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.    

JDOH - Volume 8, Number 2.

August 2007



Referral patterns and access to dental services of people affected by homelessness in Dublin Ireland
Ruth Gray 51

An audit of patient assessment and treatment outcomes in anxious patients referred for conscious sedation
RB Smith and SA Thompson 57

Barriers to oral health care access among socially vulnerable groups a qualitative study
Jaques N Vananobbergen, Ruth Van Der Beken, Leen Gyssels, Leen Deroo and Sara Willems 63

Descriptive study of factors modifying the periodontal status of a population of people with a learning disability in Spain
Guillermo Machuca, Emilia Nieves, Antonio F. Sánchez, Carmen Machuca and Pedro Bullón 73

The value of training doctors in the diagnosis of oral manifestations of HIV
CR Vernazza, BN Mayanja, JO Mugisha, L Van der Paal, CJ Young and PG Robinson 81

Student evaluation of clinical outreach teaching in Community Special Care Dentistry
Liana Zoitopoulos, Theodore Papadakis,Yogesh Tanna and Stephen Dunne 86

Preaxial acrofacial dysostosis Nager syndrome a case report
A Da Silveira, AS Joshi and M Shahani 91

Book review 95

Diary 96

Editorial Pushing Boundaries

2007 is another significant year for the Journal. We have consolidated our move to three issues a year with an impressive array of original research from an international group of authors. For the first time, subscribers can access the Journal online at, with a paper copy, or both, opening up access to many more readers. This is a distinct member advantage, allowing the subscriber not only the access to the current issue but to the archive of previously published material. In addition, this online facility enables members to access CPD online and if they wish, to set up their own CPD account for recording all their CPD without cost.

At a time when Special Care Dentistry is expanding rapidly as a recognised specialty in many countries, a resource is required that is contemporary, peer-reviewed and authoritative. More and more countries are establishing education and training programmes in the speciality and access to the innovative, to good practice and to seminal papers in the discipline is essential. This is not only for the student but for the established practitioner as part of their continuing professional development. 

The decision of the Executive of the International Association for Disability and Oral Health to take up online membership for its members is therefore timely and to be applauded for its far-sightedness. Investing in its members is a benefit that will reach out and embed knowledge and good practice for special care patients worldwide. Pushing out the boundaries is essential for many reasons but two are especially important. In many countries professionals in emerging specialities often work in isolation and without access to publications like this and thus are unaware of the opportunities that they might bring to their patients. As well, encouraging the novice academic, the innovator in their field, the experienced clinician with a cautionary tale to tell, are important functions of a scientific journal. We have a responsibility through our stringent peer review mechanism to bring the very best to the readership whilst at the same time cultivating and supporting those for whom scientific writing is a new endeavour.

In time, papers in the Journal will come to be viewed as seminal; for example, the paper in the December 2006 issue on defining the population requiring Special Care Dentistry using the World Health Organisation’s International Classification of Functioning, Disability and Health. If Dentistry, let alone Special Care Dentistry, is to be recognised for the important role it has to play in overall health, then we need to push back the boundaries of how we work to be included. For too long Dentistry has argued that it needs to be considered different and must be a special, separate case, without using the opportunities we have to be part of the wider healthcare team and work towards the ‘common risk’ approach; to put oral healthcare in context. Papers like this give us the framework to do that. It is imperative that, for our patients at least, we take up this challenge.

June Nunn, Dublin July 2007

Referral patterns and access to dental services of people affected by homelessness in Dublin, Ireland

Ruth Gray BDS, MDPH

Senior Dental Officer, Community Dental Service, Lisburn Health Centre,
Linenhall Street, Lisburn, Northern Ireland


Aims: To assess the accessibility of a dental service in a dental clinic and a homeless drop-in centre in Dublin for people affected by homelessness, evaluate current referral patterns and investigate the level of methadone use in the population and corresponding use of drug services.

Material and methods: A review was conducted of a comprehensive database of all 237 patient dental records using simple inclusion criteria. Comparisons were made with data from a general survey of homeless people in Dublin.

Results: Showed 163 men and 74 women had attended, with a modal age range of 25-34 years. Only 16% of patients were over 40 years of age, of which only 6% were females. The main source of referral was from the homeless drop-in centre, in which the clinic is situated (39%); hostels referred 19% and day centres 12%. Previous input from the dental team into the centres through education, health promotion or screening improved the number of referrals. 61% of the patients were attending for treatment in methadone clinics.

Conclusions: As the homeless population is not homogenous the targeting of services to certain sub-sets of this population is necessary, such as people over 40 years of age and women with families in bed and breakfast accommodation. Health education and screening can promote access to dental services. Finally, an interdisciplinary approach is essential so that an oral health assessment can be included in the initial assessments made by community welfare officers, hostel staff and drug centre workers.

 An audit of patient assessment and treatment outcomes in anxious patients referred for conscious sedation.

R B Smith BDS, MScD, MFGDP and S A Thompson BDS MPhil, PhD, MSND RCS Ed.

Unit of Conscious Sedation and Special Care Dentistry, Department of Adult Dental Health, Cardiff University School of Dentistry, Heath Park, Cardiff CF14 4XY, UK


Aim and objectives: The aim of this study was to audit the success of treatment outcomes following assessment and treatment planning of anxious patients referred for conscious sedation. The outcome of treatment has a marked effect on ratings of its acceptability. Treatments associated with positive outcomes appear to be more acceptable than those associated with poor outcomes.

Design: A standard was set following reference to the literature. At the examination and assessment visit the dentist decided, together with the patient, what modality should be used to carry out the treatment. The outcome was judged to be successful when the planned procedure was completed and the patient had been able to co-operate during the dental treatment without becoming distressed. One hundred consecutive adult patient treatments were included in the audit.

Results: A total of 98 completed data collection sheets were analysed. The dental treatments planned at the assessment appointment were completed for 91 (92%) patients. In 8 (8%) patients it was not possible to complete the planned treatment.

Conclusion: The standard set for the audit was met, with a successful outcome of 92% overall. No specific areas of weakness were identified. The need for staff training in the use of additional techniques was identified. This could provide a further conscious sedation option before referral for general anaesthesia was considered.

Barriers to oral health care access among socially vulnerable groups: a qualitative study

Jacques N Vananobbergen DDS, PhD1, Ruth Van Der Beken M Soc.2, Leen Gyssels M Soc3, Leen De Roo M Soc4,5 and Sara Willems MA Soc, PhD5

1 Department Community Dentistry and Dental Public Health, Ghent University, Belgium,

2 District Health Care Centres ‘De Sleep’,

3 ‘Brugse Poort’,

4 ‘Botermarkt’,

5 Department of Family Medicine and Primary Health Care, Ghent University, Belgium.


Objectives: To identify perceptions and underlying causes of important barriers to access for oral health care among socially vulnerable groups.

Methods: In a qualitative approach, focus group discussions were organised to gather information concerning barriers to oral health care. The study was undertaken in the city of Ghent, one of the major capitals in Flanders. 150 participants with different backgrounds participated in 13 focus group discussions. Group moderators were experienced health care workers. A discussion guide based on a ‘domino’ game was developed especially for use in this study. The discussions were tape-recorded and transcribed verbatim. QSR Nudist software was used to organise the data. The health belief model was the main theoretical approach for the study.

Results: From the users, the overall knowledge on preventive health care and on available dental care services and costs were limited. The importance of oral hygiene was well known but difficult to put into practice, the importance of the primary dentition was underestimated and tooth-unfriendly dietary habits were common. This was strengthened by cultural beliefs. Fear of pain and dental treatment, uncertainty about dental treatments, language barriers and out-of-pocket costs were reported. For the suppliers, the lack of information and negative experiences concerning dentists’ lack of responsiveness to patient concern were expressed.

Conclusion: An important commitment, based on these results, consists of information and motivation of the target group. The framework reported in this study offers guidance for estimating barriers experienced by the target group and for evaluating the outcome of interventions to reduce these barriers.

 Descriptive study of factors modifying the periodontal status of a population of people with a learning disability in Spain

Guillermo Machuca MD DMD1, Emilia Nieves DMD 2, Antonio F. Sánchez MD DMD3, Carmen Machuca MD DMD MSD3 and Pedro Bullón MD DMD4

1 Professor,

2 Honorary Associate Lecturer,

3 Associate Lecturer; Department of Patients with Special Needs and Periodontics

4 Professor, Department of Oral Medicine and Periodontics; Faculty of Dentistry, University of Seville, Spain.


Objectives: To evaluate, for institutionalised people with a learning disability: their periodontal status, periodontal treatment needs, the influence of social and demographical factors, behaviour, dental maintenance and malocclusions on their periodontal state.

Subjects: 143 adults (17.5±3.5 years) with a learning disability in residential care.

Design: Data were recorded relating to age, gender, illness, difficulties in behavioural management, residential status (resident/non-resident), previous contacts with dentists, and oral hygiene. The Community Periodontal Index of Treatment Needs (CPITN), periodontal treatment needs (TN) and malocclusion (WHO: 0, 1 and 2), were registered in accordance with the criteria of the World Health Organisation (WHO).

Results: 24.3% had a congenital learning disability and 20.8% were diagnosed with Down syndrome. 79.0% of subjects were non-resident; 77.6% had a dental management issue; for 61.1% it was their first dentist contact; 41.9% brushed their own teeth. For malocclusion; 10.5% had none, 15.4% had mild and 74.1% moderate/advanced. For periodontal health; 4.2% had good health, 4.1% had bleeding, 59% calculus, 25.7% moderate pockets and 7% deep pockets. None of the patients was totally edentulous. Periodontal disease increased with age (p<0.001) and women had better periodontal health (p<0.01). Patients who had their teeth brushed by their carers had better periodontal health (p<0.05). 4.2% require no treatment, 95.1% required instruction in oral hygiene, 91% instruction and calculus removal; 6.3% advanced periodontal treatment. Treatment needs increased with age (p<0.001), with difficulty in management (p<0.001), and whether they brushed their own teeth (p<0.05).

Conclusions: A high level of mild/moderate periodontal disease was observed in the sample. This increased with age, with the presence of malocclusions and with unsupervised brushing.


The value of training doctors in the diagnosis of oral manifestations of HIV

C R Vernazza, BDS MFDS RCS Ed1, B N Mayanja MBChB2, J O Mugisha MBChB MSc Epid2, L Van der Paal MD MSc Epid 2, C J Young BDS3, P G Robinson BDS, LDS RCS, MSc, PhD, FRACDS, ILTM4

1Clinical Fellow in Child Dental Health, School of Dental Sciences, Newcastle University, UK; 2Medical Officer and Clinical Epidemiologist MRC/UVRI Research Council Programme on AIDS, Entebbe, Uganda; 3Dental Surgeon, Northamptonshire, UK; 4Professor of Dental Public Health, School of Dentistry, University of Sheffield, UK.


Objectives: To assess the effectiveness of a training intervention on doctors’ diagnoses of oral manifestations of HIV infection in an outpatient medical clinic in rural Uganda.

Methods: Didactic teaching, seminars and calibration with participants were given to doctors by dental students. After the intervention, doctors’ and dental students’ diagnoses were compared against participants’ HIV status in the same 79 patients. Then, for three months doctors’ diagnoses only were compared against participants’ HIV status.

Outcome measures: Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) and likelihood ratios (LR) using HIV status as gold standard.

Results: Immediately after the intervention, agreement between doctors’ and dental students’ diagnoses was 0.71 (k) for the same 79 participants (44 HIV positive): Over the next three months, the doctors did not diagnose any further lesions in a sample of 259 participants, (111 were HIV positive) (sensitivity, PPV and LR all fell to 0). This reduction in sensitivity was significant (p<0.001) (Fisher’s exact test).

Conclusions: Doctors can be trained in the diagnosis of oral manifestations of HIV infection but diagnostic validity decreases with time from training. Further and sustained increases in diagnostic validity may be possible with increased or more effective training and if oral diagnosis forms an integral part of participants’ health care, rather than part of a research project.

Student evaluation of clinical outreach teaching in Community Special Care Dentistry

Liana Zoitopoulos BDS MCDH MHSM PhD1, Theodore Papadakis DDPH RCS MDentSci DIPDS2,Yogesh Tanna BDS MSc2 Stephen Dunne BDS FDSRCS PhD3

1Consultant in Special Care Dentistry/ Honorary Senior Lecturer and Head; 2Senior Dental Officer, Department of Community Special Care Dentistry; 3Head of Primary Dental Care: King’s College London Dental Institute, London, UK


Aim: To describe the content of an outreach teaching programme in Community Special Care Dentistry (CSCD) and assess the students’ feedback.

Design and subjects: The content and operational arrangements of the outreach programme are described. A random sample of 120 student evaluation sheets from a three-year period was analysed for recurring comments. Information collected on student attendance and number and type of patients seen were also reviewed.

Results: A high atttendance rate was noted throughout the three-year period. An average number of six patients was seen by each pair of students, per day. The percentage of special care patients as opposed to vulnerable (high caries) groups increased each year. The majority (81%) of student evaluation forms had positive comments only, with the most commonly recurring items being the tutors’ skills, the chance to get an insight into CSCD and the range of patients treated.

Conclusion: The programme has been both well attended and received by students. There are inevitably, limitations on extrapolating this information, based as it is, on students’ perceptions.

Preaxial acrofacial dysostosis (Nager syndrome): a case report

A Da Silveira DDS MS PHD1, A S Joshi MDS M(ORTH)RCS2 and M Shahani MD3

1 Chief of Orthodontics and Assistant Professor,

2 Orthodontic Research Fellow,

3 Director of Pediatric Services and Assistant Professor, The Craniofacial Center and Department of Pediatrics, University of Illinois, Chicago, Illinois, USA.


This case report describes the surgical and dental management of a 12-year-old girl with preaxial acrofacial dysostosis also known as Nager syndrome. It highlights the importance of multidisciplinary treatment at an early age and the effect of parental noncompliance on the overall physical and psychological development of a medically compromised patient.

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