An Introduction to Special Needs Dentisty


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An Introduction to Special Needs Dentisty

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An Introduction to Special Needs Dentisty

  2. 2.  Oral Maxillofacial Surgery  Orthodontic  Periodontic  Oral Medicine and Pathology  Dental Paediatric  Restorative Dentistry  Special Needs Dentistry (2008)
  3. 3. SND – What?
  4. 4.  “That part of Dentistry concerned with the oral health of people adversely affected by intellectual disability, medical, physical or psychiatric issues.” (RACDS)
  5. 5.  “That part of dental practice which deals with patients where intellectual disability, medical, physical or psychiatric conditions require special methods or techniques to prevent or treat oral health problems, or where such conditions necessitate special dental treatment plans.” (ADA)
  6. 6.  “The oral health management of patients adversely affected orally by intellectual or physical disability and medical or psychiatric issues or, more often, a combination of a number of these factors, where such conditions necessitate a modified delivery of oral health care for patients’ total health well-being”
  7. 7. SND as a specialty:  2003-New Zealand and Australia (SND) (Hospital Dentistry and Paediatric Dentistry)  2008- United Kingdom (SCD) (Dentist with special interest in SCD)  2008- Malaysia (SND)
  8. 8.  Dr Jane Chalmers: Passed away on 7th Dec 2008 after a battle of cancer. Key organizer instrumental of ASSCID. First Australian who received PhD and became an associate professor in that field
  9. 9.  Dr Peter King BDS MDS FICD Working at Hunter New England Health Service as a specialist providing oral health services to people with special needs. Peter was the first President of the Australian Society of Special Care in Dentistry and is on the editorial board of the International Journal of Disability and Oral Health.
  10. 10.  Impairment  as any loss or abnormality of physiology or anatomical structure or function  Disability  any restriction or lack (resulting from an impairment) of ability to perform an activity in a manner or within the range considered normal for a human being International Classification of Functioning, Disability and Health
  11. 11.  Handicap  seen as the disadvantage for a given individual, resulting from an impairment or a disability, which limits or prevents the fulfillment of a role that is normal (depending on age, sex, social and cultural factors) for that individual International Classification of Functioning, Disability and Health
  12. 12.  Intellectual disability  A disability characterized by significant limitations both in intellectual functioning and in adaptive behavior, which covers many everyday social and practical skills. This disability originates before the age of 18 (AAIDD website, 2011)  Examples:  Down syndrome  Global developmental delay
  13. 13.  Physical disability  Either loss or missing body parts and/or functions including hemiplegia, paraplegia, tetraplegia which affecting activities of daily living such as personal care, movement and body posture (JKM website,2011)  Examples of etiology:  Spinal Cord Injury  Stroke  Traumatic brain injury  Cerebral Palsy
  14. 14. Medical complex  Receiving treatment or medication for any other long-term conditions or ailments and still restricted in everyday activities  Any other long-term conditions resulting in a restriction in everyday activities
  15. 15.  Psychiatric/psychological disorders  a broad range of problems, with different symptoms. However, they are generally characterized by some combination of abnormal thoughts, emotions, behaviour and relationships with others (WHO website, 2011)  Examples:  Schizophrenia  Depression
  16. 16.  Geriatric dentistry  Focuses on the diagnosis, prevention and treatment of oral diseases in adults who, because of their medical condition or old age, are handicapped or institutionalised and require special management during their dental treatment
  17. 17.  Disability  Handicapped  Crippled  Sick  Deformed  Gimp  Defect
  18. 18.  Intellectual disability /Developmental disability  Mental retardation  Mental deficient  Mentally challenged  Stupid
  19. 19.  Physical disability  Crippled  Lame  Deformed  Invalid  Gimp
  20. 20.  Psychological  Psychiatric  Mental illness  Crazy  Nuts  Loony
  21. 21.  Unmet treatment needs due to barriers to dental care  Increase in numbers of the elderly population and people with disabilities with multiple medical conditions leading to impairment  Absence of follow up and maintenance care
  22. 22.  Individual barriers:  Lack of perceived needs  Anxiety or fear  Financial considerations  Lack of access  Dental profession:  Inappropriate manpower resources  Uneven geographical distribution  Training inappropriate to changing needs and demands  Insufficient sensitivity to patient attitudes and needs
  23. 23.  Society:  Insufficient public support of attitudes conducive to health  Inadequate oral health care facilities  Inadequate oral health manpower planning  Insufficient support for research  Government:  Lack of political will  Inadequate resources  Low priority  Unattractive problems * KEY - EDUCATION
  24. 24.  “The majority of problems for all could be addressed by an ideal public health system. Unfortunately, the situation in many countries is far from ideal, and the demand for secondary and tertiary care continues to grow. This is particularly true of the population with special needs where an accumulation of unmet need continues to be discovered” (Faulks & Hennequin, 2006)
  25. 25. Akta Orang Kurang Upaya 2008:-  'Orang Kurang Upaya' termasuklah mereka yang mempunyai kekurangan jangka panjang fizikal, mental, intelektual, atau deria yang apabila berinteraksi dengan pelbagai halangan, boleh menyekat penyertaan penuh dan berkesan mereka dalam masyarakat.
  26. 26. 1. Orang kurang upaya hendaklah mempunyai hak untuk menikmati kesihatan atas asas kesetaraan dengan orang upaya 2. Majlis, sektor swasta dan pertubuhan bukan kerajaan hendaklah mengambil langkah yang sesuai untuk memastikan orang kurang upaya mendapat akses kepada perkhidmatan kesihatan, termasuk rehabilitasi berkaitan kesihatan,yang peka gender
  27. 27.  Hospital-based specialty  Focusing on individual 16 year old and above  Providing clinical support at the local community health centers-visiting and consultation, combined clinic with other dental disciplines  Referral to specialist in SND – patients with complex problems (ASA III/ASA IV) or issues with multiple co-morbidities and polypharmacy  Demonstrate appropriate clinical skills in relation to behavioural management strategies, understanding legislation and ethics, positive attitude towards PWD
  28. 28. • Hospital Kuala Lumpur • Hospital Serdang Current SND service provision (2011 and 2012) • General dentistry services with modification in accordance with patient’s condition • For examples: Comprehensive dental treatment (restorative works, RCT, routine periodontal therapy, simple extraction /MOS, biopsy ) under GA, sedation or with behavioral modifications strategies. Preventive strategies including close monitoring of oral hygiene care performed by carer at home. Treatment/ procedures • Physical disabilites • Psychologic/psychiatric issues • Complex medical conditions • Intellectual/behavioural issues • Patient who requires conscious sedation/GA Type of patients
  29. 29.  Treatment modifications  Hearing and visual impairment  Wheelchair users  Managing the challenging behaviour  Ensuring airway patency  Referral for treatment and consultation by specialists  Inter-collaboration with other health care providers  Physical interventions
  30. 30.  All patients in ASA III and IV category requiring oral health care, including geriatric patients  Patients with intellectual impairments/disabilities requiring dental treatment under sedation or general anaesthesia or unable to receive treatment at the community dental setting
  31. 31.  Patients with physical disabilities with significant co-morbidities and mortality conditions  All in-patients requiring oral health assessment prior to organ transplant procedure  All in-patients requiring an assessment or oral health care prior to cardiac surgery
  32. 32.  All in-patients undergoing head and neck radiotherapy/ chemotherapy, during and after the therapy  Patients with psychiatric and psychological conditions with associated medical conditions which compromising the oral health status
  33. 33.  Patients referred by the community dental centers or rehabilitation centers because they cannot be managed at the community dental setting due to the complex medical issues or behavioural problems.
  34. 34. ASA DEFINITION DENTAL TX MODIFICATIONS I Normal , healthy patient None II A patient with mild systemic disease, e.g. well controlled diabetes, anticoagulation, mild asthma, hypertension, epilepsy, pregnancy, anxiety. Medical advice may be helpful. Often few treatment modifications needed, unless GA or major surgery is needed.
  35. 35. ASA DEFINITION DENTAL TX MODIFICATIONS III A patient with severe systemic disease limiting activity but not incapacitating, e.g. chronic renal failure, epilepsy with frequent seizures, uncontrolled hypertension, uncontrolled diabetes, severe asthma, stroke. Medical advice is helpful. Dental care should focus on elimination of acute infection and chronic disease, prior to medical/surgical procedure (e.g. haemodialysis patients). Patients are often best treated in a hospital- based clinic where medical expert is available.
  36. 36. ASA DEFINITION DENTAL TX MODIFICATIONS IV A patient with incapacitating disease that is a constant threat to life, e.g. cancer, unstable angina or recent myocardial infarct, arrhythmia, recent cerebrovascular accident, end- stage renal disease, liver failure. Medical advice is indicated. All potential dental problems should be corrected prior to medical/ surgical procedure to deal with basic problems (e.g. radiotherapy to head and neck, or organ transplant). Patients are often best treated in a hospital- based clinic where medical expert is available. Emergency dental care indicated.
  37. 37. ASA DEFINITION DENTAL TX MODIFICATIONS V Moribund patient not expected to live more than 24 hours with or without treatment. Medical advice is essential. Patients are often best treated in a hospital-based clinic where expert medical support is available. Emergency dental care indicated.
  38. 38. Generalized marginal gingivitis Chronic Periodontitis and Dental caries
  39. 39. Poor oral hygiene Chronic periodontitis
  40. 40. Manual dexterity issues Microstomia
  41. 41.  Frail and functionally dependent (relying on the carers for activities of daily living (ADL) such as bathing, eating and tooth- brushing)  Neurologic and cognitive impairments  Communication and behavioural problems  Increased chronic medical conditions including polypharmacy  Chronic psychiatric/psychological conditions
  42. 42.  Nutritional/swallowing problems  Poor motivation towards oral health care  Elderly who is categorized as ASA III or ASA IV  Patients require dental management under conscious sedation or general anaesthesia
  43. 43. Clinical presentation of patient (either one or more): -Intellectual/ cognitive/ developmental problem -Physical/ mobility/ manual dexterity issues Emotional/ mental issues -Chronic medical problem – history and current problems -Polypharmacy Impact of the above conditions on oral health Impact on coping with dental treatment at a normal setting Appropriate to refer to SND Impact on performing and maintaining oral hygiene Appropriate to refer to SND Impact of communication or behavioural challenge Appropriate to refer to SND Impact on provision of treatment Risk of medications esp. Bisphospho-nate therapy Appropriate to refer to SND Risk of bleeding and/or healing problems Appropriate to refer to SND Require sedation or GA Appropriate to refer to SND
  44. 44. • Consultation • Urgent treatment • Further management Reason for referral • Referral letters with complete patient’s details and relevant documents including valid OKU card/photocopy or guarantee letter The responsibilities of the referring clinicians • Prioritizing the patients • Review the referrals in accordance to referral guidelines • Advice for referred patients The responsibilities of the referral centers