Special Care Dentistry

special care dentistry provides preventative treatment oral care services for people who are unable to accept routine dental care because of some physical, intellectual, medical, emotional, sensory, mental or social impairment or a combination of these factors. Special care Dentistry is concerned with the improvement or oral health of individuals and groups in society who fall within these categories. it requires a holistic approach that is specialist led in order to meet the complex requirements of people with impairments. It pertains to adolescents and adults, as the care of children with disabilities and additional needs sits within the domain of the specialty of paediatric dentistry.

SCD

• Medical complexity

  • neurological conditions

  • Respiratory conditions

  • Cardiac disease

  • Renal/hepatic disease

  • Cancer

• Care of the elderly

  • polypharmacy

  • Multiple comorbidities

  • Dementia

• Learning disabilities

  • mild, moderate, severe

  • Associated with other diagnoses

• Physical disability

  • cerebral palsy

  • Spina bifida

  • Post stroke

  • Arthritis

• Dental anxiety

  • IHS/IVS

Tier 1

• General dental practice

  • UG training

  • DF training

• No further formal enhanced skils

• Experience of treating SCD patients beneficial

Tier 2

• clinical team with enhanced Skills

• +/- specialist register

• May involve additional equipment

• May be part of continuing care or require referral

• Tier 2 providers must have established link with a specialist

Tier 3

• 3a - care that requires management by a specialist in SCD

• 3b - care that requires management by a specialist in SC who is also a consultant.

Assessment

• varies

• Dependant on:

  • which tier the service is

  • experience/knowledge/ skills of team

  • services you are able to provide

• standard:

  • NDAS

  • IOSN

  • BDA CDS Case mix

Assessment tools:

Pros:

• widely used

• easy to use

• transferabie into different
  clinical settings

• assess the patientineeds

• can compare the patient
  within a population

• Quantitative data

Cons:

• subject to bias (staff and patient)

• reliable?

• accurate?

• enough evidence?

• must be used in the context of the patient

modified Dental anxiety scale

• Patient reported anxiety scale

• Patient completes form prior to referral for treatment

• Five questions regarding dental procedures and associated anxiety

• Answers score 1-5 from not anxious to extremely anxious

• 5-11 is minimal

• 12-18 is moderate

• 19-25 is high

Index of Sedation Need

• There is a high demand for dental treatment to be carried out with the support of Iv sedation

• IOSN developed to:

- support clinicians with decision making

- gives valuable information to commissioners with regard to the population so that services con be planned appropriately

- allows need for sedation to be ranked

• considers 3 factors:

- Patient anxiety (MDAS)

- Medical history (conditions relevant to dental treatment)

- Treatment need (S+P/I-2 simple XLA's, MOS compIex)

Medical History

• Does not repiace full medical mistory

• Asks information relevant to proposed treatment

• scores 1-4 with 1 meaning no medical/behavioural indicators

• Then relies on clinician to score 2-4, severity of systematic disorders/conditions that compromise cooperation, gag reflex or behavioural difficulties

Treatment Complexity

Routine (1) - Scale, single quadrant requiring restorations

Intermediate (2) - multi-rooted tooth XLA, 2 quadrants requiring restorations

Complex (3) - surgical XLA with bone removal, multiple quadrants requiring restorations, endodontics

Highly complex (4) - any treatment more complex than above, or multiples

IOSN

Anxiety (1-3) - MDAS if 5-11 scores 1, 12-18 scores 2 and 19-25 scores 3

MH (1-4) - a range of medical and behavioural indicators indicators are provided including gag reflex, fainting, hypertension, angina, asthma, epilepsy, arthritis and Parkinson’s

Treatment complexity (1-4) - see above

IOSN

3-4 - minimal need (No)

5-6 - moderate need (No)

7-9 - high need (Yes)

10-11 - very high need (Yes)

BDA SCD Case Mix Model

• first developed in 2008

• Aid clinical team to ‘score’ Complexity of patients requiring SCD

• Used in:

  • Commissioning/contracts

  • Epidemiology

  • Suitable for all clinical areas (GDP, Hospital, CDS)

• Uses six criteria, four point scalE

BDA SDC Case Mix Model

• O-C Represent increasing complexity

• Completed for each episode of treatment

• Assesses complexity of the patient, but not the dental treatment required

• Has been validated as a useful method of assessment

Ability to communicate

O - Free communication, no restriction

A - Mild restriction

• Mild learning disability, difficulty overcome easily, young child with limited verbal communication

B - Moderate restriction

• Non-verbal, limited communication, moderate learning disability

C- Severe

• Unable to communicate, profound learning disability, third-party discussions

Ability to cooperate

O - Fully cooperative, no restriction

A - Full examination and simple treatment possible with support and BMT

B - Considerable difficulty in cooperation

• Limited examination, clinical holding required, patient accepts basic treatment with difficulty, multiple acclimatisation visits

C - Serious difficult difficulty in cooperation

• Unable to examine/treat Without sedation

Medical status

O - Adequate medical history obtained, no impact on the plan treatment, no further investigations required

A - Some treatment modification required

• MH Unable to be obtained on first appointment and further info required

B - Moderate impact of medical/psychiatric Condition on provision of care

• Medical/psychiatric Status complex/unstable, Treatment affected and child in need

C - Severe impact of medical/psychiatric Condition on provision of care

• Complex medical history, requires multidisciplinary review to decide whether to treat and precautions required

Oral risk factors

O - Minimal risk, low caries/periodontal risk

A - Moderate risk

• Can comply with most DBOH, good OH Reduced due to malocclusion/dexterity issues

B - Severe risk

• Extensive support for DBOH, third-party responsibility, reduced slavery flow and access to oral cavity severely restricted

C - Extreme risk

• Unable to comply with DBOH, unable to comply with toothbrushing, regular sugar containing medication, severe xerostomia and PEG fed

Access to Oral Care

O - unrestricted, can access surgery without intervention

A - Moderate restriction

• Multiple FTA/UTA Within a course of treatment, require support to access dental surgery

B - Severe restriction

• Specialised equipment required to get their appointment

C - Domiciliary care

• Patient unable to leave place of residence

Legal and ethical Barriers

O - No legal or ethical responsibilities affecting care e.g. No issues with consent or PR

A - Some difficulties

• Best interests decision not requiring additional correspondence, children in need

B - Moderate difficulties

• Fluctuating capacity, best interest decision needing additional correspondence, looked after children

C - Severe difficulties

• Multi professional consultation in order to overcome legal/ethical Issues, IMCA/Safeguarding referral required

Case mix score

0 - No patient complexity

1-9 - Mild

10-19 - Moderate

20-29 - Severe

30+ - Extreme

Summary

• SCD provides dental care for a wide spectrum of patients with broad and diverse needs

• Assessment of SCD patient is a vital importance and ensure patients have their treatment:

  • At the right time

  • In the right place

  • By the appropriately trained team

• All members of the dental team will provide care for patients with SCD requirements - it’s important that you know what to do and when to refer