Recent Journals

JDOH - Volume 18 Number 3 (September 2017)

Journal of Disability and Oral Health Volume 18 Number 3 September 2017   Editorial       Conscious sedation using propofol for the treatment of patients with hypersensitive gag reflexes   C Dickinson, H M S Anwar, M Burke, E Heidari, S Koburunga, J Edwards and N Nizarali       Patient referrals to special needs dental units in Tasmania Australia   M A W T Lim and G L Borromeo       The oral health status of Special Olympics athletes in Trinidad and Tobago thirteen years later   Hema Singh, Rahul Naidu, Christina Royer and Ashley Meighan       Fibrodysplasia ossificans progressiva and its implications for dental treatment FOP: A case report   J Doughty, C Steel, P Thakrar and N Kuma   iADH Invitation Continuing Professional Development Programme Diary Dates 2017-2018    Editorial       There are times when you realise the effect education plays in people’s lives and this invited speech delivered by a recent dental graduate to the combined Dental and Medical graduation ceremony at the University of Liverpool is one of them.       The speech, written and delivered by Dominic Price, speaks for itself and truly highlights the power of belief, trust and motivation. I felt this was something to share with others.       Shelagh Thompson, Liverpool, UK            Graduation Speech to University of Liverpool Dental and Medical Graduates July 2017       Chancellor, Vice-Chancellor, distinguished guests, family, friends, and fellow graduates.   For those who don’t know me, I’m Dominic, a mature student, at least by definition anyway.  I have been asked to talk to you briefly today because there may just be one person in the room who might benefit from hearing my story. A quote I heard recently, “If you march fearlessly in the direction of your dreams, somehow the world conspires to help you”. For me, this sums up how I have ended up standing here talking to you today.       Thirteen years ago, I couldn’t see my dream through the fog of whatever it is that turns a teenager’s brain to mush. I loved learning but hated education, and those who asked me at the time what I wanted to do just got a confused mumble and a shrug in return. I dropped out of school with three AS levels at C and below and an unclassified grade. At the toss of a coin, I went to study plumbing at Further Education FE College rather than joining the Armed Forces, and four years later I was a craftsman for the gas board, a job which turned my relationship with education the right way up and strapped an engine on for good measure. Looking back, if I had resat at college and only achieved mediocre grades, I would not have been able to apply to dental school when I did. Not continuing was the right decision for me, both at the time and in the long term.       At this point three things happened in close succession involving 3 of the most influential women in my life;   • My mum had to be operated on by an Oral and Maxillofacial surgeon, which opened my eyes to the world of medicine.   • My step mum, who I had only known for a few years and who is a dentist, casually commented while talking about our jobs that, “Dentistry is just like plumbing, only smaller”!   • A friend in her final year of medical school told me about her university life, her plans to work and travel around the world, and how, “anyone can do it, you just have to work hard”.       With some help and guidance, I started using my annual leave to get work experience, which confirmed for me that if I was going to live without regret, I had to take a chance, so I handed in my notice, moved to the north west, and enrolled on an Access to Higher Education course (to mitigate my AS results (Advanced Subsidiary Level qualifications UK). At the time, there were only a handful of dental schools that would accept an Access course for entry criteria, and thankfully the University of Liverpool was one, I still remember the day I received the offer with such relief, surely the hard bit had been done.   I turned 25 in Fresher’s week. I had decided to live in halls of residence where everyone else was at least five years younger than me, but I am so pleased that I did because I had some amazing experiences and made friends for life. By the 2nd year, I was going out with that medical student, now doctor friend, who was doing exactly as she had planned and was working in Australia. It was while on holiday together that she had finished reading five books by the end of the second day and was trying to read mine over my shoulder but was getting frustrated at finishing two pages and having to wait five minutes for me to catch up, that I was harassed (she would prefer motivated) into ‘getting tested’. It wasn’t long before I was diagnosed with dyslexia, and suddenly there were tools and methods and systems in place to make life (and public speaking) easier.       Now life is not as perfect as social media makes out, and I ended up resitting the third year, but I needed to, and I don’t think I would have it any other way with hindsight. But there is always a positive and I had managed to persuade my girlfriend back from Australia and we were married a year later. During my repeat 3rd year my wife and I bought a house together, and while all this was going on I had become involved in the dental school student committee and the British Dental Student Association, so that by the time I was in 4th year I was the BDSA president and had the opportunity to work with the European Dental Student Association on a visiting programme in Stockholm.       In the 5th year, we had to go through national recruitment to Dental Foundation Training, and finals. This filled me with dread because I have a deep-seated discomfort with amateur dramatics, and both processes involve an element of performance. Thankfully, at the beginning of the year during a lecture, the Head of the Dental School Professor Callum Youngson offered to help anyone who wanted it, you just had to ask. So, I did. And in the weeks leading up to both milestone events, we discussed ways to manage my emotions and developed coping strategies to give me the best chance of performing well enough to get through. Since receiving the finals results my now four-week-old son was born and we moved home when he was a week old to be closer to family and my job starting in September.       So, from 17-year-old college dropout to married dental graduate, home owner, and new father, here are some things I’ve learned along the way:       • Throw yourself in at the deep end, take every opportunity that presents itself, you can do more than you think possible.   • Asking for help is a strength, not a weakness. Don’t be afraid of failure; use it to your advantage.   • Make as many friends as you can along the way, they are what get you through.       To end I would like to thank all the friends, staff and students alike, and family for getting us all here today, to congratulate you all for this massive achievement. Also to say that if you have a feeling that there is something you should do, no matter how sideways it is, do it, because somehow the world will conspire to help you. Thank you.       Dominic Price, BDS University of Liverpool, England UK         Conscious sedation using propofol for the treatment of patients with hypersensitive gag reflexes       C Dickinson1, H M S Anwar 2, M Burke1, E Heidari3, S Koburunga3, J Edwards4 and N Nizarali1       1. Consultant in Special Care Dentistry, 2. Specialist registrar in Periodontics; Guy’s and St Thomas’ NHS Trust; 3. Senior Specialist Clinical Teacher, King’s College London Dental Institute, 4. Consultant in Special Care Dentistry, King’s College Hospital NHS Trust           Abstract   Gagging is defined as an ejectory contraction of the muscles of the pharyngeal sphincter. This is a normal healthy physiological mechanism, preventing foreign objects from entering the pharynx, larynx or trachea. Although gagging is cited as a normal protective reflex, problems have emerged with some patients suffering from a hypersensitive response whilst undergoing basic dental treatment. This paper discusses the problem and describes six case reports in which propofol was used to help overcome patient difficulties.         Patient referrals to special needs dental units in Tasmania, Australia   M A W T Lim and G L Borromeo       Melbourne Dental School, The University of Melbourne, Australia           ABSTRACT   Even though Special Needs Dentistry has now been recognised as a dental specialty in Australia for more than a decade little is known about the nature of referrals to units dedicated to treating patients with special needs.   Aims and Objectives: To determine the types of patients referred to special needs dental units staffed by general dentists and the reason(s) for these referrals.   Methodology: Referrals for all patient appointments at Special Care Dental Units in the state of Tasmania during August 2015 were reviewed.   Results: Most referrals were from medical practitioners for the management of oral implications of medical conditions or medications. Hospital referrals originated mainly from oncology and geriatric evaluation and management units. Patients had an average of 3 medical conditions. Referrals relating to medications were generally related to the use of Bisphosphonates and Denosumab, and for chemotherapy patients.   Conclusions: This study provides details of the types of patients referred to special needs dental units. In particular, it provides insight into the awareness of the oral implications of medical conditions and medications on oral health and dental treatments amongst the medical profession and thus the importance of interactions between oral health professionals and other health professionals. Furthermore, the data stimulates discussion about the potential influence of clinic location and workforce on patient referrals.     The oral health status of Special Olympics athletes in Trinidad and Tobago: thirteen years later       Hema Singh DDS MPH, Rahul Naidu BDS PhD, Christina Royer DDS and Ashley Meighan BSc DDS       The University of the West Indies, Trinidad and Tobago           ABSTRACT   Aim and Objective: To assess the oral health status of Special Olympics athletes in Trinidad and Tobago in 2017 and compare the results of this study against the previous data collected in 2004 and with recent data from Special Olympic athletes worldwide. Methodology: A convenience sample of athletes who participated in the Special Olympics Special Smiles Healthy Athletes screening programme. The standardised Special Olympics screening form was used for the oral health assessment of each athlete. Results: 120 athletes participated. The mean age of participants was 24.1 years with a range of 5–80 years; 70.8% were male and 9.2% reported having dental pain. The prevalence of untreated decay was higher in 2017 than in 2004 (69.2% vs 43.7%), and gingival signs were present in 72.5% of the athletes in 2017 compared to 33.7% in 2014. There was an increase in participants with filled teeth (14.2% vs 9%) but a decrease in sealed teeth in 2017 (0.8% vs 2.9%). Urgent treatment need was found in 32.5% of the athletes. In comparison to Special Olympics athletes worldwide, the findings from Trinidad and Tobago were similar to those from developing countries in the Far-east and Eastern Europe.   Conclusion: The oral health status of Special Olympics athletes in Trinidad and Tobago suggests an urgent need to develop oral health promotion for people with intellectual disabilities and improve their access to oral healthcare.     Fibrodysplasia ossificans progressiva and its implications for dental treatment (FOP): A case report       J Doughty1,2, C Steel1, P Thakrar1 and N Kumar1,2       1.                  University College London Hospitals. 2.University College London       Abstract   Aims: This case report discusses the general and dental manifestations of Fibrodysplasia ossificans progressiva (FOP) and details the dental management considerations particular to this case.   Method: A case report methodology was employed to describe the clinical encounter of a patient with FOP.   Case summary: FOP is an extremely rare hereditary disorder characterised by progressive ossification of the tendons, ligaments, fasciae and striated muscles. The patient’s primary oral complaint was a complete inability to separate the upper and lower jaws, which were “locked” into position. At the age of twenty he underwent extraction of the lower right third molar, which led to progressive ossification and subsequent fixation of the jaws. The patient presented with pain and dental infection over multiple appointments. Treatment planning involved a multi-professional approach including oral and maxillofacial surgery, oral surgery and special care dentistry teams. A novel approach using cone beam CT to identify the location and extent of carious lesions was used. Risk assessment was critical as dental extractions posed a risk of uncontrolled heterotrophic bone formation; the provision of dental restorations posed the risk of inadequate visualisation / placement and trauma to the oral tissues when retracting.   Conclusions: This case poses both a clinical and ethical dilemma. After weighing the potential risks and benefits of dental treatment, there was no clear answer to this case – the plan is for the multi-disciplinary team to provide high quality preventative care and monitor the patient closely, with surgical intervention dictated by pain / infection frequency and any further dental deterioration.          

JDOH - Volume 18 Number 2 (March 2017)

JDOH - Volume 18 Number 2 (March 2017)  Editorial Audit of the use of clinical holding at Birmingham Community Healthcare Special Care Dental Service Patient and carer involvement in evaluating a toothbrushing programme for children and young people with neurological motor impairment The development of a mouthcare information leaflet for carers of older people Continuing Professional Development Programme Diary Dates 2017 2018 Some personal musings on Special Care Dentistry   In my experience a standard interview question used to be - ‘what are the most satisfying parts of your work’? Although my last experience was a number of years ago, I recall my reply following the usual acceptable responses were the immortal words of Hannibal Smith (George Peppard) at the end of the 1980’s TV series The A Team- “I love it when a plan comes together”. (Fox News, 2006).   Our realm of dentistry is principally not about the focus of dental treatment, but is considerably more about the emphasis of dealing with people. This is always interesting and often challenging. Inevitably, one of the most important qualities we need in our job, as indeed in all aspects of life, is communication. Planning, organisation and teamwork is essential and when it all comes together, it is very satisfying.   We should strive to provide a standard of treatment that is equitable to those people who do not have a disability. This is often very difficult and in the end, we simply have to do the best we can. We are not miracle workers and it is arrogant to think we can be. Clinical pragmatism can be a valuable approach; however, there is not universal agreement on its interpretation. This is particularly so in a world where the processes of commissioning and policy do not always equate with work at the coalface.   We seem to live in a time of increasing caution with the possible result that we can become more and more risk averse. Special Care Dentistry is a discipline that does not necessarily comply with standard protocols and requires flexibility and carefully managed risk. We should be prepared to accept that on occasion we have to take a step in the dark and consider taking an unpredictable risk. I used to work with a hugely experienced and skilled anaesthetist and infrequently, would discuss a case with complex medical and difficult management problems. After a pause, she would invariably say- “well Graham somebody has to treat this patient and it looks like us, so let’s get on with it.” She was definitely a good-doer.   It would be interesting to examine how and why our colleagues chose the path of Special Care Dentistry. I became interested following a move from Public Health. Initially, I experienced the joys of working in a dental caravan visiting schools for children with severe disability back in 1976. I feel it is important that the initial introduction to working with people with disability in dentistry is well supported. This was not the case in earlier years, when the approach of ‘just get on with it’ was the norm. My current position involves working with adults with profound complex neurodisability at the Royal Hospital for Neuro-disability Putney in London and in my opinion, working with this group of patients is particularly challenging (Royal Hospital for Neuro-disability). Medically, many patients have experienced a traumatic episode which resulted in severe brain injury. Additionally, they have complex medical conditions and are often very unwell. Dentally, these patients are like any other, presenting with a range of problems varying from requiring a full clearance to managing failing, complex restorative dentistry. Providing their treatment can be very tricky, due to limited oral access and difficult management. I cannot emphasise enough the value of intravenous conscious sedation in providing good dentistry. Planning for treatment is a hard one and communicating with their relatives/carers is often both humbling and difficult. Understandably, they may be in a state of shock because of the immediate nature of the event that has caused such a sudden change in their loved one. Many of the patients I treat have a very low level of consciousness with no obvious communication and very limited ability to respond. Commonly, their relatives/carers travel considerable distances every day to simply sit and be there to provide comfort. In addition, the prospect of improvement may be limited, such that the carers experience a grieving process that may go on for years and years. I find the capacity for kindness in the human creature can be overwhelming. In terms of dentistry, quite rightly patients’ loved ones want the very best treatment and may have high and unrealistic expectations for the type of care they feel is acceptable. In these circumstances empathetic, but realistic communication is so important.   Although working with young colleagues in a teaching and learning capacity can be quite demanding, it also provides great fun and much satisfaction. I do not subscribe to the older school of teaching that felt the best approach was first to break the student down and then build them up. On more than one occasion, my thoughts had been, ‘Stop, stop, stop take your forceps away from that tooth NOW it’s the wrong one’. I found, however, the ‘I wonder if I can make a slight suggestion’ approach created less panic and was more educationally creative, rather than damaging their confidence. There is however, one shortcoming in the enthusiasm of the youngsters entering our specialty and this is research; and I can understand why. Research is not an interest to everyone. It is however a very rewarding and essential pastime, as we all know progression in all aspects of clinical care needs to be supported by evidence. Research however can be challenging. Firstly, you have to hit on an idea, review the past literature, obtain ethical and institutional approval (ethics can be daunting) apply for funding, then do the work, write up and seek publication. What a lot of hurdles, with each one being very taxing.   Invariably, one of the first experiences of the research process is part of a formal academic training. This tends to be accompanied by the additional worry of exams and the research part of the training can be considered mainly as a stressful and necessary task. It’s no wonder that I have heard it said at the end of the training process ‘I never want to do any type of research ever again’. However, it is so important to have an enquiring approach to our work. This quality is common to clinicians, although taking it that step further is hard. Research is so much better coming from the angle of interested enquiry i.e. ‘I wonder what’s going on here?’ rather than a necessary exercise as part of a training programme. This can be demoralising and extinguish the spark and fire of genuine interest and enquiry. In the end, it all comes down to providing the protected time and financial support for research especially in newer specialty areas. The priority of where funding goes seems to leave some areas of research at the end of the queue, something our society needs to seriously consider.   What now of the future? Hats off and huge congratulations to our ‘grandparents’ who secured Special Care Dentistry as a specialty. Special Care Dentistry is predominantly a primary care community speciality and needs to be focused in the community; although links with academic centres and teaching hospitals are essential, as their expertise, research, and teaching provide substantial support and credibility to the specialty. This is particularly so since research, teaching and training must be the key areas of focus for the future. Academic teaching hospitals and universities need to seriously accept this responsibility and ensure that adequate provision is available in the undergraduate curriculum and opportunity for post graduate training in Special Care Dentistry. We need to fight for the continuing evolvement of Special Care Dentistry; it is a continuing and worthwhile battle -good luck to all.     Graham Manley BDS DDPH(RCS-Eng) MSc PhD FDS(RCS-Eng)     Fox News.   Royal Hospital for Neuro-disability.     The development of a mouthcare information leaflet for carers of older people   R Fitzpatrick1 and V Jones2   1Community Dental Officer, 2Consultant in Special Care Dentistry Aneurin Bevan University Health Board     Abstract   Aim: To design a written information leaflet to support carers when providing mouthcare for older people. Method: A literature search to identify existing information leaflets, recommendations on producing written healthcare information and current evidence based oral healthcare. Searches were carried out using the key words: carer, oral health, elderly, care homes, education, training and oral health promotion plus denture cleaning, tooth brushing, diet supplements and dry mouth. A draft leaflet was then produced and assessed using the Flesch Reading Ease Score, Flesch Kincaid Grade Level, Simplified Measure of Gobbledygook (SMOG) calculator, the Ensuring Quality Information for Patients tool (EQIP) and the Patient Education Materials Assessment Tool (PEMAT). The leaflet was peer reviewed by colleagues within Community Dental Service, Oral Health Promotion team and a Public Health Practitioner. It was further evaluated by carers using a structured questionnaire. Results: The leaflet scored well with regards to its readability and EQIP scores and could be easily understood by most carers. There were 33 respondents to the evaluation questionnaire, of which 85% felt that the leaflet was good to very good and 60% said it increased their knowledge and confidence when providing mouth care. Conclusion: A high quality, simple information leaflet was produced that supported carers when providing mouth care for older people.     Audit of the use of clinical holding at Birmingham Community Healthcare Special Care Dental Service   R Willis   Senior Dental Officer, Birmingham Community Health Care NHS Foundation Trust   Abstract:   Aim and objectives: To evaluate the use of clinical holding within one Special Care Dental Team against the British Society of Disability and Oral Health 2009 Clinical Holding Guidelines and the Department of Health 2014 publication, Positive and Proactive Care. Methodology: Data were collected over an eight-week period for patients where clinical holding had been used to facilitate care. Results: Forty-six patients were identified as receiving clinical holding during the audit period with 70 separate clinical holds used. Low level arm restrictions were used in 40% (n=28) of holds with medium or high level arm restrictions used in 36% (n=25). The main justification given for the use of clinical holding was the facilitation of treatment (96%, n=67). The majority of holds were used to facilitate examination (31%, n=22) or intravenous access (31%, n=22). The intervention was abandoned for 3% (n=2) of holds. The use of clinical holding was planned at a prior appointment for 60% (n=42) of holds. Non-dental staff were used in 44% (n=31) of holds. Conclusions: The use of clinical holding within the service was in line with current guidance and was effective in the facilitation of care for people whose behaviour limited their ability to receive care. The audit results suggest improvements are required in advanced planning and documentation of consent. Future work should focus on the use of non-dental staff in clinical holding, post clinical holding debriefs and post incident reviews.   Patient and carer involvement in evaluating a toothbrushing programme for children and young people with neurological motor impairment   R Emanuel1, E Ray-Chaudhuri2, J Parry3, L Borthwick4, D Sellers5 and S Dobson6   1Consultant in Special Care Dentistry, 2Specialty Registrar in Paediatric Dentistry, 3Consultant in Paediatric Dentistry, 4Senior Dental Nurse, 5Senior Specialist Speech and Language Therapist/Research Fellow, 6Lead Nurse; Chailey Clinical Services, East Sussex, UK   ABSTRACT   Background: People with cerebral palsy (CP) can have difficulty with eating and drinking safely and efficiently. A toothbrushing regime which includes routine use of suction and non-foaming toothpastes may be beneficial to reduce foam, debris and aspiration risk during brushing. This project sought to obtain feedback from children and young people with severe motor impairment, their parents or guardians and care staff of a toothbrushing programme, which introduced the use of nonfoaming paste and suction. Method: Two participant groups were invited to contribute to evaluate a toothbrushing programme based on non-foaming toothpaste and suction for children and young people with cerebral palsy who are unable to eat and drink safely. The groups were: Care staff involved in providing daily oral care to children and young people with CP, and twelve children and young people with CP who are unable to eat or drink safely and who use community dental services based at the specialist centre for children and young adults with neurological and motor impairment. Results: Lack of co-operative motor ability was identified by care staff as the greatest obstacle to thorough oral hygiene practice for children and young people with neurological motor impairment. Before the service evaluation, over 66% of staff thought that use of non-foaming toothpaste and suction would be useful. Some staff were concerned that suction use may be unpleasant for some children with sensory oral issues. A patient/carer oral hygiene education programme, using non-foaming toothpaste and suction, resulted in positive feedback from the carers or family members providing oral hygiene.    

JDOH - Volume 18 Number 1 (June 2017)

Journal of Disability and Oral Health Volume 18 Number 1 June 2017   Contents   Editorial   Deep Brain Stimulation literature review of the unseen challenges to optimal dentistry G X D Lim   Dental students attitudes towards understanding of health disability and disease in dental patients in Wales UK a foundation for special care dentistry H E Redford and P A Atkin   Oral health status and treatment needs of school children undergoing special education integrated programme in Malaysia a pilot study J John, S A Mani, V K Joshi, L Y Kuan, H W Lim, S LWan-Lin, L A Shoaib and R A Omar   Special Care Dentistry in Saudi Arabia development as a dental speciality an opinion paper Hassan Abed   Diary Dates 2017 2018 Obituary Professor Crispian Scully Research grants advisory Continuing Professional Development Programme Editorial   Looking back – the journey towards Special Care Dentistry   Today, Special Care Dentistry (SCD) sits proudly alongside other dental specialties in the UK as in other countries across the world. Whilst it is one of the newest (12th), and most ‘fresh-faced’ dental specialty in the UK, there is a long history to how it came to fruition, through the vision and efforts of many dentists, and with the engagement, input and involvement of people with a disability.   Its raison d’être is to promote good oral health and function for people with a disability, together with others who have an important role alongside the dental team. Seventeen years ago - a new millennium - the year 2000, was significant in many ways. I recall seeing-in the new century on the Malvern Hills, with crystal-clear starlit skies – joined by many others, who, like me, were thinking of what the future would bring.   For Special Care Dentistry, that year was a turning point – The Joint Advisory Committee for Special Care Dentistry (JACSCD) was established as a freestanding committee, to ‘promote and oversee the introduction of training programmes, the development of curricula and training standards and formative assessment processes’ (Woof, 2000; Fiske, 2006).   ‘A case of need – a proposal for a Specialty in Special Care Dentistry’ (JACSCD; 2003a) and, ‘Training in Special Care Dentistry’ were both published in 2003 (JACSCD; 2003b). Two years later, the General Dental Council approved in principle the establishment of a Specialty of SCD.   Yet, in reality, it was the ‘end of the beginning’; it is important to understand that the speciality grew out of a complex interaction and vision of many stakeholders, including the Royal Colleges, British Society for Disability and Oral Health, the British Dental Association, British Association for the Study of Community Dentistry, the Royal Colleges, lay people, and those with a disability. The journey towards the speciality was long and sometimes difficult, but it was vitally important for those individuals with a disability who were supported by promoting good oral health and function. It was a time of great change and a challenge for the many organisations and individuals who had shared values, but where care pathways and processes sometimes differed. The debate lasted many years, but the specialty of Special Care Dentistry is now on course providing consultant and specialist led services, training and importantly, education to future generations of dental team members at undergraduate and post-graduate level.   A future paper in the Journal of Disability and Oral Heath will provide further detail of the ‘The Journey’ to establishing the specialty both as a historical record and with the hope others will find the resilience to promote and advocate for similar developments in their countries.   References   Woof M. Specialisation in Special Care Dentistry - where from, where now, where to? J Disability Oral Health 2000; 1: 34-38.   Fiske J. Special Care Dentistry (Editorial). Br Dent J 2006 200: 61.   Joint Advisory Committee for Special Care Dentistry. A Case of Need – a proposal for a Specialty in Special Care Dentistry. London: JACSCD; 2003a.   Joint Advisory Committee for Special Care Dentistry. Training in Special Care Dentistry. London: JACSCD; 2003b.                                                                                                                 Marcus Woof Hon. Senior Lecturer, Disability Studies University of Birmingham, School of Dentistry.       Deep Brain Stimulation: literature review of the unseen challenges to optimal dentistry   G X D Lim MSc   Nanyang Polytechnic (Adjunct Lecturer), Geriatrics and Special Care Dental Centre NDCS (Visiting Clinician), Eastman Dental Institute (MSc Graduate)   Abstract   Deep brain stimulation is an implantable electrical generator increasingly used nowadays for movement or neuropsychological conditions. It was reported to cause significant morbidity and mortality when used with various dental devices. AIMS: This literature review seeks to unveil hazards, analyse current guidelines and practices, and highlight the controversies practitioners face when caring for individuals with deep brain stimulation. METHODOLOGY: Cochrane database, Ovid MEDLINE and PubMed searches were executed using MeSH terms “deep brain stimulation” AND “dentist*”. An open (basic) search for the databases was also done. Information from practice recommendations of the Parkinson’s Society UK, American Parkinson’s Disease Association, National Parkinson Foundation US, European Parkinson’s Disease Society, Parkinson’s Australia, FDA (US), and MEDSCAPE were also analysed for insights regarding deep brain stimulation and dentistry. RESULTS: A total of 1,778 articles were found and screened, of which 15 were reviewed in full text and 10 were deemed relevant for qualitative synthesis. CONCLUSIONS: Previous literature suggested diathermy use and post-treatment infections are the main concerns with deep brain stimulation. A deeper understanding of the safety concerns involving other dental procedures (including electrocautery, lasers, lithotripsy, magnetic resonance imaging, radiation therapy, and ultrasound) with deep brain stimulation use is required. In addition, antibiotic prophylaxis recommendations differ internationally. There are also concerns regarding the timing of dental interventions after deep brain stimulation and various considerations during general anaesthesia. This article arranges and summarises these concerns for the perusal of all dental practitioners.         Dental students’ attitudes towards understanding of health, disability and disease in dental patients in Wales, UK: a foundation for special care dentistry   H E Redford1 and P A Atkin2   1General Dental Practitioner, Swansea, 2Consultant/Hon. Senior Lecturer, School of Dentistry, Cardiff University     Abstract   Objectives: This cross-sectional study aimed to explore ideas relating to the wider medical knowledge and attitudes towards understanding of human health, disability and disease in dentistry amongst dental undergraduate students in different stages of the BDS programme at School of Dentistry, Cardiff University, Wales. Methods: A questionnaire relating to students’ attitudes, perceptions and knowledge concerning human health, disability and disease was distributed to first, third and final year students. The questionnaire used Likert scales to allow students to easily rate their attitudes on this topic. Results: Most students (99%) perceived human disease/clinical medical sciences for dentistry teaching to be relevant to dentistry. Students in their final year perceived themselves to be the most confident with their knowledge of human disease and their ability to use their knowledge when treating patients, compared to third and first year students. The majority of dental students surveyed perceived that dental patients would expect their dentist to have good understanding of their problems with heath, disability and disease and how these problems may impact on treatment choices (81%), but, that patients did not recognise that dental students learned about human health and disease (44%). Conclusions: The results indicate that dental students recognise that human diseases/clinical medical sciences teaching in dentistry are an essential component of undergraduate curriculum. The teaching provides students with increased knowledge of this topic area along with confidence in using this knowledge whilst treating patients. Students feel that as a dentist, they should have a good understanding of medical problems, disability and disease and how this impacts on treatment and also believe this is what patients expect. A sound understanding of patients’ medical history is key to safe practice, and identifying those patients who may need special consideration when planning dental treatments. The undergraduate human diseases/clinical medical sciences teaching in dentistry, which is later built upon with undergraduate teaching in Special Care Dentistry and sedation provides a good foundation for future safe clinical practice for all patients, whatever their special needs may be.     Oral health status and treatment needs of school children undergoing special education integrated programme in Malaysia – a pilot study   J John1, S A Mani2, V K Joshi1, L Y Kuan3, H W Lim3, S LWan-Lin3, L A Shoaib2 and R A Omar1   1Department of Restorative Dentistry, Faculty of Dentistry; 2Department of Paediatric Dentistry and Orthodontics, Faculty of Dentistry; 3Faculty of Dentistry: University of Malaya, Kuala Lumpur   AbstracT Aim and objective. This pilot study aimed to assess oral health status and treatment needs among children with special needs (CWSN) in a Special Education Integrated Programme school in Malaysia, to determine the feasibility of verifying a baseline prior to conducting an intervention programme. Methodology. A total of 82 CWSN with different types of learning disabilities aged 6-12 years old, who complied with the criteria, participated in this study. Data were collected by clinical examination and analysed using SPSS 20.0 system. Results. Among the respondents, 62% had one or more decayed teeth, 80% did not have any restorations in their oral cavity and 70% had between moderate to severe plaque index score. Almost all the CWSN required oral hygiene education while more than half required oral prophylaxis and restorative treatment. Only 21% required extraction and 12% were advised to undergo orthodontic treatment. 7.3% of CWSN presented with tooth anomalies. More than a third had either Class I or Class II incisor relationship respectively and two-thirds presented with Class I facial profile. 13% of CWSN had undesirable oral habits. Conclusion. CWSN who participated in this pilot study had satisfactory oral health status, however, they lacked adequate oral hygiene awareness and required further reinforcement.     Special Care Dentistry in Saudi Arabia: development as a dental specialty - an opinion paper   Hassan Abed BDS MSc Candidate   Department of Basic and Clinical Oral Sciences, Umm Alqura University, Faculty of Dentistry, Makkah, Saudi Arabia. Department of Sedation and Special Care Dentistry, Guy’s and St Thomas’ Hospital (GSTT) National Health Services (NHS) Trust, King’s College London, United     Abstract Special Care Dentistry (SCD) is an unrecognised speciality in the Kingdom of Saudi Arabia (KSA) and it is not currently taught as a major part of undergraduate or postgraduate dental curricular. The number of people with special needs is expected to increase based on the presence of many risk factors. For instance, the government is facing a rising burden of road traffic injuries as a result of rapid changes in behaviours. Therefore, more survivors are expected who might live using wheelchairs or with permanent physical impairments. Additionally, the elderly population of Saudi Arabia is expected to grow from 1 million in 2000 to 7.7 million in 2050. Improvements in paediatric health care in Saudi Arabia are expected to increase the number of people living with chronic or debilitating medical conditions. Thereby, dental care providers must anticipate patients with chronic medical conditions and/or wheelchair users in their daily practice. Implementation of SCD in the undergraduate and postgraduate dental programmes in Saudi dental universities will help oral health care providers to manage these patients and involve them in the health care pathway.    

March 2015


SM Woolley, BL Chadwick and L Pugsley
S Jalihal, R Nagarajappa, K Asawa, M Tak, G Kakatkar and G Ramesh
N Nizarali, S Moosajee, and T Newton
A Muthukrishnan, G Kelly, J McGregor and S Thompson
DA Lewis, LJ Wray, MK Sherborne, C Frolander, J Shill, K Dalley, S Bell and D Wong
Developing the New Speciality - The Welsh Way!
Many of you will know that in 2008 the Speciality of Special Care Dentistry (SCD) was established as a new specialty in the UK, and our regulatory body the General Dental Council (GDC) now holds a list of specialists in SCD. This was after years of lobbying and hard work to convince our professional bodies that patients in the UK would benefit from such a speciality. Prior to 2008 SCD was provided through our public dental service, the Community Dental Service and through hospital services. Those providing these services, some with many years of experience, were mediated on to the specialist list between 2008 and 2010 through a process by which the dentists had to demonstrate, through a detailed portfolio of evidence, that they had reached the status and equivalence of a specialist. We now have 313 specialists in the UK and four registered outside of the UK, including a group of consultants in SCD.
Achieving the establishment of such a list of specialists is not the same as developing specialist services and since the birth of the specialty the National Health Service (NHS) in the UK has been working in at least a ‘cash neutral’ environment. This meant that there was no obvious financial support available for funding new posts and training programmes in a very tight financial climate. Not the best start for a new specialty! However, we in SCD have had the opportunity to look at the services we were providing and look at what would be appropriate for the future.
Special Care Dentistry in Wales
Wales is one of the devolved countries of the UK. We have our own Welsh Government (WG) and Minister for Health and Social Services, our own Chief Dental Officer and our own NHS funding allocation within the UK. We have a population of 3.1 million people, high levels of deprivation compared with the rest of the UK, a growing older population, active community dental services across Wales providing care for those within the SCD remit and a Postgraduate Dental Deanery working alongside a University Dental School in Cardiff, our capital city. Our structures allowed us to raise the issue of SCD and the importance of developing services in Wales at the highest political level, and in 2011 our lobbying bore fruit and our Minister for Health commissioned a review of SCD services in Wales which included recommendations for the future. Such a review enabled a group of specialists from across the whole of Wales to look at services, workforce and training requirements. 
Our review was published in 2010 (Welsh Government, 2010). It described the inequalities in oral health in Wales and the evidence of the increasing incidence of disability in the population. It covered the scope of SCD, current service provision and looked at the workforce at the time and what might be required for the future. The document described models of good practice in Wales and in recognising the need to train and nurture a new generation of specialists in Wales, it considered models of specialist training, giving current examples and models for the future. The review document was considered by the Minister for Health who supported the development of SCD and established an All Wales Working Group to take forward implementation of the recommendations within the review. The SCD Implementation Plan (Welsh Government, 2014) was then published.
Managed Clinical Networks
One of the key developments to come out of the SCD Implementation Plan was the development of three Managed Clinical Networks (MCNs) in South East, South West and North Wales. Wales is a very diverse area, with a differing blend of urban, rural and ‘valleys’ (in the old days, coal mining) communities across the country, so it was agreed that working in smaller development areas would yield the best results whilst the overarching Wales Special Care Dentistry Advisory Forum would ensure the sharing of good practice across the three networks. 
MCNs have for some time been a recognised way of sharing expertise and developing services. Gallagher and Fiske (Gallagher and Fiske, 2007), whilst SCD was developing as a specialty, considered that MCNs could be a way forward and in 2009, Skipper (Skipper, 2010) described MCNs as follows;
Managed clinical networks (MCNs) are self-supporting groups of professionals working together to ensure cross-speciality sharing of patients and expertise. They are a strong mechanism for ensuring that patients receive the care they need in a timely fashion from the most suitable professional in the network area.
The networks in SCD in Wales have been in existence since late 2012. The membership of the networks includes specialists and consultants in SCD and other specialities, managers involved in service provision, representatives from the postgraduate deanery, the wider dental team and lay people. Each network is different and reflects the local population and workforce requirements. The network allows working across health ‘authority’ boundaries which encourages sharing of good practice and expertise.
The work of the networks has so far included:
  • Review of workforce and services in their geographic areas and identification of ‘gaps’ in service provision
  • Development of dental referral pathways for adults requiring SCD in the MCN area. These have been general SCD referral pathways for patients, identifying the roles within the pathway from primary care dental teams through to consultants, and more specific pathways, for example domiciliary and bariatric care pathways
  • Provision of local and regional information for patients
  • Development of training for both specialists and continuing education in SCD for the dental team and the wider multi professional team
  • Establishment of MCN web pages and mapping information for the public and dental teams. 
The establishment of MCNs has, in my view enhanced our ability to improve our services to patients requiring SCD by allowing us to work ‘outside the box’ and work with those outside our everyday working environment. The MCNs work across our Health Board boundaries (the NHS in Wales is organised in seven Health Boards). This allows cross fertilisation of ideas and sharing of expertise. It does of course require enthusiasm and energy from those who are part of the networks, to contribute and collaborate and it does take time for such bodies to start to actually change and improve experiences for patients. Our ability to do this has been enhanced by the publication of our National Oral Health Action Plan by the Welsh Government in which one of the targets for Health Boards is to implement the recommendations of the MCNs in SCD. This one sentence in the plan makes it so much easier for those of us working as small services within larger Health Boards to influence those organisations, and even when there is not too much extra money in the system it does allow us to change and improve what we can do for our patients.
The last five years have proved an exciting time in the development of services for people requiring SCD with new training programmes and specialist services enhancing what was provided before the new speciality of SCD. I see great opportunities for the networks to develop further as the specialty matures. Clinical Networks such as this have been used to develop services across healthcare provision and the establishment of such networks is possible anywhere in the world. All you need is a few enthusiasts who are keen to work to improve outcomes for their patients. 
I look forward to the future world where our enthusiastic young specialists who have been through our new training programmes take SCD to new heights and hope that in Wales, the MCNs give them the opportunity to do just that! 
Dr Sue Greening MBE
Consultant in Special Care Dentistry
Clinical Director Community Dental Service, Aneurin Bevan University Health Board
Training Programme Director for Wales - Special Care Dentistry.
Gallagher JE, Fiske J. Special Care Dentistry: a professional challenge.Br Dent J 2007; 202: 619-629. Published online: 26 May 2007 | doi:10.1038/bdj.2007.426
Skipper M. Managed clinical networks. Br Dent J 2010: 209: 242. 
Welsh Government Report on Special Care Dentistry in Wales - Review and Recommendations - Welsh Government 2010.
Welsh Government Special Care Dentistry Implementation Plan - Welsh Government - updated 2014
Dr Carlos Francisco Salinas, Professor of Pediatric Dentistry and Orthodontics at the James B. Edwards College of Dental Medicine, Medical University of South Carolina, Director of the MUSC Craniofacial Anomalies and Cleft Palate Team, Co-Director of the Clinical Resource Core of the Center for Oral Health Research passed away on Wednesday 14 January 2015.
Dr Salinas was a graduate of the University of Chile (DDS degree 1963), Medical University of South Carolina (DMD degree 1985) and received a Certificate in Medical Genetics (1974) from the John Hopkins University, School of Medicine. He developed his academic career in the Medical University of South Carolina, Charleston SC, USA and was dedicated to the service of people with disabilities, participating in different areas of clinical research such as craniofacial anomalies, ectodermal dysplasias, health disparities, and special care dentistry. Dr Salinas founded and served as director of the South Carolina Special Olympics Special Smiles Dental Program.
During his academic career, Dr Salinas published over 100 scientific publications and edited five books, the first one was sponsored by the Pan American Health Organisation. Dr Salinas was awarded a number of grants (NIH Fogarty, NIH/NCRR, SCDHEC, RWJF and the Duke Endowment). He was also the main speaker in many congresses on Special Care Dentistry.
Professor Salinas was an active member of the Editorial Board of the Journal of Disability and Oral Health, official journal of the International Association for Disability and Oral Health (iADH) from 2010. He was always a pleasure to work with on the Editorial Board and gave sage and timely advice to authors when reviewing their papers. 
Dr. Salinas was an active member of several other scientific societies and was Past President of the Society of Craniofacial Genetics and the Libero American Society of Human Genetics. Since 2006, he participated in several conferences and was invited by many Universities in Latin America, especially in Argentina and Brazil, and was the main speaker of the Santos iADH Congress in 2008. He was interested in the representation of genetic anomalies in Pre-Columbian Art and museums were his priority when visiting a city.
Those who knew him will always remember the warmth and generosity he had, the friendly chats sharing his interest in history and sports like football, and his love for his family.
Our condolences go to his wife Maria Asunción Córdova-Salinas, their children and grandchildren.
Gabriela Scagnet, iADH Past President, Argentina
Perceptions of UK secondary care adult dental conscious sedation clinics: a qualitative analysis
SM Woolley,1 BL Chadwick,2 L Pugsley3
1Clinical Lecturer in Restorative Dentistry; 2Professor in Paediatric Dentistry, Cardiff University School of Dentistry; 3Senior Lecturer in Medical Education, Wales Deanery (School of Postgraduate Medical and Dental Education)
Objective: To explore the purpose of dental conscious sedation provided within UK University-based secondary care dental settings as defined by patients, referrers and providers.
Methodology: A qualitative investigation using semi-structured interviews was undertaken. Participants comprised of sedation staff in five UK University-based hospital settings as well as referrers to, and patients attending, one UK University-based hospital setting. Thirty one participants were interviewed in total (9 patients, 9 referrers and 13 sedation providers). Participants were purposively sampled, and included to develop emerging analysis. Transcribed interviews were qualitatively analysed using a constant comparative method which coded responses and grouped codes to identify predominant themes of response.
Results: Secondary care conscious sedation clinics were shown to have a variety of both immediate and long-term intended functions for participants. Short-term outcomes were removing anxiety, providing access, and meeting institutional requirements, whilst longer-term intentions were passing on interest and rehabilitation to primary care.
Conclusions: Rather than one unified understanding being held by all participants, the meaning of ‘conscious sedation’ within such clinics varies between and within each group. Despite diverse understandings however, the majority of interpretations are compatible, and this interpretative flexibility allows participants to achieve differing needs simultaneously. Although countries provide conscious sedation differently, it is not unreasonable to expect similar interpretations of its intention. Awareness of interpretations should help both referrers and providers provide patients with appropriate information as well as understand each other groups’ aims.


Dental caries and oral hygiene status in children with physical disability attending various special schools in Udaipur, India
S Jalihal,1 R Nagarajappa,2 K Asawa,3 M Tak,4 G Kakatkar,5 G Ramesh6
1Senior Lecturer, Department of Public Health Dentistry, KLE VK Institute of Dental Sciences, KLE University, Karnataka; 2Professor and Head, Department of Public Health Dentistry, Rama Dental College and Hospital, Uttar Pradesh; 3-5 Senior Lecturers, Department of Public Health Dentistry, Pacific Dental College and Hospital, Rajasthan; 6Associate Professor, Department of Oral and Maxillofacial Pathology, Rama Dental College and Hospital, Uttar Pradesh: India.
Objectives: To assess and compare the prevalence of dental caries and oral hygiene status in children with physical disability attending various special schools in Udaipur, India.
Methods: A cross sectional descriptive survey was conducted among 724 children with physical disability aged 6-15 years representing orthopedic [44.8%], visual [16.6%], hearing and/or speech impaired [29.8%] and multiple disability [8.8%] groups. Clinical examination comprised recording of WHO dentition status and treatment needs for assessing dental caries (dmft/DMFT); Oral Hygiene Index- Simplified (OHI-S) for oral hygiene assessment. Chi-square/Fischers Exact test, one way Analysis of variance, multiple logistic and stepwise multiple linear regressions were used for statistical analysis.
Results: Dental caries prevalence was 69.4% with mean dmft and DMFT of 0.33±0.49 and 0.92±1.12 respectively. Caries prevalence was high in multiple handicap groups. Oral hygiene status was fair to good. Stepwise multiple linear regression and logistic regression analysis showed the best predictors for DMFT as oral hygiene status and mode of cleaning teeth with the variances of 23.2% and 33.7% respectively. Similarly for OHI-S it was mode of cleaning teeth with a variance of 29.4%.
Conclusions: The higher prevalence observed in this specialised population draws immediate attention for an integrated approach in improving the oral health and focus towards extensive research.
Barriers to dental care for patients with congenital bleeding disorders
N Nizarali,¹ S Moosajee,² and T Newton³
1Department of Sedation and Special Care Dentistry, Guys and St Thomas’ NHS Foundation Trust;2Department of Community Special Care Dentistry, Kings College Hospital NHS Foundation Trust:3Department of Sedation and Special Care Dentistry, Guys and St Thomas’ NHS Foundation Trust
Aim: To investigate and identify the barriers to dental care, both perceived and real, for patients with the congenital bleeding disorders of von Willebrand disease and haemophilia.
Methodology: A convenience sample of 18 patients were invited to take part in this study and asked to fill in a structured questionnaire which included questions on perceived and real barriers to dental care.
Results: Nine of the 18 patients described themselves as ‘regular attenders’ to the dentist. The ‘non regular attenders’ group expressed a greater concern that their dentist would not know enough about their medical condition to enable safe treatment. Most of this group expressed a preference to be treated by a specialist dentist in the hospital setting.
Conclusions: Individuals with the congenital bleeding disorders of von Willebrand disease and haemophilia can experience barriers to receiving dental care. This needs to be explored further and recommendations for a ‘shared approach’ to dental care have been made.
A multi-disciplinary, multi-centre audit of access to and satisfaction with dental services for patients with Congenital Bleeding Disorders (CBDs)
A Muthukrishnan,1 G Kelly, 2 J McGregor3 and S Thompson4
1Associate Specialist in Restorative Dentistry, Morriston Hospital, ABM University Trust, Swansea;2Specialist in Special Care Dentistry HSE Louth/Meath ISA, Ireland; 3Quality and Audit co-ordinator School of Dentistry, University of Cardiff; 4Professor/Honorary Consultant in Special Care Dentistry School of Dentistry, University of Liverpool
Aim and objectives: A multi-disciplinary audit was undertaken with patients with congenital bleeding disorders (CBDs). The aim was to assess their access to dental care and satisfaction with dental services in South West and South East Wales.
Methodology: The standards for this audit were: 100% of patients with CBDs should have access to dental care and 100% should be satisfied with the dental care they receive. A patient satisfaction questionnaire was given to all patients with CBDs the Haemophilia Centre at Singleton Hospital, ABM University Trust, Swansea ( (Centre 1). The results from a Phase 1 audit at Centre 1 were used to guide the development of care pathways, and Phase 2 of the audit was undertaken after the establishment of these pathways. This audit cycle was shared with a second Haemophilia Comprehensive Care Centre, based at the University Hospital of Wales in Cardiff (Centre 2). Centre 2 undertook a prospective patient satisfaction survey of patients attending their regional Haemophilia Centre, over a six month period. The results were used to guide the development of care pathways at Centre 2.
Results: All patients with CBDs at both Centre 1 and Centre 2 had access to dental care, but difficulties were identified. Overall, 98% of the patients in Centre 1 were satisfied with the dental care they received at the end of the Phase 2 audit, and 85% of the patients in Centre 2 were satisfied at the end of their Phase 1 audit.
Conclusions: This multi-disciplinary audit of patients with CBDs identified barriers to and facilitators of dental care.
The use of flumazenil for adults with learning disabilities undergoing conscious sedation with midazolam for dental treatment: a multicentre prospective audit.
DA Lewis,1 LJ Wray, 2 MK Sherborne,3 C Frolander,2 J Shill,2 K Dalley,2
S Bell,1 D Wong,2
1Dorset Healthcare University NHS Foundation Trust: 2Solent NHS Trust:
3Virgin Care Limited
Objective: This prospective audit was undertaken to determine the level of use of flumazenil and the reason for its administration following conscious sedation with midazolam for dental treatment. The patient group under investigation were People with a Learning Disability (PWLD) undergoing conscious sedation for dental treatment.
Method: A regional sedation group used a standardised data collection form to collect prospective data about the use of flumazenil for PWLD. Data were collected on the level of sedation, operating conditions, speed of recovery, and the level of learning disability.
Results: During the twenty month audit period, 325 episodes of sedation of PWLD were undertaken. Flumazenil was used on 71 occasions. The main reasons that flumazenil was administered were delayed recovery and patients attempting to leave the surgery before adequately recovered. At no time was flumazenil used for a medical emergency nor were there any adverse events.
Conclusion: The use of flumazenil following sedation for PWLD appeared to be higher than reported levels in the unaffected peer group. Its use within this group of patients was deemed justifiable on the grounds of safety during recovery for these patients with limited cognitive function. No medical emergencies were recorded during this audit.

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