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. www.foxnews.com/story/2006/11/28/tv-land-lists-100-greatest-tv-catchphrases.   Royal Hospital for Neuro-disability. https://www.rhn.org.uk/what-makes-us-special/services/dentistry     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.    

JDOH - Volume 7, Number 1.

April 2006

Contents

Editorial 2

Oral health findings in a group of Greek schoolchildren with mild intellectual impairment
Sotiria Gizani, William Papaioannou and Lisa Papagiannoulis 3

A comparison of the effectiveness of chlorhexidine varnish, fluoride varnish and fluoride gel in children with intellectual disability
Nazan Kocatas Ersin, Özant Önçağ 10

Feeding habits of children with Down syndrome living in Riyadh, Saudi Arabia
Maha Al-Sarheed 17

Continuing Professional Development Programme 22

An approach to the restoration of fractured anterior teeth in adolescents with intellectual impairment
Alexandra Roman and Ovidiu Păstrăv 25

The use of hypnosis and systematic desensitisation in the management of dental phobia: a case report
K E Wilson 29

Mortality after full mouth rehabilitation under general anaesthesia for a child with Tetralogy of Fallot: report of a case
C.C. Liao, Y.H. Chen and C. Y. Yang 35

Oral hygiene status and behaviour of the special needs children in Lahore, Pakistan
Muhammad Shoaib, Nazia Yazdanie, Ayyaz Ali Khan, Omer Hafeez Kaleem, Noorya Ibrahim and Bushra Azad 43

The oral health status of Special Olympics athletes in Trinidad and Tobago
Rahul S Naidu, Tricia Percival, Visha Ramroop, Soorebettu R Prabhu and Steven Perlman 48

The dental management of a patient with erythromelalgia: a case report
L. Zoitopoulos and H. Ghoddousi 53

BSDH News 55

Addendum 56

Mortality after full mouth rehabilitation under general anesthesia for a child with Tetralogy of Fallot report of a case

Oral health findings in a group of Greek schoolchildren with mild intellectual impairment

The use of hypnosis and systematic desensitisation in the management of dental phobia a case report

Editorial

Special Care Dentistry –a reality

The year 2005 will be recalled as a landmark year for Special Care Dentistry.

Three members - Norman Campbell, Janice Fiske and Janet Griffiths - were honoured in the Queen’s Birthday Honours List in the summer for their contributions to the speciality and in December, the General Dental Council (GDC) approved in principle, the need for a speciality of Special Care Dentistry (SCD).

It had to come; countless patients, parents, support groups and dental teams could not have all been wrong. The submissions received by the GDC in its call for views were testimony to the need and demand out there for formal recognition of what selfless, dedicated oral health care teams had been doing for years. Now comes the really hard work.

It was a year too which saw much activity in related areas. The Department of Health had commissioned the British Society for Disability and Oral Health to set up a working group to explore a way forward in establishing dentists with a special interest – DwSI – in SCD and that group is now ready to present its finished document on competencies for such a group of dentists in the UK health service.

The Society also launched its competencies for undergraduate education in this journal in the spring of 2005 and in the closing stages of the year we welcomed the incoming president of BSDH, Peter Holland, our first non-dentist to take the helm for what will surely be an important year.

There is of course much hard work to do; the task now of making the case amongst relevant bodies in the different jurisdictions to ring fence money and posts for education and training, as well as ensuring a good case is made to commissioners for the resources to provide high quality care for the vulnerable groups that SCD is all about.

It is however, a time for reflection also. To think back to all those people, some of them sadly no longer with us, and be grateful for all their dedication, often working in isolation, facing much more suspicion and hostility than we can ever imagine, for what they saw as, and we know is, important, Special Care Dentistry

June Nunn

Dublin , April 2006

O ral health findings in a group of Greek schoolchildren with mild intellectual impairment

Sotiria Gizani, William Papaioannou and Lisa Papagiannoulis

University of Athens , Greece

Abstract

Aim: To describe the oral health condition and the need for dental and periodontal treatment in children with mild mental impairment. Information was gathered concerning family characteristics and the oral hygiene and dietary habits of the children. The influence of these factors on the oral health condition of the children was evaluated using a statistical model.

Material and methods: The sample was a convenience sample selected from eight special schools in the greater Athens area. The children were clinically examined in a mobile dental unit and the following parameters were assessed: periodontal condition, caries experience and past dental treatment.

Results: The participants comprised 171 students (114 boys and 57 girls) with mild mental impairment and a mean age of 11.46 years (SD: 1.92). The results for the provision of dental treatment index showed that only 8.39% (SD: 24.76%) of carious permanent tooth surfaces were treated. The picture was similar for the primary dentition. The multiple linear regression analysis showed that lack of tooth brushing and frequent daily sugar consumption influence negatively the periodontal and dental condition of the children, respectively. The index for periodontal treatment need showed that scaling and root planning was necessary for 41.44% of the children examined while only one child had a healthy periodontium.

Conclusions: It seems that the absence of motor impairment in the children made parents and teachers believe that their children could be trusted to perform oral hygiene, which was shown clinically not to be the case. Programmes of oral health education addressed to parents, teachers and children are necessary.

A comparison of the effectiveness of chlorhexidine varnish, fluoride varnish and fluoride gel in children with intellectual disability

Nazan Kocatas Ersin and Özant Önçağ

Ege University, Faculty of Dentistry, Department of Pedodontics, Bornova-Izmir, Turkey

Abstract

Objective: To compare the effectiveness of chlorhexidine and fluoride varnishes and fluoride gel within a group of intellectually disabled patients.

Design: A randomised controlled trial.

Methods: Ninety young people aged between 12-15 years, who had previously received full-mouth rehabilitation under general anaesthesia, participated in this study. Subjects were randomly allocated to one of three groups for treatment with Cervitec â , a chlorhexidine-containing varnish or a fluoride gel or Bifluorid 12 â , a fluoride containing varnish. The Cervitec â varnish was re-applied every three months and the fluoride treatments semi-annually. The outcomes were the caries increment (DMFS index), dental plaque, mutans streptococci (MS) and lactobacilli counts by comparison at baseline and after one year.

Results: Thirty-seven subjects showed poor compliance to the follow-ups and were excluded from the study. The Cervitec â varnish group showed a statistically significant reduction in MS counts after one year in comparison to the fluoride gel and fluoride varnish groups (p<0.05), but no inhibitory effect was found in the lactobacilli counts in all groups. There were also no statistically significant differences in the pre- and post-treatment plaque scores between the groups. The caries increments were 0.74±1.5, 1.06±2.26, 1.38±2.03 in the Cervitec â , fluoride gel and Bifluorid 12 â groups, respectively. The differences between the groups in mean caries increment were not significant.

Conclusion: The preventive agents tested showed equal efficiency in one-year caries increment within a group of children with intellectual disabilities.

Feeding habits of children with Down syndrome living in Riyadh, Saudi Arabia

Maha Al-Sarheed

Consultant Pedodontist, Assistant Professor, Division of Pediatric Dentistry, Department of Preventive Dental Science, King Saud University,

Riyadh , Saudi Arabia

Abstract

Aim: The aim of the study was to investigate the duration of breastfeeding and the timing of introduction of solid food among children with Down syndrome living in Riyadh, Saudi Arabia.

Subjects and Method: Mothers of 225 children attending three institutes providing education for children with Down syndrome were asked to complete a questionnaire. Data were collected on knowledge of feeding procedures, pattern of feeding, and the introduction of solid food.

Results: Although 66.7% of mothers breastfed initially, 30% of them discontinued breastfeeding at 3-6 months of the child’s age. Overall, mothers of children with Down syndrome introduced solid food to their children between 6-9 months of age and the most frequently used formula was Similac “yellow”. Just over 15% of the mothers gave their children sweet food every day as part of weaning. Most mothers believe that chocolate is bad for their children teeth.

Conclusion: In Saudi Arabia, mothers with Down syndrome children are more likely to breastfeed. The introduction of solid food was relatively late.

An approach to the restoration of fractured anterior teeth in adolescents with intellectual impairment.

Alexandra Roman 1 and Ovidiu Păstrăv 2

1 Associate Professor, 2 Assistant Lecturer, Department of Odontology–Periodontics, The “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania

Abstract

Aim: To restore traumatic lesions of the anterior teeth, in a group of adolescents (age range 13-16 years) while conscious, with mild and moderate mental impairment.

Study design: The study group consisted of 10 teenagers selected from an orphanage, with good oral hygiene, motivated and cooperative, in which 14 traumatic fractures were diagnosed. For the aesthetic restoration a microhybrid composite Herculite ® and a fifth generation adhesive system Optibond Solo ® were used in conjunction with t he stratification technique suggested by Vanini (1996), utilising a silicone palatal guide produced in the laboratory. In the case of fractured but non-vital teeth, endodontic treatment was carried out.

Results: Nine central maxillary incisor fractures and five lateral maxillary incisor fractures were treated. Immediately postoperative, one-week, six months and 12 months later, results were considered satisfactory.

Conclusions: We believe that the value of this report is in the illustration of relatively complex dental treatments in adolescents with intellectual impairment, whilst conscious; improving function, aesthetics and self esteem.

The use of hypnosis and systematic desensitisation in the management of dental phobia: a case report

Katherine Wilson

South Tyneside Primary Care Trust, Community Dental Service

Abstract

This case report presents a patient with dental phobia, which reportedly developed at the age of 9 years of age, following a traumatic dental experience. It describes the use of hypnosis and a programme of systematic desensitisation in the management of dental and needle phobia.

Mortality after full mouth rehabilitation under general anesthesia for a child with Tetralogy of Fallot: report of a case

C C Liao, Y H Chen, C Y Yang

Division of Pedodontics and Orthodontics, School of Dentistry, Tri-service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C.

Abstract

This paper presents the case of a 9-year-old boy with uncorrected Tetralogy of Fallot (ToF) who was admitted to our hospital for comprehensive treatment of his dental problems under general anaesthesia. Treatment included three amalgam restorations, four sealants, eight resin-based composite restorations, two preformed metal crowns (SSC), eight primary tooth or residual root extractions, two supernumerary tooth extractions, and a lower arch impression for the fabrication of a lower lingual holding arch (LLHA). Immediately after the operation, the patient was sent to the paediatric intensive care unit and after he was stabilised, his nasotracheal tube was removed. Unfortunately, the patient then developed severe breathing difficulty and lost consciousness but was resuscitated after reintubation and cardiopulmonary resuscitation. The patient died two months postoperatively from spontaneous, massive bleeding from the pharyngoesophageal region. The poor outcome in this case, after full mouth rehabilitation under general anaesthesia, indicates the risk associated with these special patients, the need to work with a well trained paediatric anaesthetist and the importance of cautiously embarking upon this form of dental care.

Oral hygiene status and behaviour of the special needs children in Lahore, Pakistan.

Muhammad Shoaib 1, Nazia Yazdanie 2, Ayyaz Ali Khan 1, Omer Hafeez Kaleem 2,

Noorya Ibrahim 2 and Bushra Azad 2

1 Department of Oral Health Sciences, Sheikh Zayed Federal Postgraduate Medical Institute, Lahore, Pakistan

2 de’Montmorency College of Dentistry, Lahore, Pakistan

Abstract

Aim: To investigate the oral health status of individuals with mental and medical disabilities in Lahore and compare the results with an age and gender matched healthy control group.

Material and methods: A cross-sectional study conducted on 424 individuals with a mean age of 10.7 years (age range: 6-17years) at two day schools for individuals with intellectual impairment and Down syndrome. Medically compromised subjects were recruited from the paediatric ward of a local hospital. Age and gender matched controls were selected from one school.

Outcome measures: Oral hygiene status and tooth brushing practices.

Results: Medically compromised individuals reported highest mean OHI(S) values (poorest oral hygiene) among the three groups. The mean difference was significant between the groups (p< 0.05). Among the compromised individuals, those with insulin dependent diabetes mellitus (IDDM) had poor oral hygiene, followed by persons with mild intellectual impairment. The oral hygiene status of sub-classes of intellectually disabled and medically compromised groups was significantly poorer when compared to normal individuals (p < 0.05). However, the mean difference was not significant among the individual disability groups (p > 0.05). Individuals with special needs had irregular tooth brushing practices when compared with their normal counterparts. The difference between the groups was statistically significant at (p < 0.05). The two main disability groups (intellectual impairment and medically compromised) did not differ significantly in their brushing practices (p=0.602).

Conclusions: Individuals with special health care needs had poor oral hygiene and irregular tooth brushing practices as compared to their normal counterparts. There is an essential need to improve the oral health status of this neglected group in society.

The oral health status of Special Olympics athletes in Trinidad and Tobago

Rahul S Naidu 1, Tricia Percival 1, Visha Ramroop 1, Soorebettu R Prabhu 1 and Steven Perlman 2

1 School of Dentistry, Faculty of Medical Sciences, The University of the West Indies, Trinidad and Tobago

2 The Boston University Goldman School of Dentistry, Boston, Massachusetts, USA

Abstract

Aim: To assess the oral health status of Special Olympics athletes in Trinidad and Tobago (a developing country in the English-speaking Caribbean).

Design: A convenience sample of athletes competing in the Trinidad and Tobago Special Olympics Spring Games in 2004.

Subjects: A sample of 410 athletes who participated in the Special Olympics Special Smiles Healthy Athletes screening programme.

Main outcome measures: A standardised oral exam and screening form were used for the assessment of each athlete.

Results: The mean age of the athletes was 18.8 years with a range of 5-58 years; 57% were male and 13% reported having pain in their teeth. The prevalence of untreated molar decay among those who completed the oral exam was high (43.7%). Few participants had filled (9.3%) or sealed teeth (2.9%). Gingival signs were present in 34.6%. Urgent treatment need was found in 27.6%. Compared to Special Olympics athletes in the United States of America (USA), those in Trinidad and Tobago had generally worse oral health.

Conclusion: The oral health status of Special Olympics athletes in Trinidad and Tobago suggests the need to develop oral health promotion for people with intellectual disabilities and improve their access to oral healthcare.

The dental management of a patient with erythromelalgia: a case report

L. Zoitopoulos and H. Ghoddousi

Department of Community Special Care Dentistry, Guy’s, King’s & St. Thomas’ Dental Institute, London, UK.

Abstract

Erythromelalgia is a painful paroxysmal dilatation of the blood vessels of the skin, usually affecting the feet and extremities. We present details of a 50-year-old female who required simple dental treatment, the delivery of which was made difficult by erythromelalgia. This was due to vasodilatation which rendered local anaesthetic ineffective. She attended a series of appointments during which dental treatment was carried out with articaine as the local anaesthesia. It is important not to dismiss the patient’s perception of pain and to take a good medical and social history to establish a reason for this.

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