An Introduction to Special Needs Dentisty

1. SITI ZALEHA HAMZAH
BDSc(Perth), DClinDent(SND) (Otago)
SPECIAL NEEDS DENTISTRY
ORAL MAXILLOFACIAL /DENTAL PAEDIATRIC
HOSPITAL SERDANG

2.  Oral Maxillofacial Surgery
 Orthodontic
 Periodontic
 Oral Medicine and Pathology
 Dental Paediatric
 Restorative Dentistry
 Special Needs Dentistry
(2008)

3. SND – What?

4.  “That part of Dentistry concerned with the
oral health of people adversely affected by
intellectual disability, medical, physical or
psychiatric issues.” (RACDS)

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.  “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. 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)

9.  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

10.  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.

11.  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

12.  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

13.  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

14.  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

15. 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

16.  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

17.  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

18.  Disability
 Handicapped
 Crippled
 Sick
 Deformed
 Gimp
 Defect

19.  Intellectual disability /Developmental
disability
 Mental retardation
 Mental deficient
 Mentally challenged
 Stupid

20.  Physical disability
 Crippled
 Lame
 Deformed
 Invalid
 Gimp

21.  Psychological
 Psychiatric
 Mental illness
 Crazy
 Nuts
 Loony

23.  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

24.  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

25.  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

26.  “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)

27. 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.

28. 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

29.  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

30. • 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

31.  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

32.  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

33.  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

34.  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

35.  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.

36. 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.

37. 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.

38. 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.

39. 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.

40. Generalized marginal gingivitis
Chronic Periodontitis and
Dental caries

41. Poor oral hygiene Chronic periodontitis

42. Manual dexterity issues Microstomia

43.  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

44.  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

45. 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

46. • 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