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 11 Number 1

March 2010

Editorial 2

Osteoradionecrosis a review of prevention and management
Mary Burke and Michael Fenlon 3

Patients and carers views of a Special Care Dentistry general anaesthetic service
Louise Hopper and Lucy Szymkowiak 10

Establishing a procedure for managing poor standards of oral care in vulnerable and dependent adults
Daniel Knibb 14

The Mental Capacity Act 2005: implications for primary care dental services: a summary
D Mudie, S Berman and A Kaul 17

The Mental Capacity Act 2005 its significance for Special Care Dentistry and patient care
A Kaul, D Mudie and S Berman 21

The Mental Capacity Act 2005 implementation within Special Care Dental services
A Kaul, D Mudie and S Berman 25

Arthrogryposis Multiplex Congenita dental findings and treatment of an 8 year old child
D E Emmanouil, T Roumani and G Petsi 32

Disability and cultural issues in research lessons learned
Mili Doshi, Mary Burke and Janice Fiske 37

Diary Page 2010

Editorial

I am honoured to write an editorial for the Journal of Disability and Oral Health. As a medical doctor with a disability, a past campaigner for the rights of people with disabilities and a non-expert in oral health, it is heartening to see a health journal refer repeatedly in its editorials to both the rights of people with disabilities to receive high quality healthcare and a recognition of the predominance of the social over the medical model of disability.

My personal passion is access to healthcare. Previous editorials have addressed the issue of access for people with disabilities. I wish to address the issue of access for those in poverty. The distance between inaccessibility for people in poverty versus with disability is not great. In fact, they are inextricably linked with reports consistently showing disabled people being hugely more likely to end up in poverty than the general population (National Disability Authority, Leonard Cheshire Disability).

Tudor Harts Inverse Care Law, which states that the need for healthcare is inversely proportional to the provision of healthcare (or more simply put, those who most need health services are least likely to get them) sadly is persistently and consistently validated. It is my contention that no matter how high its standards of healthcare delivery, an inaccessible healthcare service can lay no claim to being a quality service. It has been demonstrated that lack of access results in patients being less likely to attend a physician, avail of preventive or appropriate diagnostic and therapeutic services, or bring their prescriptions for dispensing (Weinick et al., 1996; Krauss et al., 1998; Newacheck et al., 1998; Baker et al., 2000; Lasser et al., 2006). Prewitt identified continuous access to primary care in inner cities as the primary approach to address health inequalities (Prewitt, 1997).

Homeless people suffer from high levels of dental problems (Conte et al., 2006). In Ireland, access to both primary care and dental health services is dependant on having a medical card, a means-tested way of accessing care. Yet in Dublin, it has been shown that 45% of homeless people do not have medical cards (O’Carroll and O’Reilly, 2008). A specialised dental service had been set up in Dublin to provide access to dental services for homeless people was set up, yet it has not had an incumbent for some months for lack of staffing. Thus in the specialised GP clinic we run, we frequently come across homeless people with acute dental pain and no access to any clinic (never mind those requiring non-acute dental treatment). In the UK it has been reported that homeless people find it difficult to access dental services (Dentistry; Homeless Link, 2009)

Even if you have a medical card in Ireland it can be difficult to get a dentist to provide treatment. Reports indicate that the case may be similar in the UK with cost deterring many patients from accessing treatment (BBC News, 2007). Marmot, in reviewing the evidence on the effect of having to pay out-of-pocket expenses on the health of middle to low-income earners, comments that this illustrates how health systems perpetuate injustice and social stratification (Marmot and Shipley, 1996). Community and Personal Dental Services offer a route for the provision of specialised services to hard to reach groups such as homeless people. These services seek to deliver services to where the patients feel comfortable. Hard to reach groups find mainstream services difficult to access and intimidating. It is not acceptable in a society that espouses social inclusion that medical or dental care remains unavailable for all. As Martin Luther King said: ‘Of all the forms of inequality, injustice in health is the most shocking and the most inhumane.’

Dr Austin O’Carroll
General Medical Practitioner, Dublin, Ireland

Baker DW, Shapiro MF, Schur CL. Health insurance and access to care for symptomatic conditions. Arch Intern Med 2000; 160: 1269-1274.
BBC News, 2007. http://news.bbc.co.uk/2/hi/7041291.stm
Conte M, Broder HL, Jenkins G, Reed R, Janal MN. l Oral health, related behaviors and oral health impacts among homeless adults. J Public Health Dent 2006.
Dentistry. http://www.dentistry.co.uk/news/news_detail.php?id=2388
Homeless Link. Survey of Needs and Provision 2009. Homeless Link London 2009. http://homeless.org.uk/sites/default/files/SNAP2009_Full_Report1.pdf
Krauss NA, Machlin S, Kass BL. Use of Health care Services, 1996. MEPS Research Findings No. 7. AHCPR Publication No. 99-0018. Rockville, MD: Agency for Health Care Policy and Research. 1998
Lasser KE, Himmelstein DU, Woolhandler S. Access to Care, Health Status, and Health Disparities in the United States and Canada: Results of a Cross-National Population-Based Survey. Am J Pub Health 2006; 96: 1300-1307.
Leonard Cheshire Disability. Disability Poverty in the UK. Available at http://www.lcdisability.org/?lid=6386
Marmot MG, Shipley MJ. Do socioeconomic differences in mortality persist after retirement? 25-year follow-up of civil servants from the first Whitehall study. BMJ 1996; 313: 1177-1180.
National Disability Authority. http://www.nda.ie/cntmgmtnew.nsf/0/877A60DB1411D35980257066005332F6?OpenDocument
Newacheck PW, Stoddard JJ, Hughes DC, et al. Health insurance and access to primary care for children. N Engl J Med 1998; 338: 513-519.
O’Carroll A, O’Reilly F. Health and Homelessness in Dublin: has anything changed in the context of Ireland’s economic boom? EJPH 2008; 8: 448-453.
Prewitt E. Inner City Health Care. American College of Physicians. Ann Intern Med 1997; 127: 485-490.
Weinick RM, Zuvekas SH, Drilea SK. Access to Health Care—Sources and Barriers,. (MEPS research findings No. 3, AH CPR publication No. 98-0001.) Rockville, MD: Agency f or Health Care Policy and Research 1996.

Osteoradionecrosis - a review of prevention and management

Mary Burke BDS FDS RCS(Eng)1 and Michael Fenlon MA PhD BDentSc MGDS FDS RCS(Ed)2

1Guy’s and St Thomas’ NHS Foundation Trust, 2King’s College London

Abstract

It has been long recognised that patients who receive radiotherapy for cancer of the head and neck area are at risk of developing osteoradionecrosis (ORN) of the jaws. Guidelines to reduce risk have been written, based upon the evidence of many studies which have looked at the incidence of ORN in different groups. Much of the research was carried out over 20 years ago and more recent analysis of data and consideration of the changes in radiotherapy raises the question as to whether modifications to the guidance is now needed. There is a wide variation in recommendations and a simpler, more unified approach to prevention of ORN could be developed as well as research on recent management techniques.

Clinical relevance: ORN is a serious condition which can adversely affect quality of life and treatment outcome of patients who have already suffered the trauma of oral cancer. Features include chronic exposed bone which fails to heal, pain, fractures and fistulae. The incidence is decreasing, probably as a result of improved radiotherapy techniques. The general dental practitioner may play the greatest role in prevention with regular oral health care.

Establishing a procedure for managing poor standards of oral care in vulnerable and dependent adults

Daniel Knibb BDS MFDS RCS Eng, DSCD
Senior Dental Officer, Devon Primary Care Trust
(previously Community Dental Officer, Cardiff & Vale NHS Trust)

Abstract

Vulnerable adults who, for reasons of impairment or disability, cannot achieve good oral hygiene for themselves may be dependent on paid carers for their oral care. When this care falls below the standard necessary to prevent oral disease, their oral and general health may suffer. If standards fail to improve despite intervention by the dental team and oral health continues to deteriorate, this could be seen as neglect and thus become an issue that requires liaison with the Safeguarding Adults team. This paper describes the development of a local procedure which aims to establish proper procedure in such cases, in the absence of national guidelines on this subject.

The Mental Capacity Act 2005 –Implications for primary care dental services: a summary

D Mudie BDS LDS MCCD (RCS Eng) 1, S Berman BDS, MSc2, A Kaul BDS MFGDP (UK), MFDS (RCS Eng) 2

1Senior Dental Officer, Adult Special Care; 2Deputy Head of Primary Care Trust Dental Service, Wandsworth Teaching Primary Care Trust, London, UK

Abstract

The Mental Capacity Act 2005 for England and Wales came into force in October 2007. Prior to its implementation, the law surrounding the provision of care for people unable to give valid consent was based on case law, notions of best practice, and the provision of treatment that was deemed to be in the patient’s best interest. The 2005 Act places the provision of care for such people within a defined legislative framework supported by new systems and statutory bodies.

The main provisions of the Act, and the changes in the landscape around consent for the vulnerable adult, are discussed. The Act defines capacity, sets out a test to assess it and describes the responsibilities of those providing care for vulnerable adults. It states the rights of these adults to be as fully engaged as possible with the decision-making process. The application of the Capacity Test is described, together with its implications for patient, carer and clinician. In addition, the Act sets out who should be consulted when decisions about treatment are to be made.

Clinicians must now act with due regard to the guidance published in the Code of Practice which accompanies the Act. Special Care dentists need a sound working knowledge of the Act, an understanding of how it impacts on the provision of care for the vulnerable adults they treat, and must ensure that they comply with their ethical and legal responsibilities as they treat these patients.

The Mental Capacity Act 2005: its significance for Special Care Dentistry and patient care

A Kaul BDS MFGDP (UK), MFDS (RCS Eng) 1, D Mudie BDS LDS MCCD (RCS Eng) 1 and S Berman BDS, MSc2,

1Senior Dental Officer, Adult Special Care; 2Deputy Head of Primary Care Trust Dental Service, Wandsworth Teaching Primary Care Trust, London, UK


Abstract

The Mental Capacity Act 2005 came into force for both England and Wales, and was fully implemented by October 2007 (for Scotland separate legislation exists, which is the Adults with Incapacity Act 2000). Since this time, many Primary Care Trusts in England and Wales have developed guidance on implementing the legislation. However, there has been very little written about the day to day challenges faced by the healthcare professionals who must abide by the Act, and its accompanying Code of Practice.

Within Adult Special Care Dentistry, a significant portion of the caseload can consist of vulnerable adults who lack decision-making capacity, or whose decision-making capacity may be in doubt; in these situations, the Mental Capacity Act will be of particular relevance. Composite scenarios based on the authors’ experiences are presented to illustrate some of the challenges that may be faced by the clinician, along with their impact on patient assessment, and oral health care provision. The Act emphasises the need for effective communication within the multi-disciplinary care environment which surrounds many of these potentially vulnerable adults.

It is important to raise awareness of the Act and the Code of Practice amongst all members of the care team, including those who provide informal care, and support for the patient, and most importantly, the patients themselves.

The Mental Capacity Act 2005: implementation within Special Care Dental services

A Kaul BDS MFGDP (UK), MFDS (RCS Eng) 1, D Mudie BDS LDS MCCD (RCS Eng) 1 and S Berman BDS MSc2

1Senior Dental Officer, Adult Special Care; 2Deputy Head of Primary Care Trust Dental Service, Wandsworth Teaching Primary Care Trust, London, UK


Abstract

There are certain patient groups within Special Care Dentistry for whom the Mental Capacity Act 2005 will have particular relevance. Once the principles and legal implications of the Mental Capacity Act (MCA) have been understood, the dental team must apply and integrate these principles into their patient assessment and oral health care plans. Implementation of the Act will involve raising awareness amongst patients, family, friends and others who provide care for vulnerable adults.

Factors that may affect capacity are discussed including how they may impact on the delivery of oral healthcare, and some of the challenges which clinicians may face in assessing capacity. The importance of the Capacity Test and the Best Interest Checklist, along with their documentation is discussed.

The role of the Independent Mental Capacity Advocacy Service (IMCAS) and the situations when they may be required are outlined, with particular reference to what may be defined as serious medical treatment within the context of special care dentistry.

Arthrogryposis Multiplex Congenita: dental findings and treatment of an 8-year-old child

D E Emmanouil DDS MSc PhD, T Roumani DDS MSc and G Petsi DDS

Dept. of Paediatric Dentistry, School of Dentistry, University of Athens, Greece

Abstract

This report describes a case of Arthrogryposis Multiplex Congenita (AMC) with limited mouth opening and dental caries. Conservative dental treatment and physiotherapy exercises were prescribed. The aim of this case report is to describe the method and difficulties in the dental care of this patient and outline the importance of a preventive programme.

Disability and cultural issues in research – lessons learned

Mili Doshi BDS MFDS RCS (Eng) MSc1, Mary Burke BDS FDS RCS (Eng) 2 and Janice Fiske MBE BDS MPhil FDSRCS (Eng) 3

1Senior Dental Officer, Tower Hamlets Community Dental Service, 2Associate Specialist in Special Care Dentistry, Guy’s and St Thomas’ NHS Foundation Trust, 3Senior Lecturer/Consultant in Special Care Dentistry, King's College London

Abstract

Aim: To discuss the disability and cultural issues, which need to be considered during the planning and implementation of a study to investigate the oral health of young adults with a learning disability and from a minority ethnic group.

Design: A study of the oral health of Bangladeshi young adults with a learning disability is used as an example, to highlight the barriers identified in the research process for this group. These barriers included: access, culture, language and literacy, consent, communication and co-operation. The paper highlights the approach required to gain co-operation for access to the study population via day centres; the development of an oral health questionnaire relevant to the particular ethnic community; and translation requirements. It also describes how support was given during a structured, informed consent process and the use of props, photographs and scales used to support and aid understanding.

Results: A participation rate of 98% was obtained in the study and 80% of individuals appeared to enjoy participating. The results showed participants were very aware of oral health and their social implications indicating that the approach used facilitated understanding and communication.

Conclusion: By considering and adapting the research process to meet the needs of people with a disability and from an ethnic minority background, the study was acceptable to their needs and participation levels were high.

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