Although special care dentistry (SCD) is a fairly recent specialty, the principles and practice of SCD have been developed since the 1980s. Shared care of these patients with general dental practitioners remains vital to ensure that comprehensive care is provided. This article aims to discuss some of the patient groups commonly seen in SCD clinics and give an insight into the varied complex medical and social aspects of care which are managed as part of providing appropriate, safe and holistic care.
Clinical Relevance: Many patients who currently fall under the remit of special care dentistry could be treated safely in general dental practice. This article acts as an introduction to special care dentistry for general dental practitioners.
Article
Special Care Dentistry (SCD) is primarily concerned with providing care and improving the oral health of individuals or groups who have a physical, sensory, intellectual, mental, medical, emotional or social impairment or disability or, more often, a combination of these factors.1
The majority of specialist care is provided in a secondary care community-based setting. However, the shared care of patients with general dental practitioners remains vital to ensure comprehensive care.
Although SCD is a fairly recent specialty, the principles and practice of SCD have been developed since the 1980s when the British Society of Disability and Oral Health was established with the following objectives:
To promote the oral health of disabled people of all ages;
To promote links with organizations representing disabled people;
To consult with disability groups to identify their needs and demands;
To study the barriers relating to the provision of oral healthcare for disabled people;
To develop Undergraduate and Postgraduate teaching in the subject;
To encourage research in the field of oral health for disabled people.
The impact of oral conditions on an individual's quality of life can be profound.2 Poor oral health may add an additional burden, whereas good oral health has holistic benefits in that it can improve general health, dignity, self-esteem, social integration and quality of life.3
This article aims to discuss some of the patient groups commonly seen in special care dental clinics. For more information or further reading please see guidelines available on the BSDH website: www.bsdh.co.uk.
Consent and legislation
As set out in GDC guidelines, there are three main principles4 which are essential in order to gain valid consent from a patient:
Informed consent – the patient has enough information to make a decision;
Voluntary decision-making – the patient has made the decision;
Ability – the patient has the ability to make an informed decision.
If a patient is unable to understand or retain the information presented to him/her, or is unable to communicate the information provided in order to give a decision, he/she cannot be deemed to have the ability or capacity to consent.
Throughout all branches of dentistry, the ability to obtain informed consent is required. However, owing to the nature of the patient groups often treated in special care dentistry and their often fluctuating capacity, a thorough working knowledge of relevant legislation is required.
Two key acts with regard to consent are:
The Adults with Incapacity Act (Scotland 2000);5 and
The Mental Capacity Act (2005)6 concerning England and Wales.
These two acts share common principles aiming to protect the interests of patients aged 16 and over who lack the capacity to give valid consent.
With regard to both of the aforementioned pieces of legislation, practitioners must act in the best interest of their patients at all times and aim to involve the views of the patient and those who have an interest in the welfare of said patient in the decision-making process.7
Advocacy is of vital importance in terms of the clinical decision-making process in special care dentistry for patients who may not be able to voice their own opinions for a variety of reasons, including mental illness or physical disability. Advocacy refers to the process of pleading the cause of, and/or acting on behalf of, another person to secure services they require and/or rights to which they are entitled and is recognized as an important way of enabling people to make informed choices about, and to remain in control of, their own healthcare.
The Equality Act (2010)8 advances further the legislation outlined in the Disability Discrimination Act (2005).9 This act protects individuals from discrimination not only in the workplace but in wider society, including healthcare provision. This act defines a person as having a disability if he/she has ‘a physical or mental impairment and the impairment has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities’. Examples of impairment are listed in Table 1.
There is evidence that those in residential care or secure units10 are more likely to have poor oral health and restricted access to dental services. In addition, people confined to their homes present a high need for dental care and poor oral health has been cited as a barrier to obtaining dental care by American researchers.11,12
As more people are both living longer and retaining their natural teeth,13 this presents challenges in terms of providing safe and appropriate dental interventions for the heavily restored dentition, taking into consideration the complex medical and social needs this group may have.
Domiciliary care involves providing dental treatment outwith dental clinics for patients whose personal circumstances make it unfeasible to attend a dental clinic. The Equality Act (2010)8 makes it clear that services must be flexible and make reasonable adjustment to ensure nobody is unfairly discriminated against or denied access to service as a result of factors such as disability. The provision of domiciliary dental care by general dental practitioners represents such an adjustment.
Unfortunately, an analysis of health service records shows that only 40% of dentists in general dental practice provide home visits and this is in decline.14 Some of these dentists restrict their services to prosthodontics alone and, within this population, a further proportion provide complete prostheses only. A study of availability of domiciliary dentistry indicated that only 21% of dentists willing to do domiciliary work would be willing to undertake the restorative treatment14 essential to maintain an increasingly dentate population.
The BSDH provides a comprehensive guideline15 to aid the planning and provision of domiciliary dental care by all members of the dental team, including GDPs.
Medically compromised patients
Special Care Dentistry provides oral healthcare to patients who are significantly medically compromised and who cannot be safely managed in a general dental setting. Some of these patients may also require medical intervention before treatment, ie blood products, such as platelets or fresh frozen plasma, or continuous oxygen therapy, to ensure the provision of safe dental treatment. Shared care of patients is important and, in the majority of cases, some or all of the treatment can be provided in a general practice. Within the scope of this article we have chosen to discuss a few target groups of patients which can present challenges in terms of care provision in the general dental setting.
Oncology
Patients suffering from cancer may experience a range of oral symptoms,16,17 many of which are due to infection and are a consequence of changes in the oral microflora. The commonest oral symptom is oral dryness16,17 (Figure 1), which is often drug-related. Saliva plays a major role in the maintenance of health of both the hard and soft tissues of the mouth and xerostomia can lead to rapid deterioration in oral health. In cancer patients this problem is compounded by other factors, for example their relative immunosuppression, which predispose to oral infections such as candidosis (Figure 2). These are distressing problems for patients who are already seriously ill and every effort should be made to minimize discomfort.
Figure 1. Profoundly dry mouth in a patient following head and neck radiotherapy.Figure 2. Oral candidosis in an immuno-suppressed patient.
In the case of the most common problem of oral dryness, symptoms such as difficulty with talking and eating are often reported, along with problems retaining dentures, which is further compounded in many cases by the loss of bulk of the facial musculature that occurs in cachectic cancer patients.
The clinical importance of prevention, denture hygiene and oral hygiene in this group of patients with such a marked predisposition to oral candidosis18 cannot be over-stated.
When providing active treatment, it is important to liaise with the patient's GMP or oncologist with regard to timing of treatment. Patients undergoing chemo-radiotherapy may be neutropenic or thrombocytopenic, compromising the safety of dental treatment. In denture-wearers, simple treatment, such as easing or relining dentures, can provide a great deal of comfort for this population group.
Bleeding disorders
Inherited
Haemophilia is a hereditary disorder linked to the X chromosome. Haemophilia A is a factor VIII deficiency with Haemophilia B (Christmas disease) a deficiency of factor (IX). It is termed severe, moderate or mild based upon plasma activity. These patients receive regular replacement of clotting factor by intravenous infusion to help prevent or control bleeding.
Prevention of dental problems is the cornerstone of care, however, when dental treatment is required, careful consideration should be given to where this is best undertaken and will depend on the severity of the disease and the procedure required.
Restorative treatment can be undertaken safely in general practice for patients with mild to moderate haemophilia, however, this must be provided as atraumatically as possible so as to protect mucosa.19 Buccal infiltrations, intra-papillary injections and intra-ligamentary injections can be provided without factor replacement therapy. Inferior dental blocks and lingual infiltrations, however, should have appropriate factor cover.20 Articaine can be considered to anaesthetize lower molar teeth for routine restorative treatment in place of an ID block.
With regard to analgesia, aspirin should be avoided and NSAIDs only prescribed after consultation with a haematologist.20
All surgical treatment requires planning and consultation with the patient's haematologist via the regional haemophilia treatment centre to ascertain the safest environment in which to deliver treatment. Provision of any surgical procedure in the general dental practice setting is inappropriate.
Anti-platelet medication
Common anti-platelet drugs include aspirin, Clopidogrel and Dipyridamole. Evidence suggests that stopping anti-platelet medication before dental treatment can result in stroke or myocardial infarction.21–25 Anti-platelet medication in mono or dual therapy should never be stopped without consultation with the patient's cardiologist. Patients on dual therapy may need to be referred for treatment at the local dental hospital or maxillofacial service.
Patients on warfarin
The treatment of patients on warfarin can be managed in general dental practice in the majority of cases. Local healthboard policy will dictate the accepted INR below which patients can be safely managed in primary care and will give guidelines on timing for checking INR pre-treatment. Ideally, this will be within 24 hours, but some healthboards may accept an INR within 72 hours.
Evidence suggests that there is a significant risk of thrombo-embolic events when warfarin is stopped before dental treatment26–28 which, in the majority of cases, outweighs the risk associated with continuing warfarin and having a post-operative bleed (reference from warfarin paper). It is therefore not advised that warfarin is stopped before any routine dental procedure. For patients with an INR maintained at 4.0 or above, referral for surgical treatment should be made to a hospital-based setting.29,30
In cases where multiple teeth need to be extracted, it is wise to arrange multiple visits in which to undertake treatment to reduce the risk of post-operative bleeding.
Known drug interactions with warfarin include: metronidazole, erythromycin, aspirin and antifungal medication.31 Consultation with the physician responsible for maintaining the patient's anticoagulation therapy should be sought before prescribing these.
New oral anticoagulant medication
Practitioners should be aware that, as part of taking a relevant medical history, it is pertinent to enquire about any anticoagulation therapy the patient may be prescribed. Practitioners should be familiar with any new oral anticoagulation therapy patients may be receiving as an alternative to warfarin including: Dabigitran, Rivaroxiban and Apixaban.
Before undertaking surgical dental procedures in general practice, it is important to consult with a patient's haematologist as there may be a need to omit one or more doses of the aforementioned anticoagulant therapy prior to treatment and advice should be taken as to when treatment should be resumed. As in the case of patients on warfarin, local healthboard policy will dictate how these patients should be managed.
Azole antifungal medication is known to increase the concentration of the aforementioned anticoagulant medications and so should be considered as contra-indicated.32 Non-steroidal anti-inflammatory medications shouldn't be prescribed without consultation with a haematologist owing to the risk of prolonged haemorrhage and increased risk of a gastro-intestinal bleed.32
Bisphosphonate-related osteonecrosis of the jaws
Bisphosphonates are drugs that alter the turnover of bone by impairing the recruitment, formation and function of osteoclasts. These can be prescribed orally or intravenously. Bisphosphonate-related osteonecrosis of the jaws (BONJ) is defined as exposed necrotic bone, in either the maxilla or mandible, which has been present for more than 8 weeks, where there is no history of radiotherapy33 (Figure 3). This exposed bone can arise spontaneously, after dental extraction, or as a consequence of ill-fitting dentures causing trauma. It has been reported that, for adults prescribed bisphosphonate medication, BONJ occurs in 1 in 300 patients post dental extraction and in 1 in 2250 patients without a history of tooth extraction.34 Symptoms described by patients include:
Figure 3. BONJ which has occurred spontaneously in the mandible of a patient with myeloma who has been treated with intravenous bisphosphonates.
Pain;
Paraesthesia;
Delayed healing;
Soft tissue infection; and
Swelling and numbness.
Patients with osteoporosis most commonly receive bisphosphonates, however, these drugs are also prescribed to patients with cystic fibrosis or malignant cancer, including breast cancer, prostate cancer and myeloma.
SDCEP guidelines33 state that ‘before commencement of bisphosphonate therapy, or as soon as possible, practitioners should aim to get patients as dentally fit as feasible, prioritising care that reduces mucosal trauma or may help avoid subsequent oral surgery procedures including extractions that may impact on bone’. These patients require regular maintenance and preventive advice. SDCEP guidelines33 classify patients that have not yet started taking bisphosphonates, or are taking bisphosphonates for osteoporosis, as low risk. Patients taking bisphosphonates for any other reason are classified as high risk. For high risk patients, before undertaking any procedure which may impact on the bone, the local maxillofacial or oral surgery unit should be contacted for advice as to whether referral may be appropriate. Low risk patients can be managed in general practice and referred if, after 4–6 weeks, the surgical site has failed to heal.
Adults with learning disabilities
Adults with learning disabilities have a higher incidence of dental disease than the general population.35–37 Learning disability has been described as ‘a significant impairment of intelligence and social functioning acquired before adulthood’.38
Approximately 1.2 million people in the UK have a mild to moderate learning disability and a further 210,000 have severe disability.39 Treatment in general practice may not always be feasible as an individual may not be able to co-operate with dental procedures, in which case referral for treatment under sedation or GA may be required.
Communicating preventive and oral hygiene advice to carers, both family and professional, for patients who are unable to care for their own mouths is vital. Unfortunately, studies confirm that there are inadequacies in the standard of oral healthcare provided by carers.40,41
With regard to learning disabilities, the transitional stage between paediatric and adult services is of key importance. It can be a time when individuals move from parental care into community or residential care and, throughout this time, a clear oral health management strategy should be in place to ensure access to dental care is maintained. Communication with the patient, carers, health and social services should be maintained at this stage to ensure that patients continue to receive adequate dental care.
Physical disability
Over 4 million people in the UK have a mobility problem.42 The prevalence of disability with impaired mobility increases with age, affecting 20% of 60–74 year-olds and 46% of over 75s.43
Advancing the work of the Disability Discrimination Act (2005)9 and the Equality Act (2010)8 ensures that most patients with physical disability can be treated in a general practice environment, helping overcome the inequality in physical access to premises. In cases where hoists or other transfer aids are required, referral to the special care dental team can be considered.
Mental illness
The term mental illness is used to describe clinically recognizable patterns of disturbed thought and behaviour, causing acute or chronic problems and personal distress or distress to others.44 Mental illness is not a single condition, nor do mentally ill people form an ‘homogeneous group’ of the sick in society. Mental illness is a continuum, ranging from minor distress to severe disorders of mind and behaviour, such as dementia and schizophrenia.45
The oral health of patients with mental illness has not been widely studied, but is reported to be poor.46–48 Whether institutionalized or in the community, people with mental health problems are entitled to the same standards of care as the rest of the population. However, there are several reasons why they may not receive it. To begin with, many of the patients are beyond normal reasoning, thus making it difficult to discuss various treatment options. Often there is a total ignorance of dentistry and dental problems – the patients do not understand the scope of possible treatment and frequently have a total disregard for simple health messages, such as the importance of a good diet. A large proportion of patients in this group suffer from self-neglect – a symptom of their illness. However, there is no part of the body that suffers more from such neglect than the mouth (Figure 4). In addition, a percentage of these patients are addicted to alcohol and tobacco or experience other forms of substance abuse.
Figure 4. Dental neglect in a hospitalized psychiatric patient.
In the majority of cases, it is possible to treat patients with mental illness in general dental practice, however, there must be understanding given to the chaotic lifestyles some of these patients live and time taken to gain trust.
Dependent elderly
The elderly represent a complex combination and expression of individual genetic predispositions, lifestyles, social situations and environments, all of which affect their health, including oral health. The demographic of the UK is changing and, by 2020, the percentage of adults aged 65 and over is projected to rise to 18.9 %, as opposed to 15.7% in 2002.49 In addition, adults in the UK are retaining their natural teeth for longer, with only 21% of adults in England, Northern Ireland and Wales over 65 being edentate, as opposed to 78% in 1978.50 With adults living longer and retaining more of their natural dentition comes the challenge of maintaining complex restorations in a population that may have equally complex medical and social needs.
An important factor to consider in this population group is the impact of medical risk factors and polypharmacy. Many older patients have chronic diseases and, whilst these may not directly affect the oral tissues, they may have indirect effects. For example, patients with rheumatoid arthritis may have difficulty in maintaining oral hygiene through the inability to hold a toothbrush or manipulate other tooth cleaning aids such as floss.
Oral mucosal lesions are common in the elderly, but many of these are expressions of oral manifestations of systemic disease, poor nutritional status, side-effects of drugs and oral infections (Figure 5), rather than age changes in the mucosa per se. A high suspicion should always be maintained with regard to oral cancer and regular screening should be undertaken as GDPs will frequently be the first clinician contacted.51 A study in 2011 has, in fact, identified that patients with reduced cognitive function are at a higher risk of developing an advanced sized squamous cell carcinoma (SCC)52 (Figure 6). This could be attributed to a loss of ability to sense changes in their oral condition or an inability to communicate any changes noted.
Figure 5. Dry mouth secondary to polypharmacy.Figure 6. Squamous cell carcinoma in a patient with dementia living in residential care.
Maintaining a good standard of oral hygiene in the dependent elderly population is a basic but essential requirement to maintaining a quality of life. Unfortunately, it is well documented that this population group, especially those in residential care, are likely to have the poorest oral hygiene and the least access to dental care.53
Prevention
Overarching everything discussed in this article is the necessity to provide a high standard of preventive practice, especially given the complex medical need and challenging behavioural and social management factors the patient groups discussed in this article may have.
Table 2 outlines the key principles of prevention set out in the Department of Health's evidence-based toolkit for prevention.54
Increase Availability of Fluoride
The higher the fluoride concentration of toothpaste the better the prevention
Twice yearly application of 22,600 fluoride varnish can reduce caries by up to 46% in adults
Sodium fluoride 5000 ppm should be prescribed to adults with a high risk of caries with risk factors including potential for root caries, dry mouth, cariogenic diet or medicines
Fluoride mouthrinses and tablets can be used at a different time from toothbrushing to maximize topical effect
Dietary Advice
The amount and frequency of consuming sugary foods should be reduced and restricted to meal times
Diet Diaries are a useful tool in planning dietary modification
Improve Periodontal Health
Teeth should be brushed twice daily with fluoride toothpaste
Chlorhexidine mouthwashes can be a useful adjunct for short-term use when patients are unable to brush owing to acute illness or incapacity
Daily interdental cleaning should be encouraged
Sugar-free Medications
Where possible sugar-free medication should be prescribed
Smoking Cessation
All patients should have their smoking status recorded and checked regularly
Patients should be advised of local stop smoking services and referred where appropriate
Assess Risk of Alcohol Misuse
Patient's alcohol status should be recorded
Patients should be referred for support where appropriate
Men should drink no more than 21 units of alcohol per week (and no more than four units in any one day)
Women should drink no more than 14 units of alcohol per week (and no more than three units in any one day)
Prevention of Erosion
Give tailored, specific dietary advice with regard to erosion
Investigate habits which exacerbate erosion
Give toothbrushing advice with regard to erosion
The need for multidisciplinary team work
Providing care for patients with ‘special needs’ is often very demanding but can also be extremely rewarding. Maintenance of a high standard of oral hygiene is important for all groups of patients with special needs. Some patients may be able to undertake all or part of their own oral care, but a large number will need help to enable them to achieve a standard of care which will lessen the need for operative intervention. It is well documented, however, that unrecognized and untreated oral disease is widespread among this category of patient, both in hospital and in those being cared for at home or in other environments, as discussed previously in this article.
Conclusion
This paper is a brief overview of a dynamic and ever-changing specialty and the patient groups and aspects of care discussed is by no means exhaustive. The growing nature of the specialty is demonstrated by the 18 registrars currently in training throughout the UK, with further posts in development at present.
Special care dentistry has been described as simple dentistry in complex patients. To meet the complex needs of the patients treated by special care dentists, there is a reliance on interaction and communication with wider dental and medical specialties, however, special care dentistry remains unique in its ability to provide holistic care aimed towards establishing oral health and helping patients to maintain this.
