This article will give the reader insight into special care dentistry and the role of the dental nurse within it

The health of Great Britain has changed dramatically even in the early stages of this, the 21st century. Modern medicine has evolved and refashioned the lives and expectations that people have for their health. For example, looking back in time to the 1970s, people with Down Syndrome tended to die at a younger age due to conditions such as congenital heart disease.

Nowadays, such individuals are living much longer, with the help of more sophisticated medical and surgical management. Apply these principles to society as a whole and health services are faced with a population which is advancing into older age in greater numbers, with a more convoluted portfolio of diseases and drugs to manage (and their side effects), plus varying levels of dependency.

Coupled with this, patients are retaining more teeth into older age, with many having undergone extensive restorative dental work.

Evolution of special care dentistry

There have been many changes within society as a whole in the relatively recent past, including fundamental ones such as the closure of the many mental institutions that were designed for the care of those with a learning disability and/or mental ill health.

This led to the evolution of ‘care in the community’—the emphasis being on ‘normalisation’ of care, where ideally such patients would receive dental care in much the same way as any other member of the public. NHS dentistry evolved accordingly and the salaried dental service (Community Dental Service) took on an even greater role in accepting the referral of such patients, where access within the general dental service was not possible.

Special care dentistry is, therefore, a relatively new specialty. It was created in 1976 from a small interest group, who first met to look at the additional dental care requirements of patients with special needs. In the past, individuals with a learning disability and sensory or medical needs may have been treated in a variety of environments—for example, within a paediatric dental hospital department—until well into adulthood. Specialist services were more limited, and frequently such complex patients may well have undergone a general anaesthetic for dental treatment, with a bias towards extraction and not restoration. This pattern began to change with the development of special care dentistry as a specialty, along with the availability of specialist facilities.

Definition of special care dentistry

As defined in the Speciality Training Curriculum, ‘Special Care Dentistry provides preventive and 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 of 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’ (Specialist Advisory Committee for Special Care Dentistry, 2012).

Types of referrals received by special care dental departments

Practitioners refer patients to special care dentistry because they feel that the patients' needs cannot be dealt with in the primary care setting.

Referrals may vary enormously from those with medical, physical, sensory complexities or learning difficulties, extremes of age or body mass, to psychological or psychiatric conditions.

Patients may present with any combination of these factors with varying severity.

There may also be a range of dependency that the patient lives with, an important factor in this complex equation. Certain patients have ‘common’ medical conditions that have progressed to a point beyond where they are safe to be treated in primary dental care. Such conditions may be, for example, severe congestive heart failure, severe asthma, or advanced dementia.

‘Knowledge, insight, forward planning, training, communication and care are essential skills that must be possessed by a dental nurse when dealing with patients with additional and complex needs.’

Special care dental units are frequently linked to an adjacent general hospital, and some patients are referred to special care directly from those hospitals, either after having received a potentially life-threatening medical diagnosis or as they enter a complex phase of a cancer treatment pathway. An example of this is referral from the specialist Haematology unit, where patients due to undergo stem cell transplants must be made dentally fit prior to their immune systems being completely suppressed as part of their treatment. A dental infection occurring in a patient who is immunosuppressed can prove life threatening, and there is frequently a race against time to ensure the dental treatment is carried out as quickly as possible so that their vital medical treatment can proceed.

Assessment of a new referral

What must be considered when assessing new patients is: what risk is the patient placed at by receiving dental treatment, for example extraction, if a patient has a complex underlying condition?

Other aspects to be taken into consideration are:

? Is the patient emotionally and physically robust enough to undergo the dental procedure?
? Are the correct facilities available to manage the patient safely?
? What else needs to be undertaken to render the patient fit enough to proceed?

Assessment of the special care patient is complex. This involves the assessor having to think not only about the medical conditions present and whether or not they impact on the dental procedure required, but also to look at wider issues such as consent, carer support and education. There is also the need to reduce the physical and emotional barriers to care, with possible issues of communication, and to determine who else needs to be involved in the safe management of the patient.

After assessment, patients may require management with local anaesthetic alone, intravenous or inhalation sedation, with a consultant anaesthetist providing the sedation, or possibly a general anaesthetic. Sometimes a decision has to be made to plan for a patient's failing dentition if their health is deteriorating; it may be necessary to provide a more radical treatment plan while the patient is still well enough to manage. Indeed, a decision may be made that it is better to do no restorations or extractions at all. This is sometimes the situation when, for example, a very elderly patient with dementia presents with multiple carious teeth, who not only cannot cooperate with treatment, but where the benefits of treatment do not outweigh the risk to the patient. These difficult decisions are made after thorough consideration, and in particular, after close communication with the patient, family or key care providers.

What is special about special care dentistry?

One of the great joys of special care dentistry is the endless variability of the day. It is in every sense challenging, yet very rewarding. As described, patients may present with any condition with any severity, possibly coupled with further complexities such as issues of mobility or learning disability. Each condition forms part of the mosaic of the patient's problems and hence adds to the layers of thought that must be given to their safe management.

First and foremost, special care dentistry is about managing the individual and being aware that if someone is dependent on others to live their life, that dependency may well impact on their ability to access and receive oral care. It is important to bear in mind that many individuals have complex lives—involving the care and attention of a number of agencies—and there may be a very good reason why, for example, there is a ‘no show’ at the clinic, or that the patient is late.

It is very important in special care dentistry for the team to have good interpersonal skills, to enjoy interacting with people, to be able to problem solve, often through lateral thinking, and to value the ability to make a difference—there are many opportunities for this.

One of the keys to gaining a patient's trust and confidence is to demonstrate that the team understand not only the patient's situation, but also specifics of their condition—and to show, by their actions, that the patient is regarded as a human being first and foremost, and not as a dental ‘procedure’. Many patients feel a sense of powerlessness when they come to the dentist, and this can be additionally so when they attend a dental hospital, where it can be a time of great anxiety and stress. What is just another day at work to staff is very often a big deal to the patient, their families and carers. Much rearranging of work schedules, carer rotas, and transport arrangements may well have been put in place to allow the visit to the dental hospital to occur.

The practical dentistry itself is fortunately generally reasonably straightforward. The skill in special care dentistry is ensuring that:

? The treatment plan is realistic for that patient's circumstance
? The patient has been rendered medically fit enough to proceed
? They are in the correct treatment environment appropriate to their condition and procedure, and that every other necessary pre-treatment intervention has taken place before dental treatment begins.

Special care dentistry, therefore, offers the team the opportunity to help patients in very differing circumstances and to gain an insight into their lives, the conditions they live with and the spheres of support that surround them.

Role of the special care dental nurse

Special care dentistry is rich in complexity, planning, cooperation and reward. To work in this environment requires a truly dedicated, well-prepared, responsive and empathic team. Within this particular department, much of the liaison with other specialist organisations takes place via the senior dental nurse, who not only must manage his or her own clinical nursing team, but also must be highly organised in order that crucial preoperative events have been instigated.

From the nursing perspective, special care dentistry is about understanding the key factors, recognising the barriers to care that the patient's situation presents, and knowing how to reduce those barriers.

This may involve anything from:

? The dental nurse ringing a care home before a patient's first visit to gain further information
? Finding out from carers or family what help is needed to make the patient's visit to clinic easier
? Sensing a patient's agitation about the numbers of people in the room and gently removing anyone not specifically required, as can occur in a teaching environment
? Giving appropriate advice in an appropriate manner to whoever is the key individual in a dependent patient's life.

Team working is essential, and the role and input of the dental nurse is vital. Many factors are involved—from the preparation of the clinic, the patient and the smooth running of the procedure, the care and monitoring of the patient, to an ability to respond quickly when events change. Knowledge, insight, forward planning, training, communication and care are essential skills that must be possessed by a dental nurse when dealing with patients with additional and complex needs, as well as excellence in their role as a dental nurse.

Such knowledge and skills may be enhanced if a post-qualification course in special care dentistry is undertaken, one of which is quality assured and examined by the National Examining Board for Dental Nurses. In the author's opinion, nurses who have undertaken such a course demonstrate a greater independence of thought and an increase in confidence when dealing with complex patients, plus a greater ability to ask questions and make appropriate suggestions relating to the patient's condition.

Further training for dental nurses

Dental nurses can apply to become a special care dental nurse by completing a post qualification course in special care dentistry.

Summary

Special care dentistry is not for everyone, but for those who enjoy it, there is richness of experience to be gained, and the opportunity to learn not just about the diversity of the human condition, but also to gain a sense of humility and respect for others in how they deal with life's many challenges.

Key Points

? Thanks to advances in medicine, people are living longer, which also has implications for health services.
? Special care dentistry arose in 1976 from a small interest group, who first met to look at the additional dental care requirements of patients with special needs.
? The range of referrals to special care dentistry can vary from the medical, physical, sensory complexities or learning difficulties, extremes of age or body mass to psychological or psychiatric conditions.
? A special care dental nurse understands and recognises the barriers to care that the patient's situation presents, and knows how to reduce those barriers.

Author: MA Healthcare