Abstract
This paper considers the oral health of people with disability and the disadvantage they experience compared to those who do not have a disability. There are many influencing factors for this including service provision and appropriate training for staff. A potential solution is proposed demonstrating that even advanced dental care is possible for people with complex disability. This meets the principal of equitable care for people with disability. The example concerns the provision of a lower anterior bridge for a gentleman with mid to end stage Huntington’s disease and significant uncontrolled choreic movements. Intravenous conscious sedation is used to facilitate complex treatment and to demonstrate a clinical skill which can open doors for the treatment of adults with disability
Oral health
For people with disability the opportunity for dental treatment and equitable standard of dental health is significantly poorer compared to the non-disabled community. Evidence has shown that people with learning disability have a higher level of dental decay, poorer gum conditions and more likely to have teeth extracted rather than filled compared to people without a disability.
It is suggested that this inequality of health may be related to the accessibility, availability and acceptability of dental care.
Accessibility
Surgery design is a particularly relevant factor. Dental surgeries older than the disability discrimination act 1995 may not be on ground level with appropriate toilet access and space. The surgery itself may not be wheelchair friendly or easy for those who are less ambulant
Availability
The provision of dental care for people with a disability should not be marginalised but available from all dental practices in the health service. However not all dental surgeons will have the experience or skills in meeting some of the requirements in caring for a person with complex disability. In such cases a specialist service should be available to support those practitioners and or to provide the service directly. The UK salaried Community Dental Service and Hospital Services play a crucial role in this. Special Care Dentistry is the dental specialty in the UK that is concerned with the dental care of adults with complex disability but represents only approximately 7% out of the total number of specialist practitioners registered with the General Dental Council. Special Care Dentistry is commonly provided by the UK Community Trust primary care sector. This is a very small sector of the total dental service and tends to be marginalised with regard to funding compared to the other areas of dentistry. Although committed dental practitioners have been providing care for both adults and children with disability for many years this was only recently recognised by the General Dental Council as a specialty in 2008. In addition the numbers of specialist training posts in Special Care Dentistry are of limited number compared with other specialties such as orthodontics.
Acceptability
People with disability need to be accepted by a dental service which is flexible to their needs, which does not provide barriers to care, including financial, which is kindly and efficient and importantly has the surgery time available to provide care appropriate to the individual’s needs. Also all dental staff working in this area of care need to have a clear knowledge of the individual’s support system. The relationship between the person with disability and their carer/relative requires a sensitive and understanding approach by the dental practitioner who needs to have an empathetic and considerate approach to holistic care.
Changes in societal care for people with disability arising from Care in the Community, had a significant effect of a change of residence from the hospital accommodation to the Community homes further shifting dental care onto the smaller Community Dental Service. People with impairment experience difficulties in obtaining effective, and appropriate care. These problems are not as a result of their inherent condition rather because the various barriers to care as outlined above create considerable disadvantages.
The prevention of dental decay
An interesting historical link between oral health and people with disability can be seen in the Vipeholm study.
The National Dental Service in Sweden was started in 1938. The dental health in Sweden at that time was not well observed, and it was suspected that diets rich in sugar caused tooth decay. In 1945 the then-Medical Board commissioned a study. This was the start of the Vipeholm experiments.
Vipeholm, was the country’s largest facility for adults with disability. A group of patients were used as subjects in a full-scale experiment designed to bring about tooth decay. They were fed copious amounts of sweets resulting in many of them having their teeth ruined. One of the results of the study was the recommendation that it was better for children to eat sweets once per week, compared to a smaller total amount spread out over most of the week. This study was an abusive, shameful and ethically abhorrent treatment of people with disability. Although prevention is overwhelmingly essential for oral health treatment may at some stage be required.
Treatment
For many people with disability dental treatment can be provided in the conventional form using local anaesthetic and careful gentle patient management. However for some individuals a dental examination may be difficult for the patient and dentist perhaps resulting in undiagnosed oral health problems. The provision of any type of dental treatment may be problematic. For these reasons the use of general anaesthesia may be an option. General anaesthesia for dental treatment can now only be provided in a hospital environment, and the sessions dedicated to providing care for people with disability under general anaesthetic may be limited competing for operating theatre availability with other specialities. In addition treatment options may be limited. Complex fillings and or periodontal/gum treatment can commonly require a course of at least two visits therefore needing multiple sessions of general anaesthetic. Although general anaesthesia is a safe procedure it does carry a risk which although relatively low must if possible always be avoided. When treating under general anaesthetic the option of temporarily dressing a tooth in order for symptoms to settle which can be permanently restored once symptoms resolve or even filling a tooth with a very deep cavity is taking an unacceptable risk when dealing with dental pain. An extraction ensures that the painful source is decisively removed. This is always the last option for the dental surgeon whose main ethos of care is to restore the dentition rather than extract teeth. Such treatments decisions may unfortunately need to be taken when all necessary care is provided at one session under general anaesthetic. This may well be upsetting for the patient, family and also for the dental team who are trying to provide the best possible care for that person. For some adults with disability these reasons may partly explain the inequality in oral health.
A potential solution
An alternative treatment method that can be provided in a community setting is the use of intravenous conscious sedation provided by trained, skilled and experienced dentists. Intravenous sedation can provide for people with disability an increased chance of having their teeth restored rather than simply extracted. Evidence providing the option of conscious sedation strongly supports this alternative. Intravenous conscious sedation can be provided by a single dental surgeon acting as an operator/sedationist within a primary care dental surgery assisted by a trained nurse. This enables the opportunity for a range of different treatment options to be provided safely over a series of appointments thereby potentially ensuring an improved standard of dental care. When making the decision to arrange how care should be provided, all options must be considered. In some circumstances for example, if there is difficulty in attending a series of appointments, or if extensive or complex surgery is involved general anaesthesia may be more appropriate than sedation.
An example provided here shows that even the more complicated dental treatments can be available by using conscious sedation provided by trained and experienced clinicians. The case presented describes treatment for an adult with advancing stages of Huntington’s disease
The patient was a 65 year old man with mid-stage Huntington’s disease living semi-independently alone in the community. He was supported by community care staff and also accessed intermittent respite care at the Royal Hospital for Neuro-disability. This hospital is an internationally renowned UK centre of excellence sited in Putney, London and cares for approximately 35 adults with Huntington disease varying from the mid to late stage of this condition.
The patient’s primary symptoms were severe involuntary movements and an unsteady gait.
On presentation, his main concern was the recent loss of four lower anterior teeth for which he requested replacement. He was not otherwise anxious of dental treatment
He had significand choreic body, arm, and mouth movement and consequently the management of a lower denture would be difficult. Communication and the issues around consent are vital in the process of providing treatment. The facilities for communication are not always readily available in an acceptable manner to the patient and in the case for example of cultural, language barriers, visual, hearing impairment, and limitations in cognition, misunderstandings may cause distress to the patient and the family member/carer.
In the example of the our case following discussion with the patient including independently witnessed verbal and also written consent, the agreed decision was to replace the missing teeth with a fixed bridge prosthesis. This involved preparing the teeth either side of the gap to accept crowns. The crowns were attached to the false teeth filling the gap hence the name bridge as the prosthesis bridges the gap. This was undertaken using the drug midazolam administered intravenously by careful titration resulting in complete suppression of involuntary movements. The bridge was subsequently fitted at a second appointment with the use of minimal sedation. The sedation and treatment was provided by a single dental surgeon acting as operator sedationist assisted by a trained and experienced dental nurse.
He was extremely pleased with the appearance of his bridge, and also reported improved oral function.
Discussion
The replacement of four lower anterior teeth for this gentleman, helped him to enjoy a drink with friends at the local pub and allowed the necessary mouth support when smoking his cigarette. These simple activities enhanced his quality of life which was ebbing away due to this cruel condition.
In this case the use of intravenous conscious sedation using midazolam was shown to be very effective. The only realistic option of meeting the patient’s requirements was a bridge which would not have been possible using local anaesthetic alone due to his uncontrolled choreic movements. General anaesthesia would have required two hospital sessions involving further social, economic considerations and importantly medical risk
Conclusion
The use of conscious sedation enabled treatment to become a reality in a relatively simple, economically acceptable and readily available way. This technique demonstrated that a quality of care involving an advanced dental procedure can in favourable circumstances be provided for a person with complex disability in a primary care general dental practitioner non-hospital facility. This offers a potential solution to the problems of the inequality in the standards of care for adults with disability
Recommendations
Training in this technique, the use of intravenous conscious sedation, is required urgently and to be more widely available particularly for those in the specialty of Special Care Dentistry.
There needs to be an increase in the number of training opportunities in Special Care Dentistry.
Primary Care Trusts throughout the UK should support their Community Dental staff by creating opportunities for training with a career structure appropriate to specialist and consultant level.
NHS England needs to commission and fund appropriate dental services for adults with disability.
The dental profession needs to recognise its shortcomings in providing care for people with disability and take action to prevent a disadvantage in the care it provides.
Dental care for people with disability should increase its focus on prevention in order to reduce the need for the provision of treatment.
Acknowledgements
Particular thanks are due to the patient involved in this case study for his understanding and willingness to become engaged with this work. In addition the authors are grateful to the staff at The Royal Hospital for Neuro-disability, for their consistent care, support and encouragement of their patients and the dental service
Disclosure statement
There was no conflict of interest financial or otherwise involved in any part of this work or publication.