F07151-Ch02.

qxd 10/3/06 9:43 PM Page 5

2
Chapter

APPROPRIATE ORAL
HEALTH CARE

Provision of oral health care for individuals with special needs involves not
only the delivery of safe and appropriate dental care but also focuses on the
need to improve the oral health status of these populations by employing
effective preventive measures. These objectives can be facilitated by the
development of clinical guidelines and integrated care pathways to help
overcome barriers to oral health care.

BARRIERS TO ORAL HEALTH CARE

The barriers to oral health care for people with special needs can be classified
by illustrating the role of the dental profession and its interaction with
individuals and society and government, as follows:
Barriers with reference to the individual ■ Lack of perceived need
■ Anxiety or fear, which may be heightened by previous dental or medical
encounters ■ Financial considerations ■ Lack of access (e.g. Fig. 2.1).
Barriers with reference to the dental profession ■ Inappropriate
manpower resources ■ Uneven geographical distribution ■ Training
inappropriate to changing needs and demands ■ Insufficient sensitivity to
patient attitudes and needs.
Barriers with reference to society ■ Insufficient public support of
attitudes conducive to health ■ Inadequate oral health care facilities
■ Inadequate oral health manpower planning ■ Insufficient support for research.
Barriers with reference to government ■ Lack of political will
■ Inadequate resources (e.g. Fig. 2.2) ■ Low priority.
The key to removing these barriers and improving oral health care
provision for people with special needs is education of the individual, the
dental profession, society and government as to the importance of oral health
and its positive effects on general health.

GOALS

Whilst perfect oral health is the ideal goal, five important objectives when
5
providing oral health care are: ■ enabling patients to care for their own oral
F07151-Ch02.qxd 10/3/06 9:43 PM Page 6

6
Special care in dentistry

Figure 2.1 Impaired physical access

Figure 2.2 Transport vehicles adapted to accommodate wheelchairs

F07151-Ch02.qxd 10/3/06 9:43 PM Page 7

health, with or without assistance ■ keeping patients free from pain and 7
acute disease ■ maintaining effective oral function ■ retaining aesthetics
■ causing no harm.

Appropriate oral health care

THE PEOPLE INVOLVED IN PROVIDING CARE

Although the dentist may be the team leader, dental care professionals are
essential to successful provision of care. Care may also involve the following
groups: ■ parents/carers ■ social services/social work departments
■ health visitors ■ general medical practitioner ■ paediatric consultant/
other hospital specialists ■ school teachers and assistants ■ colleagues in
paediatric dentistry, oral surgery, oral medicine, periodontics, endodontics,
prosthodontics, orthodontics.
A multidisciplinary team approach to patient care leads to a more effective
sharing of resources, generates more creative responses to problems involving
patient care, heightens communication skills, produces new approaches to
learning and clinical practice, and results in the formulation of a practical and
appropriate treatment plan. Furthermore, involvement of other professionals
ensures that they appreciate the importance of oral health care and its
relationship to general health, and dispels the misconception that oral disease
and tooth loss are unavoidable consequences of certain disabilities.

TREATMENT PLANNING

While patients from a specific special needs group may have several treatment
needs in common with other members of that group, each patient should be
considered and treated as an individual with a distinctive set of treatment
needs. The development of individualised treatment plans may involve several
members of the multidisciplinary team, as outlined above.
In order to facilitate appropriate oral health care, it is important to:
■ obtain a careful medical, dental, family and social history ■ determine
the oral/dental needs of the patient ■ obtain informed consent to any
investigations that may be needed ■ obtain informed consent to the
resulting treatment plan.
The main objectives when formulating a treatment plan include: ■ early
assessment of oral health ■ realistic methods of oral hygiene intervention –
a dental hygienist can be particularly helpful in delivering advice and support
■ dietary advice – liaise with a dietician where appropriate ■ formulation
of an oral health care plan – this should include preventative measures to minimise
further oral disease ■ management of current oral disease – this may include
the management of dental emergencies, in addition to stabilisation of oral
health status ■ regular oral examination – the frequency of these examinations
must be individually assessed in terms of the risk of further oral disease.

Medical history An apparently fit patient attending for dental treatment

may have a serious systemic disease and may be taking medication which
may further compromise the provision of care. Many patients with life-
F07151-Ch02.qxd 10/3/06 9:43 PM Page 8

8 threatening diseases now survive as a result of advances in surgical and medical

care. Either or both can significantly affect the dental management or even the
fate of the patient. These problems may be compounded by the fact that patients
Special care in dentistry

are seen briefly and medical support is lacking in most primary care dental
surgeries. A detailed medical history is essential in order to: ■ determine
any effect on oral health ■ assess the fitness of the patient for the procedure
■ decide on the type of behaviour and pain control required ■ decide how
treatment may need to be modified ■ warn of any possible emergencies that
could arise ■ determine any possible risk to staff or other patients/visitors.
The history must be reviewed before any surgical procedure, general
anaesthetic, conscious sedation or local anaesthetic is given, and at each new
course of dental treatment.

Preoperative assessment An arbitrary guideline to assist in the selection

of appropriate treatment modalities for a patient may be based on the Classification
of Physical Status of the American Society of Anesthesiology (ASA) (Table 2.1).
According to the current guidelines, dental treatment must be significantly
modified if the patient has an ASA score of III or IV. Of note, a relatively
high percentage of the population aged between 65 and 74 years (23.9%) and
75 or over (34.9%) has an ASA score of III or IV.

Preoperative planning Good preoperative assessment and organisation

will assist in anticipating potential hazards when providing oral care, and also
help to ensure measures are in place to manage emergencies quickly and
efficiently. In most situations dentistry is safe, provided that the patient is
healthy and the procedure is not dramatically invasive. Risks arise when these
conditions do not apply and the dental team attempts anything over-ambitious
in terms of their skill, knowledge or available facilities. It is helpful to
formulate a checklist to ensure that factors such as transport, disabled parking
and the need for accompanying carers are considered prior to the first
treatment appointment. It may also be of benefit to devise a treatment plan
consisting of a preoperative, operative and postoperative phase, to ensure that
other factors (such as the provision of preoperative antibiotics for the
prophylaxis of infective endocarditis) are also considered (Table 2.2).
Analgesia and behaviour management Morbidity is minimal when
local anaesthesia (LA) is used. Sedation is more hazardous than local
anaesthesia; it must be carried out by adequately trained personnel and with
due consideration of the possible risks. General anaesthesia (GA), whether
intravenous or inhalational, leads to impaired control of vital functions and is
thus only carried out by a qualified anaesthetist, and permitted only in a
hospital with appropriate facilities.

CONSENT

Consent in relation to dentistry is the expressed or implied agreement of the

patient to undergo a dental examination, investigation or treatment. The law in
relation to consent is evolving and there are significant variations between
countries. However, the principles remain essentially the same:
F07151-Ch02.qxd 10/3/06 9:43 PM Page 9

Table 2.1 Classification of Physical Status of the American Society 9

of Anesthesiology (ASA)

Appropriate oral health care

ASA Definition Dental treatment modifications

I Normal, healthy patient None

II A patient with mild systemic Medical advice may be helpful.
disease, e.g. well controlled Often few treatment modifications
diabetes, anticoagulation, mild needed, unless GA or major
asthma, hypertension, epilepsy, surgery is needed.
pregnancy, anxiety
III A patient with severe systemic Medical advice is helpful.
disease limiting activity but not Dental care should focus on
incapacitating, e.g. chronic renal elimination of acute infection
failure, epilepsy with frequent and chronic disease, prior to
seizures, uncontrolled medical/surgical procedure (e.g.
hypertension, uncontrolled haemodialysis patients).
diabetes, severe asthma, stroke Patients are often best treated
in a hospital-based clinic where
expert medical support is available.
IV A patient with incapacitating Medical advice is indicated.
disease that is a constant threat All potential dental problems should be
to life, e.g. cancer, unstable corrected prior to medical/surgical
angina or recent myocardial procedure to deal with basic problem
infarct, arrhythmia, recent (e.g. radiotherapy to head and
cerebrovascular accident, neck, or organ transplant).
end-stage renal disease, liver Patients are often best treated
failure in a hospital-based clinic where
expert medical support is available.
Emergency dental care is usually
indicated.
V Moribund patient not expected Medical advice is essential.
to live more than 24 hours with Patients are often best treated
or without treatment in a hospital-based clinic where
expert medical support is available.
Emergency dental care is usually
indicated.

■ Before you examine, treat or care for competent adult patients you must
obtain their consent.
■ Adults are always assumed to be competent unless demonstrated otherwise.
If you have doubts about their competence, the question to ask is: ‘can this
patient understand and weigh up the information needed to make this
decision?’ Unexpected decisions do not prove the patient is incompetent,
but may indicate a need for further information or explanation.
■ Patients may be competent to make some health care decisions, even if
they are not competent to make others.
■ Giving and obtaining consent is usually a process, not a one-off event.
Patients can change their minds and withdraw consent at any time.
F07151-Ch02.qxd 10/3/06 9:43 PM Page 10

10 Table 2.2 Example of clinic appointment schedule

Special care service
Special care in dentistry

Patient Last name

First name
Date of birth
Unit number
Telephone
Mobile
Fax
E-mail
Systemic disease Main problems
Communication Main problems
difficulties
Appointment Date Date Date
Hour Hour Hour
Treatment planned Restorative
Surgical
Mixed
Support required Transport
Disabled parking
Special seating
Caregiver present
Additional staff
Other
Appropriate dental care Antibiotic prophylaxis*
Blood tests (e.g. INR)
BP monitoring
Cardiac monitoring
Medical assessment
Others
Drugs to avoid No restraints
Drugs*
LA
Behaviour control Relative analgesia
IV sedation
GA
Others

*Specify drugs, doses and time of administration.

F07151-Ch02.qxd 10/3/06 9:43 PM Page 11

To give valid consent, patients must receive sufficient information about 11

their condition and proposed treatment. It is the dentist’s responsibility to
explain all the relevant facts to the patient, and to ascertain that they understand

Appropriate oral health care

them. The information given to patients must, as a minimum, include:
■ The nature, purpose, benefits and risks of the treatment.
■ Alternative treatments and their relative benefits and risks.
■ All aspects of the procedure expected to be carried out.
■ The prognosis if no treatment is given.
If the patient is not offered as much information as they reasonably need to
make their decision, and in a form they can understand, their consent may not
be valid. For example, information for those with visual impairment may be
provided in the form of audio tapes, braille, or large print.
Consent can be written, oral or non-verbal. A signature on a consent form
does not itself prove the consent is valid; the point of the form is to record the
patient’s decision, and also increasingly the discussions that have taken place.
Your Trust or organisation may have a policy setting out when you need to
obtain written consent.
There are several legal tests that have been described in relation to
consent. The Bolam test states that a doctor who: ‘acted in accordance with a
practice accepted as proper by a responsible body of medical men skilled in
that particular art is not negligent if he is acting in accordance with such a
practice, merely because there is a body of opinion which takes a contrary
view.’ However a judge may on certain rare occasions choose between two
bodies of medical opinion, if one is to be regarded as ‘logically indefensible’
(Bolitho principle). The main alternative to the Bolam test is the ‘prudent-
patient test’ widely used in North America. According to this test, doctors
should provide the amount of information that a ‘prudent patient’ would want.
In the UK, competent adults, namely a person aged 18 and over who has
the capacity to make their own decisions about treatment, can consent to
dental treatment. They are also entitled to refuse treatment, even where it
would clearly benefit their health. The defence of ‘emergency’ is to allow
restraint where you must act quickly to prevent the patient from harming
themselves or others (or committing a crime). Emergency treatment to save
life or to prevent serious harm to the patient must always be given, if the
patient is unable to give consent, e.g. owing to unconsciousness. Another
example is that of a patient running amok, who you could restrain, before you
have the chance to fully assess the situation. Furthermore, the UK Mental
Health Act 1983 (sections 63, 57) enables dental treatment of someone
suffering from a mental disorder, to prevent further deterioration of their
mental health (e.g. treatment of a dental abscess).
Minors aged 16 and 17, and children below 16 who are Gillick competent
(understand fully what is involved in the proposed procedure), may also
consent to treatment without their parents’ authorisation, although their
parents will ideally be involved. Legally, a parent can consent if a competent
child refuses, but it is likely that taking such a serious step will be rare.
Adults without capacity cannot give consent to treatment. Mental capacity
legislation has been the subject of debate and legislative change around the
world. Currently, in England and Wales, no-one can authorise treatment on
F07151-Ch02.qxd 10/3/06 9:43 PM Page 12

12 behalf of an adult. However, patients without capacity to consent may

receive dental treatment if it is in the patient’s best interests, with the views
of relatives and carers taken into account. In contrast, The Adults with
Special care in dentistry

Incapacity (Scotland) Act 2000, which came into effect in 2002, allows a
competent adult to nominate a person, known as a welfare attorney or proxy,
to make medical decisions on their behalf if and when they lose the capacity
to make those decisions for themselves. The Act also provides for a general
power to treat a patient who is unable to consent to the treatment in question.
In order to bring that power into effect, the medical practitioner primarily
responsible for treatment must have completed a certificate of incapacity
before any treatment is undertaken, other than in an emergency. The Mental
Health (Care and Treatment) (Scotland) Act 2003 was passed by the Scottish
parliament in March 2003, with most of it coming into effect in April 2005.
It allows for medical/dental intervention to prevent serious deterioration in the
patient’s mental health condition or to prevent the patient from harming
themselves.
The new Mental Capacity Act (England and Wales) received Royal Assent
in April 2005 and will probably come into force in April 2007. It is central to
the legal issues around treating patients over the age of 16 who lack capacity
to consent to treatment. The Act is particularly significant in two ways
relevant to consent to medical management:
■ It will, for the first time, allow consent to be given or withheld for the medical
treatment of patients who lack capacity, by another person (typically a
close relative). [Under current law there is no proxy consent (and therefore
no relevant lack of consent) for adult patients who lack capacity.]
■ It provides, again for the first time, for statutory recognition of ‘advance
directives’. These are statements made by a person whilst competent
(i.e. whilst having legal capacity) about the treatment that they would
want, or not want, in specified situations, in the future were they to lack
capacity at the time the treatment would be relevant.
The information provided is an example of UK law. It is important to
remember that the legal situation with regard to consent varies around the
world and is subject to continued debate and development.
Further reading ● Bridgman A M, Wilson M A 2000 The treatment of adult
patients with mental disability. Part 1: Consent and duty. Br Dent J 189(2):66–68
● Bridgman A M, Wilson M A 2000 The treatment of adult patients with a mental
disability. Part 2: Assessment of competence. Br Dent J 189(3):143–146
● http://www.markwalton.net/ ● http://www.markwalton.net/guidemha/index.asp?

ORAL HEALTH IN PEOPLE WITH DISABILITIES

■ A healthy mouth is important in maintaining quality of life for patients

with disabilities.
■ The evidence is that there is significant unmet need in many people with
disabilities and that the care offered does not always match that for other
people.
F07151-Ch02.qxd 10/3/06 9:43 PM Page 13

■ Most oral disease is caused by: 13

● frequent dietary consumption of refined carbohydrates, causing dental
caries

Appropriate oral health care

● infrequent or inadequate removal of dental bacterial plaque, causing
gingivitis, periodontitis and halitosis.
■ A preventive approach is essential.
■ Key workers assigned to a patient should be aware of the importance of
preventive dental advice as part of the overall care plan.
■ Regular oral examination by a dental professional is important.
■ The frequency of these examinations must be individually assessed.
■ Early intervention can minimise future oral disease, pain, and the need for
operative intervention and the associated use of anaesthesia and other drugs.
■ The key points for an oral health plan for patients with disabilities are:
● early assessment of oral health
● individual care plans drawn up following liaison with family and other
health care providers for each case
● establish a good diet in liaison with a dietician – minimise refined
carbohydrates, confectionery and between-meal snacking
● establish realistic methods of oral hygiene:
– teeth should be cleaned at least twice daily, using a fluoridated
toothpaste and a small-headed toothbrush
– if the patient is unable to rinse and spit, chlorhexidine gel (gluconate)
may be used in place of toothpaste
– there are various aids available to help patients or their carers
maintain a clean, comfortable oral environment; a dental hygienist
can be particularly helpful in delivering advice and support
– dentures should be assessed for fit and comfort as ill-fitting dentures
can rub and cause discomfort and ulceration. Dentures (complete and
partial) should be removed after every meal, rinsed in cold running
water to remove food debris and checked for sharp edges and cracks.
They should be replaced in the mouth after the mouth has been
checked for food debris and wiped or rinsed clean. At night, dentures
should be cleaned with a toothbrush and left to soak in fresh tap
water overnight.

KEY CONSIDERATIONS FOR DENTAL MANAGEMENT

Many people with disability are amenable to routine treatment in the dental
surgery, but more time may be required. Some people with disabilities require
special facilities or an escort to facilitate dental treatment. In patients who are
medically compromised, preventive oral health care and the avoidance of non-
essential surgery and other invasive procedures are particularly important.
Special issues that may need to be considered include: ■ modifications
required to routine treatment procedures ■ accommodating a person who
has hearing or visual impairment ■ treating a person who uses a wheelchair
■ managing/accommodating the behaviour of a patient who has difficulty
cooperating ■ ensuring airway patency ■ referral for treatment and
consultation by specialists.
F07151-Ch02.qxd 10/3/06 9:43 PM Page 14

14 The treatment modifications indicated to take into account these issues

depend not only upon the skill and experience of the team(s) involved, but
also on the: ■ type and severity of concurrent disease, its treatment and
Special care in dentistry

complications (clearly the more invasive and prolonged the operative

interference, and the more severe the medical condition, the more are the risks
to the patient) ■ type of pain control or behaviour management needed
■ extent and duration of operative interference ■ extent of interference
with normal feeding and life postoperatively.
Communication with the medical team and other care providers can be
crucial and ensures optimal care. This is particularly important in relation to:
■ assessment of competency/consent ■ timing and sequencing of dental,
medical, surgical and other treatment; nurses, social workers or support
coordinator, psychologists, physicians and surgeons may need to be involved
■ use of sedation or general anaesthesia ■ antibiotic prophylaxis
■ control of bleeding tendency ■ potential drug interactions.
Unfortunately, there are few, if any, randomised controlled trials in this
field, so the level of evidence available on which to base clinical decisions is
not always of the highest (Box 2.1). Most evidence is from levels 3–5.

Behaviour management
Although many patients can be managed using conventional techniques,
some may require the implementation of behavioural management strategies,
ranging from adapting the clinical environment to create an empathic
relaxed environment, to full general anaesthesia. This is particularly true
when undertaking complicated procedures, which the patient’s medical,
psychological or behavioural conditions prevent from being performed in the
normal manner.
People with autism, Down syndrome or other learning disabilities,
or systemic medical conditions, commonly need behavioural support.
Furthermore, demanding, manipulative and resistant behaviours may be seen,
particularly in some psychiatric patients and those with dementia or learning
disability. The family, partner or caregivers should be consulted to help
determine the patient’s needs, and help prepare such patients for treatment.
Some behaviour management strategies are: ■ creating a quiet,
caring, empathetic relaxed environment ■ scheduling appointments
at the appropriate time of day ■ behaviour modification techniques:

Box 2.1 The five levels of evidence

1a. Systematic review of multiple randomised controlled trials (RCTs)

1b. Individual well-designed RCT
2a. Systematic review of cohort studies
2b. Individual cohort study, or low quality RCT
3a. Systematic review of case-control studies
3b. Individual case-control studies
4. Non-analytical studies (case series)
5. Opinions of expert committees or respected authorities
F07151-Ch02.qxd 10/3/06 9:43 PM Page 15

● desensitisation (progressive desensitisation may be effective with some 15

anxious individuals – this modality should at least be attempted ● positive
reinforcement ● voice control ● distraction via music or television

Appropriate oral health care

● physical or chemical restraint – rarely.
Many patients with disabilities can readily be treated under local
anaesthesia (LA), but this is not the case in some patients who move
uncontrollably or who cannot cooperate. A step-wise approach should be
employed, whereby the least invasive form of pain and behaviour control is
attempted prior to the more potentially dangerous methods of sedation or
general anaesthesia (GA).

Intervention (restraint) The question of the use of intervention

(restraint) for those unable to comply with routine care, particularly in
people with disabilities – and especially in those with learning disability or
dementia – is highly controversial. Indeed, this is the area in special care
dentistry that often excites the most controversy and passion. No consensus
exists regarding either the definition of restraint or what constitutes the use
of restraints. Nevertheless, restraint is often divided into ‘physical restraint’
or ‘chemical restraint’. Physical restraint refers to one person holding another
person’s arms, legs or head to control movements and prevent self-injury
by the patient, but also encompasses the use of devices such as mouth
props, blankets, straps, Papoose boards, pedi-wraps, and tape (‘mechanical
restraint’). Chemical restraint refers to the use of sedation or general
anaesthesia.
Considerations as to the use of chemical restraints include: ■ can and
will the patient cooperate? ■ can and will the patient take the medications
orally? ■ what are the potential drug interactions or adverse effects?
■ what is the opinion of the patient’s physician and other care providers?
■ is informed consent from the patient possible, and has it been obtained?
Conscious sedation (CS) requires an appropriately trained team and
monitoring equipment, with the ability to respond to complications. CS can be
a very effective and safe modality, and it is disappointing that it may be less
attractive to some parents than is GA.
GA should normally be the last resort in the behavioural management
armamentarium but, for those patients who have greatest difficulty in
cooperating, it can be the most ideal method, permitting a higher standard
of technical dentistry to be achieved, since the anaesthetic team manages
the patient’s medical status and vital signs while the dental team can
concentrate on the dentistry. GA may also be used to carry out more complex
procedures and, by saving time, may enable more comprehensive treatment
to be provided.
Most people with disabilities can be safely managed under general
anaesthesia for dental treatment in a hospital setting with minimal morbidity.
Nevertheless, there is little doubt that GA is more dangerous than CS.
Intraoperative complications are uncommon, but may include non-fatal
ventricular arrhythmias, slight falls in blood pressure, hypertension (greater
than 20% of preoperative value), laryngospasm and minor airway problems
resulting in a desaturation of oxygen to a level below 85%. However, to use
GA presupposes the assistance of an anaesthetist, the presence of other
F07151-Ch02.qxd 10/3/06 9:43 PM Page 16

16 essential facilities and emergency support, and absence of any medical

contraindications.
When physical restraints are used, it is generally accepted that they
Special care in dentistry

should not: ■ cause any physical injury to the patient ■ be used for the
convenience of the staff ■ be used except when absolutely necessary
■ be more restrictive than necessary ■ be used as punishment.
The British Institute of Learning Disabilities summarises key policy
principles on physical interventions as follows:
1. Any physical intervention should be consistent with the legal obligations
and responsibilities of care agencies and their staff and the rights and
protection afforded to people with learning disabilities under law.
2. Working within the ‘legal framework’, services are responsible for the
provision of care, including physical interventions, which are in a
person’s best interest.

Values
3. Physical interventions should only be used in the best interests of the patient.
4. Patients should be treated fairly and with courtesy and respect.
5. Patients should be helped to make choices and be involved in making
decisions that affect their lives.
6. There should be experiences and opportunities for learning that are
appropriate to the person’s interests and abilities.

Prevention of challenging behaviour

7. Challenging behaviours can often be prevented by the careful management
of setting conditions.
8. The interaction between environmental setting conditions and personal
setting conditions should be explored for each patient who presents a
challenge. Setting conditions should be modified to reduce the likelihood
of challenging behaviour occurring (primary prevention).
9. Secondary prevention procedures should be developed to ensure that
problematic episodes are properly managed with non-physical
interventions before patients become violent.
10. For each patient who presents a challenge there should be individualised
strategies for responding to incidents of violence and reckless behaviour.
Where appropriate, the strategy should include directions for using
physical interventions.
11. Individualised procedures should be established for responding to patients
who are likely to present violent or reckless behaviour. The procedures
should enable care staff to respond effectively to violent or reckless
behaviours while ensuring the safety of all concerned.
Promoting the best interests of patients
12. Physical interventions should only be used in conjunction with other
strategies designed to help patients learn alternative non-challenging
behaviours.
13. Planned physical interventions should be justified in respect of: what is
known of the client from a formal multidisciplinary assessment; alternative
F07151-Ch02.qxd 10/3/06 9:43 PM Page 17

approaches which have been tried; an evaluation of the potential risks 17

involved; reference to a body of expert knowledge and established good
practice.

Appropriate oral health care

14. The use of physical interventions should be subject to regular review.
Physical intervention and risk assessment
15. The potential hazards associated with the use of physical interventions
should be systematically explored using a risk assessment procedure.
Physical interventions should not involve unreasonable risk.
Minimising risk and promoting the wellbeing of patients
16. Physical interventions should be employed using the minimum reasonable
force.
17. Any single physical intervention should be employed for the minimum
duration of time.
18. For individual patients, physical interventions should be sanctioned for
the shortest period of time consistent with the patient’s best interests.
19. Physical interventions should not cause pain.
20. Patients should have individual assessments to identify contraindications
of physical interventions before they are approved.
21. Patients who receive a physical intervention should be routinely assessed
for signs of injury or psychological distress.
Management responsibilities
22. Service managers are responsible for developing and implementing
policies on the use of physical interventions.
23. The use of any procedure should be clearly set out in the form of written
guidance for staff.
24. Service managers are responsible for ensuring that all incidents involving
the use of physical interventions are clearly, comprehensively and
promptly recorded.
25. All patients and their families and representatives should have ready
access to an effective complaints procedure.
26. Careful consideration should be given to the impact of resource management
on the use of physical interventions.
Employers’ responsibility towards staff
27. Employers and managers are responsible for the safety and wellbeing of
staff.
28. Staff should be encouraged to monitor all physical interventions and to
report any incidents that give cause for concern.
Staff training
29. Staff who may be required to use physical interventions should receive
regular training on knowledge, skills and values.
30. Training should be provided by an instructor with appropriate experience
and qualifications.
31. Staff should only employ physical interventions they have been trained
to use.
F07151-Ch02.qxd 10/3/06 9:43 PM Page 18

18 32. Staff deployment should be organised to ensure that appropriately trained

staff are available to respond to any incident requiring physical
intervention.
Special care in dentistry

Further reading ● Bridgman A M 2000 Mental incapacity and restraint for

treatment: present law and proposals for reform. J Med Ethics 26(5):387–392
● Bridgman A M, Wilson M A 2000 The treatment of adult patients with a mental
disability. Part 3: The use of restraint. Br Dent J 189(4):195–198 ● Carr K R, Wilson S,
Nimer S, Thornton J B Jr 1999 Behavior management techniques among pediatric dentists
practicing in the southeastern United States. Pediatr Dent 21(6):347–353 ● Connick C,
Palat M, Pugliese S 2000 The appropriate use of physical restraint: considerations. ASDC J
Dent Child 67(4):231, 256–262 ● Connick C, Pugliese S, Willette J, Palat M 2000
Desensitization: strengths and limitations of its use in dentistry for the patient with severe
and profound mental retardation. ASDC J Dent Child 67(4):250–255 ● Connick C M,
Bates M L, Barsley R E 1999 Dental treatment guidelines for use of restraints within the
nine Louisiana developmental centers. Louisiana State University Dental Health Resources
Program. LDA J 58(2):23–26 ● Geary J L, Kinirons M J, Boyd D, Gregg T A 2000
Individualized mouth prop for dental professionals and carers. Int J Paediatr Dent
10(1):71–74 ● Kupietzky A 2004 Strap him down or knock him out: Is conscious
sedation with restraint an alternative to general anaesthesia? Br Dent J 196(3):133–138
● Limeres J, Vázquez E, Medina J, Tomás I, Feijoo JF, Diz P 2003 Evaluación
preanestésica de discapacitados severos susceptibles de tratamiento odontológico bajo
anestesia general. Medicina Oral 8:353–360 ● Scully C, Kumar N 2002 Dentistry for
those requiring special care. Primary Dental Care 10:17–22 ● Scully C 2004 The
medically compromised patient: an overview. In: Prabhu S R (ed) Textbook of oral
medicine. Oxford University Press, New Delhi, p236–244 ● Tyrer G L 1999 Referrals
for dental general anaesthesia: how many really need GA? Br Dent J 187:440–443
● http://www.bild.org.uk./physical_interventions/summary_of_principles.htm
● http://www.friendlyreports.org.uk

Prevention
Prevention of oral disease is of paramount importance for individuals with
disabilities, not least to prevent disease and complications such as pain but
also to obviate the need for operative intervention.
Prevention programmes must be started at as early an age as feasible
and reinforced on a long-term basis, incorporating them into other daily
programmes such as rehabilitation, education and occupational therapy.
Dental recalls should be planned in accordance with the individual patient’s
needs: people with severe dental disease or a predisposition to it (e.g.
xerostomia predisposing to caries) may need to be seen every 2–3 months.
Patients should be involved in maintaining their own oral hygiene as much as
possible, but carers may need to assist. Education of the family members, partner
or other care providers may be critical for ensuring regular and appropriate
supervision of diet and oral hygiene. Caregivers may well need dental health
education, and should be shown how to properly position the person for oral hygiene
care. Chairs, pillows, head rests, bean bags, and other devices may be helpful.
Dietary counselling is crucial, to avoid caries and erosion. Ideally, patients
should brush their teeth after each meal and before bedtime, but at least twice
F07151-Ch02.qxd 10/3/06 9:43 PM Page 19

daily is acceptable. Brushes can be modified to assist people with physical 19

disabilities to brush their own teeth. Electric toothbrushes may improve
patient compliance in patients with physical or mental disabilities. Other aids

Appropriate oral health care

helpful to many people include:
■ Fluoride toothpastes, mouth rinses or gels, which may be beneficial in
controlling caries. Patients who might swallow a rinse can benefit from
application with a toothbrush, cotton bud or sponge-sticks. Additional
topical fluorides such as professional applications of varnish are indicated
when the caries rate is high.
■ Chlorhexidine mouth rinses or gels, which may be beneficial in controlling
gingivitis and periodontitis. Patients who might swallow a rinse can
benefit from application with a toothbrush, cotton bud or sponge-sticks.
Intermittent use (e.g. weekends or every other day) may help to minimise
problems with staining.
Where cooperation is good:
■ Tooth flossing is recommended daily, although a second person may need
to assist.
■ Disclosing solutions may be beneficial in promoting behavioural changes.
■ Fissure sealants may be beneficial.
Further reading ● Diz Dios P, Fernández Feijoo J 2000 Pacientes especiales en
atención primaria. In: Suárez Quintanilla J (ed) Odontología en atención primaria. Instituto
Lácer de Salud Buco-Dental, Barcelona ● Eirea M, Diz P, Vázquez E, Castro M et al
1996 Effectiveness of a new toothbrush design for physically impaired patients. Stoma
40:37–42 ● Rutkauskas J S (ed) 1994 Practical considerations in special patient care.
Dent Clin North Amer 38(3):361–584 ● Helpin M L, Rosenberg H M 1997 Dental care:
beyond brushing and flossing. In: Children with disabilities, 4th edn. Brookes Publishing
Co., Baltimore, p643–656 ● http://www.nohic.nidcr.nih.gov/poc/publication/careguide.aspx

Access and positioning

Access to oral health for individuals with special needs has been limited in
the past, but legislation such as the Disability Discrimination Act (DDA) 1995
has improved the situation. Special attention should be paid to non-ambulatory,
home-bound, and institutionalised patients who may need access to portable
dentistry programmes (domiciliary care) and treatment facilities based inside
institutions. Patients with severe disabilities generally benefit from short dental
appointments but there is a balance between this, achieving an adequate amount
of treatment, and the difficulties and costs encountered with transporting
patients to the dental surgery on repeated occasions.
Patients using a wheelchair may have to be transferred from their
wheelchair to the dental chair. In these situations, it is an essential
requirement that all staff have training in manual handling, and that such
training should also include the safe use of equipment to assist transfer
(e.g. sliding board, turntable, and hoist). Where patients need to be treated
in their wheelchairs, the surgery layout should provide enough space for this.
Furthermore, surgeries may be designed with tilting floor ramps/platforms,
and dental units which can directly lift wheelchairs are now available.
F07151-Ch02.qxd 10/3/06 9:43 PM Page 20

20 Operative procedures and the airway Individuals with disabling

conditions may not possess the ability or reflexes to adequately protect their
own airway during operative procedures in the mouth. This may be due to
Special care in dentistry

their specific disabling condition or their inability to cooperate. Such a patient

might inadvertently swallow or aspirate dental restorations, materials or
instruments. It is vital therefore that, if a rubber dam cannot be used, these
patients are properly positioned at 45 degrees to prevent aspiration, and not
placed in a supine position. The use of the rubber dam may in any event be
contraindicated because of the patient’s inability to control or swallow oral
secretions (e.g. severe Parkinson’s disease).
Surgery Surgery can be undertaken on the conscious patient only where
the patient can remain both still and cooperative. However, simple procedures
may sometimes be performed if the patient who moves involuntarily is
appropriately restrained, either with consent having been obtained or in
their best interests. In others, sedation or GA is required.
Special care should be taken in patients requiring antibiotic prophylaxis
and in those with bleeding tendencies. In all patients having surgery,
consideration should be given to ensuring an adequate escort postoperatively,
and to minimising complications and the need for further procedures such as
suture removal.
Further reading ● Chalmers J M, Kingsford Smith D, Carter K D 1998 A
multidisciplinary dental program for community-living adults with chronic mental illness.
Spec Care Dentist 18(5):194–201 ● Harrison M G, Roberts G J 1998 Comprehensive
dental treatment of healthy and chronically sick children under intubation general
anaesthesia during a 5-year period. Br Dent J 184(10):503–506 ● Frassica J J,
Miller E C 1989 Anesthesia management in pediatric and special needs patients undergoing
dental and oral surgery. Int Anesthesiol Clin 27(2):109–115.

Treatment modification
Restorative dentistry Patients with disabilities may be more likely to
have dental anomalies, such as hypodontia, and to suffer from tooth wear,
erosion, and caries. While prevention plays a key role, expedient restoration
of the dentition (if dental disease has already occurred) can be crucial, as it
will help to minimise the need for advanced restorative procedures in the
longer term. Furthermore, it is often critical to prevent tooth loss, particularly
when dentures would be poorly tolerated.
However, clinical work can be very difficult as access to the oral
environment is often limited and patient tolerance and concentration may be
reduced. The use of rotatory instruments may be especially hazardous in
patients with uncontrollable movements or those unable to be cooperative.
Individuals with disabling conditions may not tolerate the rubber dam or
cooperate during restorative procedures without the aid of chemical restraints
such as sedation or general anaesthesia. The choice of restorative material and
technique may require modification. Restoration by indirect techniques may
not be possible, so the choice is often limited to amalgam, resin composite
and glass ionomer. Glass ionomer restorations may be particularly appropriate
for patients with a high caries rate, since they adhere to tooth substance and
F07151-Ch02.qxd 10/3/06 9:43 PM Page 21

release fluoride. Stainless steel crowns may be appropriate for restoring 21

severely damaged teeth when the patient’s lack of cooperation precludes more
complicated restorative procedures. In addition, alternative techniques, such

Appropriate oral health care

as the atraumatic restorative treatment technique (ART), or a chemo-
mechanical caries removal technique (Carisolv®) may be employed. These
may reduce the need for local anaesthesia.
Further reading ● Gryst M E, Mount G J 1999 The use of glass ionomer in special
needs patients. Aust Dent J 44(4):268–274 ● Jones J A, Mash L K, Niessen L C 1993
Restorative considerations for special needs patients. Dent Clin North Am 37(3):483–495.

Periodontics Individuals with disabling conditions may not possess the

ability to adequately maintain good oral hygiene, which can lead to periodontal
diseases and/or halitosis. It is frequently not possible to improve the level of
plaque control with standard toothbrushes, because of the patient’s impaired
cognition, mobility and manual dexterity. Electric toothbrushes may, therefore,
be easier and more effective under these circumstances. Chlorhexidine spray
or mouthwashes, used twice daily, can provide significant assistance with
plaque control. Chlorhexidine at a concentration of 0.06% appears to be as
effective in reducing plaque accumulation as a 0.12% concentration. Regular,
routine scaling usually improves gingival health considerably, however there
is little indication for sophisticated periodontal surgery. If there are certain
cardiac defects, antibiotic cover may be indicated.
Other factors contributing to periodontal diseases include gingival enlargement
caused by some drugs, e.g. phenytoin or ciclosporin, or by one of the genetic
syndromes. Gingivectomy may sometimes be justifiable for aesthetic and
social reasons, or if the enlarged gingival tissues interfere with occlusion or
effective oral hygiene. Electrosurgery or laser surgery may be considered
instead of the external bevel gingivectomy where periodontal packs may
not be well retained or tolerated. Gingival enlargement is likely to recur,
particularly if there is inadequate improvement in oral hygiene. Therefore,
frequent recall examinations and prophylaxis, as often as every 2 or 3 months,
can be justified.
Further reading ● Craig D C, Boyle C A, Fleming G J, Palmer R 2000 A sedation
technique for implant and periodontal surgery. J Clin Periodontol 27(12):955–959.

Endodontics Maintaining severely damaged or worn teeth is critical

in individuals with disabling conditions who cannot tolerate removable
prostheses. Endodontic treatment should be considered when a tooth is
restorable and the patient can cooperate. Sedation or general anaesthesia may
facilitate endodontic treatment, particularly of anterior teeth, in those patients
who are less cooperative. There is no convincing evidence that poor systemic
health compromises the chances of a successful endodontic outcome – only
one study has implicated diabetes as potentially reducing the success of root
canal treatment.
The use of rubber dam and one-appointment procedures are advisable
when possible. When radiographs cannot be obtained, an apex locator can be
helpful in determining working length. Rotary instrumentation may facilitate
effective and speedier canal preparation, but root canal irrigation should not
be compromised. Irrigant delivery may be enhanced using endosonics.
F07151-Ch02.qxd 10/3/06 9:43 PM Page 22

22 Provided that canal preparation is well controlled, obturation may be simplified

by using commercially available, thermoplasticised gutta-percha on a carrier.
Special care in dentistry

Further reading ● Battrum D E, Gutmann J L 1994 Comprehensive endodontics

for special needs patients: a case report. Univ Tor Dent J 8(1):7–9 ● Scully C,
Gulabivala K, Ng P 2003 Systemic complications of endodontic manipulations. In: Glick M
(ed) Endodontic topics, vol 4. Blackwell, Copenhagen, p60–68.

Fixed prosthodontics The provision of fixed prosthodontics involving

teeth or implants may be appropriate if the patient can cooperate and adequate
oral hygiene can be maintained by the patient and/or caregiver. If the patient
is unable to cooperate, so precluding more complicated procedures for
restoring severely damaged teeth, long-term provisional restorations or
stainless steel crowns may be more appropriate. Although technique sensitive,
resin-bonded bridges can also be useful as treatment is generally quicker and
less invasive.
Replacement of anterior teeth with fixed prosthodontics is generally
contraindicated for the patient who has severe epilepsy or is likely to suffer
trauma – as in some patients with severe learning disability or dementia, or
those who suffer self-harm – as restorations or abutment teeth may fracture.
Further reading ● Gilmour A G, Morgan C L 2003 Restorative management of the
elderly patient. Prim Dent Care 10(2):45–48 ● Jones J A, Mash L K, Niessen L C 1993
Restorative considerations for special needs patients. Dent Clin North Am 37(3):483–495.

Removable prosthodontics Removable prostheses can be a helpful

solution to the restoration of occlusal function and appearance in many people
with disability. Implant-stabilised prostheses can be advantageous if peri-
implant health can be adequately maintained. However, conventional
removable prostheses are contraindicated for patients with severe epilepsy,
who may inhale foreign bodies during a convulsion. Such prostheses are also
not indicated for the patient with insufficient muscle control or physical or
mental capacity to adapt to them. These patients include some with learning
disability, dementia, stroke, or movement disorders (Parkinson’s disease,
Huntington’s chorea or tardive dyskinesia). Patients must also be capable of
recognising, inserting, removing, and cleaning their denture. Any prosthesis
for a person with epilepsy should be constructed of radio-opaque material,
whilst those for patients with a learning disability or dementia should be
marked with their identity as they can be mislaid or lost.
Impression taking can also be difficult, but may be facilitated by using
a viscous material, such as composition or a putty-type silicone material.
If the patient objects violently, these materials can be readily removed
without leaving unset material in the oropharynx. If patients will not keep
their mouths open, a mouth prop on alternate sides and sectional impressions
may overcome the difficulty. However, in patients with severe cerebral palsy,
stridor can be caused by a bite block.
Registration of occlusal records can be very difficult if cooperation is
lacking, and some people with more severe disabilities tend to have a
deterioration of breathing function when using a bite registration block.
Those patients who are incapable of managing complete dentures can become
‘dentally impaired’ in addition to their other disabilities.
F07151-Ch02.qxd 10/3/06 9:43 PM Page 23

Further reading ● Jones J A, Mash L K, Niessen L C 1993 Restorative 23

considerations for special needs patients. Dent Clin North Am 37(3):483–495
● Paunovich E D, Aubertin M A, Saunders M J, Prange M 2000 The role of dentistry in

Appropriate oral health care

palliative care of the head and neck cancer patient. Tex Dent J 117(6):36–45 ● Thomson
W M, Brown R H, Williams S M 1992 Dentures, prosthetic treatment needs, and mucosal
health in an institutionalised elderly population. NZ Dent J 88(392):51–55.

Implants Early clinical studies on osseointegrated implants (OI), which

provided much of the evidence base for their success, employed strict patient
selection criteria. These studies excluded many systemic disorders, which it
was believed might contraindicate implant treatment. However, in recent
years the justification for some of these assumptions has been challenged,
as – perhaps unsurprisingly – the evidence for any increased failure rates
of implant treatment in medically compromised patients is quite sparse.
There appear to be apparently few absolute contraindications to implant
treatment, but a number that may increase the risk of treatment failure or
complications.
In all patients with disabilities in whom OI are considered, it would
clearly be prudent to weigh carefully the cost–benefit analysis. Furthermore,
it is crucial to undertake the procedures with strict asepsis, to minimise
trauma and take especial care in avoiding stress and undue haemorrhage.
Crucially, the patient must be able to maintain an excellent standard of oral
hygiene. Treatment modifications may be indicated (Table 2.3).
Orthodontics Comprehensive treatment of patients with orofacial clefts
is best carried out within a multidisciplinary team which includes, in addition
to orthodontists, oral and maxillofacial, ENT and plastic surgeons; paediatric
dentists; people to assist oral rehabilitation; and speech therapists. Active
orthodontic treatment is provided at the appropriate stages in the patient’s
growth and development, and may extend from shortly after birth until early
adulthood.
Orthognathic surgery involves cooperation between orthodontists and
maxillofacial surgeons. The aim of such treatment is to correct serious
malformations of skeletal jaw structures, from patients for whom conventional
orthodontic treatment is insufficient to correct the abnormal jaw relationship,
to patients suffering from syndromes which affect the jaw and skull growth
(e.g. Crouzon’s or Apert’s syndrome, hemifacial microsomia and other
asymmetry malformations), to patients with tumours or growth disorders
which impair normal jaw development.
Further reading ● AlSarheed M, Bedi R, Hunt N P 2003 Orthodontic treatment
need and self-perception of 11–16-year-old Saudi Arabian children with a sensory
impairment attending Special Schools. J Orthod 30:29–34 ● AlSarheed M, Bedi R,
Hunt N P 2004 The views and attitudes of parents of children with a sensory impairment
towards orthodontic care. Eur J Orthod 26:87–91 ● Onyeaso C O 2003 Orthodontic
treatment need of mentally handicapped children in Ibadan, Nigeria, according to the dental
aesthetic index. J Dent Child (Chic) 70(2):159–163 ● Waldman H B, Perlman S P,
Swerdloff M 2000 Orthodontics and the population with special needs. Am J Orthod
Dentofacial Orthop 118(1):14–17.
 Special care in dentistry 24

Table 2.3 Implants in various conditions

Condition Evidence that Implant success rate Other considerations Management modifications
condition is a compared with that that may be indicated
contraindication in healthy population
to implants (level of evidence)

Alcoholism – Similar (5) Tobacco use, bleeding problem, May not be a good risk group
osteoporosis, impaired
immunity, malnutrition,
behavioural problems
Bleeding disorder Medical advice Similar (5) Possibility of blood-borne May not be a good risk group,
should be taken first infections medical advice should be
F07151-Ch02.qxd 10/3/06 9:43 PM Page 24

taken first
Bone disease – Similar (4) – Sinus lifts may be
(osteoporosis, contraindicated
osteopenia)
Cardiac disease Medical advice Similar (5) May be anticoagulated. Avoid GA
should be taken first Poor risk for general Give endocarditis prophylaxis
anaesthesia (GA)
Corticosteroid therapy – Similar (5) May be impaired immunity Consider parenteral
corticosteroid cover.
Consider antimicrobial
prophylaxis
Table 2.3 Implants in various conditions—cont’d
Condition Evidence that Implant success rate Other considerations Management modifications
condition is a compared with that that may be indicated
contraindication in healthy population
to implants (level of evidence)

Diabetes mellitus – Slightly reduced (2a) Microvascular disease. Avoid hypoglycaemia

Osteoporosis Use chlorhexidine
Consider antibiotic prophylaxis
Immunocompromised Medical advice Similar (4) May be blood-borne infections Use chlorhexidine
patients should be taken first Consider antibiotic prophylaxis
F07151-Ch02.qxd 10/3/06 9:43 PM Page 25

Mucosal disease – Similar (4) – –

Neuropsychiatric Medical advice Similar (4) Behavioural –
disorders should be taken first
Radiotherapy or – Reduced (1b) Prognosis Surgery 21 days before DXR.
chemotherapy Similar (3b) DXR <66 Gy (ORN) or <50.
Hyperbaric oxygen. Defer
implants 8 months. Consider
antimicrobial cover
Xerostomia – Similar (4) – –

Appropriate oral health care

25