their teeth are mostly damaged or lost because of convulsions. They also show high level of anxiety towards dental services.[31]

The mentally challenged patients have various specific oral health issues. These are missing or discoloured teeth, periodontal disease and oral malodour. Furthermore, they suffer from xerostomia (dry mouth) because of their medications. This situation increases their risk of dental caries. These patients often require support to maintain their overall health.[31]

[33]

• Be consistent with your technique and treatments, Autistic patients rely on familiarity to make themselves comfortable. This may even involve having the same staff present, and the same surgery set out as per previous appointments.
• Prior to treatment, identify through medical history how severe the condition is, and whether there are certain triggers for undesirable behaviours or actions; and avoid these where possible.
• Communication is important in managing Autistic patients. Use the ‘tell-show-do’ method. Explain each dental procedure before you start and take them through step by step. Offer them a mirror to observe what you are doing, provided it is a non-invasive procedure, and motivate the patient to ask questions.
• Plan a desensitising appointment prior to any formal treatment, show them all aspects of the dental office, let them look at the equipment and instruments likely to be used with the patient in future (for example, mirror, triplex, and suction). This can also extend into a limited examination for the first appointment if the patient permits it. Begin an extra-oral examination using your hands first, and if the patient cooperates, try using a toothbrush to gain access into their mouth. The familiarity of the toothbrush will allow them to feel comfortable, but also allows the operator to further examine the mouth.
• Always make the appointments short and positive with rewards and reinforcements when/where necessary
• Keep the light out of the patients eyes, and ensure any instruments are out of their sight, try to be cautious of noises within the dental surgery. Calming background music can be a positive addition to the surgery, particularly if it is something the patient will recognise.
• Immobilisation techniques are only to be used when absolutely necessary to protect the patient and staff during dental treatment.

[34]

• Patients with Cerebral Palsy may require the assistance of a wheelchair. If the patient is moved to the dental chair, ensure the patient has time to get into a position that is safe, and comfortable for them.
• Always ensure their head and neck are securely stabilised with pillows. This is to avoid uncontrolled movements and primitive movements, which commonly occur with movements of the head and neck, or if the patient is startled. This causes the limbs to extend and/or flex, a potential danger with dental treatment to the patient, operator and staff.
• If the patient requires dental treatment in their wheelchair, consider using a backboard or head/neck pillows for support.
• Observe patterns in the patients uncontrolled movements, trying to blend your own movements around them.
• Be gentle and slow when moving the patients head, and exert gentle but firm pressure on patients’ arm/leg if it begins to shake.

[35]

• Early intervention of healthy oral hygiene habits can prevent severe disease in patients with Down Syndrome
• Provide the patient with extra time and attention to allow them to feel comfortable and become familiar with yourself and other staff.
• Take treatment very slowly, introducing different tools/equipment each visit, trying not to overwhelm the patient, start with the most minimally invasive procedure possible, for example, prophylaxis.
• Be consistent with surgery set out and staff to also influence familiarity
• Reward cooperative behaviour
• Down Syndrome patients commonly suffer from a range of cardiac disorders and may benefit from antibiotic prophylaxis.
• Schedule appointments early in the day and make sure they are not waiting too long for the appointment.
• Provide oral care in an environment with few distractions
• Atlantoaxial instability is a common spinal defect in Down Syndrome patients, which can lead to neck pain and unsteady gait, use neck pillows throughout dental procedures for safety and stability.
• Always maintain clear pathway for patient.
• Determine best position for patient when they become comfortable and are in the safest position.

[36]

• Prepare the Dental surgery prior to the patients arrival. This can include clearing a pathway for the patient, removing the dental chair armrest, and relocating foot controls, operator lights and bracket tables.
• Once the patient is in the preferred position, lock the wheels of the chair to avoid any undesired movement throughout treatment.
• Ensure the patient has adequate head, neck and back support with pillows where required.
• If the patient is unable to be transferred to the dental chair, most dental chair headrests can be reversed, so the patient may be treated within their wheelchair, with the support of the dental headrest.

[37] Dementia is a progressive disease where each stage requires different clinical management. One of the main areas of difficulty with this disease is the progressive loss of capacity for the patient to consent for treatment. For this reason, it is important to plan for the patient's future wishes and to restore dental health for a dentition that will be easily maintained as symptoms progress.

Early stage

• Complete any major restorative treatment as soon as possible while the patient has capacity to consent
• Plan long-term care to restore function; gain consent at this stage for future treatment
• Include friends, family and carers in the provision of care; ensure care will be provided throughout progression of disease
• Prevention is key

Moderate stage

• Minimally invasive treatment
• Easily maintained treatment
• Complete treatment in short stages/shorter appointments
• Least traumatic intervention where possible
• Prevention is key

Late stage

• Relieve pain
• Provide antibiotics if systemic involvement
• Minimally invasive treatment
• Prevention is key