Reflections

Disclaimer: All patients or legal guardians with parental responsibility consented for using fully anonymized information for educational purpose only.

Is there real need to employ a special measures for all patients with special needs ? No, according to available sources, only 20% of special needs patients requires either conscious sedation or general anaesthesia.

Communication skills – the key issue. Full understanding of the patient expectations

Gentle, understanding and reassuring approach (‘iatrosedation’) makes dental treatment manageable for vast majority of cases (80%).

Even without any special sedative measures, dentist is likely to achieve a satisfactory outcome.

If justified, it is wise to rearrange or postpone the “invasive” treatment, especially in phobic/anxious/emotionally/mentally unstable patients

A brief discussion prior tx plan commencement, soothing, calming vice and eye contact helps are vitally important for creating a trust between patient and clinician.

Always provide a different treatment options for special needs patient, including: referral for a second opinion, for conscious sedation, for treatment under GA.

Take ‘a little break’ reflecting what to do in a different way if, eg. phobic/anxious patient seems to be reluctant to accept a routine dental care. Rearranging an appointment (pt does not feel well, has a low mood, etc), postponing an invasive treatment (if not urgent) are sometimes ery welcome by patient who does not feel ready for eg. extraction.

Accept the situation that some of the patient may not return for dental treatment following initial assessment. It is not down to the dentist and reflects the fact of hight prevalence of FTA’s in patients with special needs

“Psychological counseling” has a place in patient’s management. Sometimes, it is more important how to say something to the patient rather than what we tell them.

 

“We need to compromise…”. This statement is going to be used relatively often for  patients with special needs due to their complex problems.

Always balance risk and benefits ! Particularly in case of: patients with severe complex medical problems, elderly individuals and terminally ill patients

According to available data – 0nly 10 up to 20% of persons with special needs require some sort of sedation or general anaesthesia. The vast majority of them are manageable with behavioral management technique, CBT and using just an empathetic approach.

Changes and adjustment to modern special dental care is necessary. Wrong statement: “It has been done always in this way”.  For instance: gradual reduction of traditional GA sessions which should be replaced by TM/IV sedation.

Combination of both intranasal sedation and intravenous sedation is an efficient measure to manage phobic patient, instead of GA

GA should be avoided especialy in case of elderly patients, very obese patient and multiple medical conditions, esp. heart failure and disfunction of corticosteroids production (eg. empty stella syndrome)

Rules in Special Dental Care to improve dental patient quality of life by teaching dental students and young dentists: a) empathy ‘cultivation’, b) enhancement of observational skills, c) enhancement of subjective analysis

Patient-centered clinical practice involving: a) inner experience, b) perspective of the patient, c) capability to communicate this to the patient

Key skills of caring clinician: interpersonal relationship, communication competency, diagnostic observational skills, understanding the patient, observing body language, focusing on important nuances, empathy, methodical approach.

Interdisciplinary approach and team work essential and vitally important! Work much more predictable and efficient in cooperation with, eg. dental hygienits, therapist, paediatric specialist, sedationist, specialist in oral surgery, etc.

 

Always attempt to find the best possible outcome! eg. in case of uncertain/unexplain dental problems in patient with severe deisability who would not allow a proper dental assessment – consult with GP/hospital consultants re: other potential problems(salivary glands, sialolithiasis, tonsillitis), try to take alternative radiograph (oblique lateral), send CD with oblique lateral radiograph to medical professional for further investigation, ask consultant to carry out a good intraoral general dental assessment during eg. endoscopy unde sedation/GA searching for any suspicious pathologies.

Emotional and background context of dental care equally important.

Always worth to get advice from senior colleagues with a vast experience in providing special dental care.

Do not afrraid to implement the positive but radical changes and take your own initiative in the service.

Use special techniques for dental radiographs, especially when they are essential for treatment planning, eg. prior to general anaesthesia. Oblique lateral radiographs (bimolars technique) very useful in these cases.

If child would not tolerate a standard ‘Rinn’ holder for intraoral radiographs, so-called ‘crokodile holder’ can be very useful

 

Be competent all the time. Excellent practical skills are essential. Empathy is vitally important but clinical competency is paramount.

Be positive and compassionate all the time. Show enthusiasm, initiative and drive.

Be empathetic but also be methodical, with attention on details re: treatment planning

Be aware of “nocebo” effect whilst communicating with patients

Be careful re: person with parental responsibility towards child and consent

Be curious: ask as many questions as posssible to assess patient’s general health conditions

Use as often as possible various distraction techniques for childen, eg. twinching, clenching, wiggling, etc.

Asking about pain pattern in young child – try to use eg. 10 grades scale

Use any accessible aids and modalities to improve patient access and comfort

Even very simple methods like head support, muscles relaxation, gentle touching around patients cheeks and mandible may improve co-operation

Be flexible and adaptable. Treatment plan alterations are sometimes inevitable.

Be up-to-date re: current dental techniques, materials and modalities

Some parents may provide excellent ‘total care’ for  their disable child, including all available oral hygiene measures

Be ‘very well understanding’ and carefuly listen to your patients! this particulary apply for eg. patients with mental health issues. They may start a long chat and description of their dental and medical problems, including medications, previous dental experience, problems with access to health/medical care, etc.

Do not ignore patients’ wishes and preferences. If patient, even with severe acute dental problem, declines any intervention, embrace it and try to gently explain the potential risk and complications.

Always consider other options to manage a special needs patient. This include: referral to specialist, a second opinion, joint session with other colleague.

If EUA not currently justified and uncooperative patient with severe LD (or carer(s) does not indicate any dental probls, would not allow a proper dental assessment – make the effort to try even a brief assessment another day.

Patient with mental health problems demands multiple extractions ‘in one go’. Be assertive, explain that this could not be the best treatment options, by providing a simple pros and cons potential complications etc.

Root canal treatment for patients with special needs can be limited or contraindicated if patient would not tolerate rubber dam, irrigation with antibacterial agent (NaOCl due to the ‘strange taste’).

Explain, warn about the ‘strong smell’ of some of irrigants for RCT. Reassure the patient that this is normal and harmless antiseptic agent

Use high volume suction, diluted NaOCl and rubber dam while performing root canal irrigation

If patient swallows a small amount of NaOCl – give a water to rinse, reassure.

 

 

Be ‘oral lesion and oral cancer-sensitive’, ie. pay special attention on even ‘innocent’, benign-looking oral mucosa lesions. Example: epulis-like lesion which clinically seems to be benign overgrowth of gingiva/interdental papilla may mimic a potentially more ‘serious’ problem eg. peripheral giant-cell granuloma according to histopathological diagnosis (real case example).

Gingival hyperplasia is a common problem in patients on anticonvulsive medications (Phenytoin). Replacing Phenytoin may resolve a problem with gingival overgrowth

Always attempt to carry out a full dental assessment during first appointment, despite of patients disability/limited cooperation. However, it may not be achievable due to multiple reasons related to patients with special needs. Example:

Capacity assessment and best interest decision need to be carried out every time when there is a doubt about patient’s capacity to consent

Perform a regular clinical self-assessment (clinical audit) to improve quality of dental care.

Learn from failings – sedation sessions can be tough (but always rewarding!)

Good relationship with anaesthetist team is essential. Demonstrate your confidence in eg. cannulation, IV sedation.

Develop your professional skills, maintain close connections with professional organizations, societies.

Share your knowledge, also by publishing clinically relevant articles, including interesting cases.

Show enthusiasm, initiative and drive for the patients and staff.

Despite of best efforts, sometimes there is no ‘golden solution’ and patient/parents/guardians/carers have to embrace this fact.

Follow rational  ‘golden’ rules, stick with guidelines and well recognized standards in dental practice. Do not trust ‘unwise’ houghts, eg. let’s carry out this difficult extraction in elderly and medically compromised patient, if your ‘intuition’ is saying – “something is not quite right”. Better to postpone procedure than take a risk of complications. Do not follow someone else advise (family) and do not try to please eg. carers/suport workers as they urgently request to go ahead and they do not want to wast a time and come back. Be assertive.

From time to time we need to compromise, doing nothing (no action) has to be justified and expained, eg. asymptomatic roots, decayed teeth and lack of cooperation

Adhere to recent up-to-date general guidelines provided by Royal College of Surgeons, Faculty of Dentistry (FGDP), eg. dental radiogtaphy, record keeping and antimicrobial prescribing.

Standards are compulsory to follow, guidelines are good practice recommendations.

Is capnography really advisable for IV sedation ? Is valid evidence for it ?

 

 

Do not overestimate efficiency of conscious sedation. Some patients may surprise you (‘failing is a learning curve’). However, so called ‘deep sedation’ provided by anaesthetist in hospital environment (not common in UK) can be helpful in selected cases following thorough risk assessment.

Sometimes, patient (or parents) say that ‘IV sedation did not work for him/her’ and requests DGA, not accepting any other option. Duscussion and thorough explanation of all avalialbe options always viable.

Do not be ‘overenthusiastic’ re: treatment planning and predictability. Unpredictability makes you more cautious and better prepared for difficult situations and clinical cases.

Always listen to patients regardless any medical/mental conditions and trust what they say about their dental problems. Example: elderly patient complained of ‘loose front tooth with crown’. On intraoral examination no obvious tooth mobility or signs of chronic periodontitis. No intervention applied. Patient returned a few days later with horizontally broken upper central incisors. Reason: potential microfracture or coronal portion.

How to efficiently manage the phobic, but not special needs patient in pain and and acute dental problem? Who is in charge to provide a reasonably urgent dental treatment under sedation for this group of patients? How to manage a case of urgent and anticipated difficult surgical extraction of third molar tooth when the waiting list for secondary care in hospital setting is very long?.

Be prepared for challenging situations and clinical cases. Each patient is highly individual.

Be prepared for patients who do not accept your treatment plan, advice and or suggestions. Our professional opinion can be fairly often not coherent with patient expectations.

Basic but well established practical skills (restorative work, extractions, RCT, prosthodontics) along with proper communication are paramount to achieve the clinical goals.

Antibiotic cover provision seems to be highly controversial in some cases. eg. does type 1 diabetic person need AB cover before/after simple extraction ? or does diabetic patient need AB cover before/after complicated extraction with associating local odontogenic swelling ?

Does diabetic patient need antibiotic cover ? Does it depend on well or poorly controlled diabetes ? or does it depend on type 1 or type 2 diabetes? Are there any clear guidelines associated with this topic ? What happens if patient with type I but very well controlled diabetes develops severe ‘dental infection’ following eg. a difficult extraction and no ABC was provided as there are currently no guidelines?

To prescribe or not prescribe antibiotic in case of non-spreading chronic periapical periodontitis and no symptoms of systemic involvement for the time being? If the patient, especially medically compromised, is highly likely to develop an acute odontogenic infection soon, antibiotic seems to be justified in case of any deterioration and severe symptoms.

What are clinical indications for prescribing a phenoxymethylpennicilin instead of amoxicillin to fight an odontogenic infection? Are there any nowdays?

Give enough time for local anaesthetic work. Local anaesthesia first and then eg. scaling to allow an efficient local anaesthesia. Do not start procedure too early.

Apply additional, specific examinations (tests) allowing to establish a proper definite diagnosis eg. : cold/hot test, transillumination, EPT with pulp tester always in case of any doubts.

EPT test very useful dealing with the cases of patients who suffer from sinusitis, with atypical facial pain, multiple oral health problems, hypochondria, mental health problem, etc.

Be aware of “overlapping” symptomatic dental problem which occur the same time and the same quadrant eg. irreversible pulpitis due to caries, chronić apical periododontitis due to failed endodontics and localised chronic periodontitis with infrabony pocket. Patient my complain of poorely definied spontanes throbbing and radiating pain and is not sure which tooth is causative.

Remember about ‘referred pain’, eg. pulpally involved posterior tooth may cause a pain radiating to upper area and ear due to common nerve trunk (trigeminal nerve).

Pay special attention onto distal areas within posterior quadrants during dental assessment. Some cavities can be potentialy difficult to detect if not careful enough intraoral examination, due to eg. difficult access (buccally malpositioned upper third molar, prone to plaque acccumulation by buccal aspect and caries development within this surface, which can be difficult to detect.

Patient with well controlled mental health issue, including depression, schizophrenia, bipolar disorder are usually very compliant and cooperative.

Some antipsychotic medications may interfere with local anaesthetics, mainly with regards to adrenaline content.

Be a good observer: any unusual signs of abnormal symptoms should trigger ‘red light’. Example: Down syndrome patient with suspicious signs of ‘blue, cyanotic’ hands (changed skin colour) may clearly indicate undiagnosed congenital heart disease, eg. ASD/VSD.

Similary, if patient looks weirdly very pale – not because of being anxious/nervous – look for any problems with anaemia or even heart conditions, including undiagnosed severe congenital problems.

Be careful and conscious of providing local anaesthesia within palatal site in patient with severe gag reflex. The submucosus pressure whilst doing LA on palatal area, especially for molars, can make severe discomfort mimicking ‘foreign body’ or ‘something in the throat’ which triggers gagging.

Use the standard “short” needle, rather then ‘ultra-short” especially for buccal infiltration within maxillary posterior region. Ultra-short needle may nor reach right top area and local anaesthesia may not be efficient there.

Be fully aware of maxium dose of LA !. Remember that articaine supplied as 4% solution, double concentration of lidocaine. Calculate a dose of LA per kg/body mass. Although articaine is metabolised mainly in the blood, a recommended dose of articiane for infiltration LA should not exceed 3-4 cartridges per session.

Use LA with lower concentration of adrenaline (epinephrine), ie. 1:200000 for standard dentla procedures. Shivering after LA may indicate epinephrine overdose.

Check expiry date on LA cartridge !. If nearly expires, eg. in a few months time, best  practice is to replace them (easy to forget in the next few months time).

Avoid infiltration LA on palatal aspect in case of visible swelling/abscess. Incision first.

High concentrated fluoride toothpaste (Duraphat 2800ppm or 5000ppm) might not be accepted by some of the patients as certain ‘intraoral sensations’ have been reported, including: tongue tingling, mild ‘burning’, pinching, stinging, etc.

Headache in children up to 11 y.o. can be potentially related to ‘pneumatization’ of frontal sinuses

Chronic infection of sinuses complex may result in atypical pain, mimicking pain originated from posterior maxillary teeth

Inflammation of sinus cavernous can be a causative factor of facial pain

Potential reasons of atypical facial pain: sinusitis, TMJ disorders, neuralgia, neurological problems

More about being skillful ?  or more about being highly empathetic ? Perhaps it is all about the proper balance between these two features.

 

Being practically skillful and good operator, eg. in surgical extractions (wisdom teeth, buried roots) can be highly beneficial for the role dealing with particularly multiple exodontia under GA.

Great source of guidelines and information regarding dental extraction performer in patients on long-term steroids therapy: Gibson N, Ferguson JW. Steroid cover for dental patients on long-term steroid medication: proposed clinical guidelines based upon a critical review of the
literature. Br Dent J. 2004 Dec 11;197(11):681-5.

Piezosurgery with special cutting tip allows minimally invasive and efficient surgical procedures. This technique can be extremely useful during semi-surgical extractions of partially erupted third molars.

F/S’s can be applied even in adult patients

Avoid putting teeth in a “restorative cycle”, minimally invasive approach much more efficient

Is there any evidence-based data recommending extraction or the opposite –  no intervention, in case of buried retained, asymptomatic roots, with no obvious signs of pathology? To extract or to leave ?

How to assess the risk of complications associated with extraction in severely medically compromised elderly patient, undergoing complex polytherapy?

Careful assessment of root morphology on pre-RCT or pre-xla radiograph. Any irregularities, ‘double-PDL’ contours or ‘overlapping structures’ may indicate the presence the eg. double rooted morphology in case of standard, usually single rooted teeth, eg. upper second premolars, lower premolars, lower canines.

Plastic, non-metal perio probe for BPE assessment seems to be better tolerated by some patients (less unpleasant sensations)

Perform a proper risk assessment before any invasive and irreversible dental procedure, particularly in elderly patients, medically compromised individuals with associated co-morbidities, patients currently undergoing  chemotherapy and/or radiotherapy.

Is there any contraindications for XLA in patients who are awaiting cancer operation/removal but are generally in a reasonably good health condition and not currently on chemotherapy or medications?

Is ‘LA allergy test’ justified in patients who reported ‘unusual reaction’ to local anaesthetic during dental treatment?

Can local anaesthetic cause ‘general weakness’ and ‘prolonged body paresthesia’ ?

Can local anaesthetic cause loss of voice in patient with dystonia or even temporary voice loss?

Be careful while prescribing high concentrated fluoride toothpaste (Duraphat) for patients with dysphagia, PEG fed and problems with swollowing (eg. MS). Duraphat TP is not ‘non-foaming’  (seems to be ‘less-foaming) therefore should not be prescribed in these cases. Instead: OraNurse, Biotene, Proenamel which are non-foaming types.

Mouth cleansers for daily oral care in bed bound/elderly/disable/hispitalized patients. Cotton swabs must not be used as risk of top part detachment and swallowing/choking.

Extra surgical equipment including full set of luxators, PDL cutters and desmotoms can be very useful for anticipated difficult extractions.

Be ‘morphology-wise and procedure-wise’ while performing root canal treatment or extraction on upper second premolars. So-called ‘molarisation phenomenon’ is linked to double (palatal and buccal) or triple rooted (MB, DB, P) second premolars.

Careful and precise separation of the molar tooth roots  during a challenging  extraction. If not sectioned within furcation area, this may ‘weaken’ one of the remaining roots making it more difficult to retrieve.

Be competent while carrying out difficult extraction, always ask “are you still ok?” ” “shall we carry on?”, check of patient vital signs. If any doubts, abandon or postpone procedure.

If small portion of apical portion fractured and anticipated difficult surgical extraction in medically compromised patient, take a risk assessment and decide. Sometimes better to leave it in situ rather than attempting removal unsuccessfully.

Use mainly luxators and elevators before applying forceps to any tooth, particularly multirooted to prevent root fracture during extraction.

Luxators with lateral horizontal notches are very efficient for cutting PDL ligaments

Fractured root apex eg. during general anaesthesia or sedation session. To attempt removal or leave it? (brilliant article: “Fractured root tips during dental extractions and retained root fragments. A clinical dilemma?”. Nayyar J, Clarke M, O’Sullivan M. Stassen LF. Br Dent J. 2015 Mar 13;218(5):285-90).

Is “steroids cover” necessary prior non-complicated dental extraction of molar teeth in patient on prolonged supplementation of corticosteroids (eg. hydrocortisone, prednizolone) due to eg. autoimmune diseases, Crohn’s diseases,  MS, pituitary glands dysfunction? (dose above 30 mg per day). Does the patient require an increased dose of steroids on the day of procedure? Who is in charge to make this decision? (dentist?, GP?, consultant?). What to do in case when patient’s GP’s is unable to provide a strict advice regarding steroids cover?

Empty sella syndrome – permanent supplementation of corticosteroids. Steroids cover always necessary

Management of fully, horizontally impacted and symptomatic third molars (pain, oedema) is challenging. Acute odontogenic symptoms need to be resolved promptly, however due to antibiotic inefficiency (quite often) and long waiting list to get to local oral surgery (MOS) or maxillo-facial surgery department, patient may wait for a while despite an urgent need for immediate extraction(s) according to NICE guidelines. Is there anything else a dental practitioner (not skillful oral surgeon) can do in the meantime ?

Should NICE guidelines regarding third molars extraction be currently revised? Decision about removal of third molars has to be made considering potential odontogenic complication in future (caries, apical periodontitis, local inflammation), preventing from getting severe pain. This ought to be particularly applicable in patients with special needs who would not tolerate well such discomfort.

Hence, should carious, asymptomatic and partially erupted wisdom tooth with no chance for proper eruption but revealing a poor long term prognosis be added into elective treatment planning in special needs patients ? eg. extractions under GA ?

If root deeply fractured during xla, eg. upper firs premolar root, and close proximity towards sinus, patient anxious, do not attempt root retrieval with a anticipated difficult surgical procedure. It is  reasonable to abandon procedure with a thorough explanation to patient about potential post-op problems, potential options, eg. referral to oral surgery dep. You need to know when stop procedure which may cause traumatic experience to patient (especially phobic, anxious)

Success story: surgical extraction of supernumerary molar tooth (undeveloped and reduced in size) under IV sedation to allow a proper eruption of UL8:

supernumerary-molar

supernumerary-tooth

 

It is important to present good skills in oral medicine and oromucosal surgery due to reasonably high needs of dealing with common oral mucosa problems.

What kind of oral surgery better to avoid if not carried out in hospital setting by skilled dental team? : palatal flat rise, lingual intervention within mandible, removal of severely impacted teeth, attempt of removal of small fractured fragment of root of upper premolars and molars, anticipated difficult extraction in elederly, medically compromised person at domiciliary visit.

Is 38% Silver Diamine Fluoride beneficial as treatment option for dental caries in children ?

Special attention when dealing with patient with latex allergy ! local anaesthetic ampule cap may contain latex and LA potentially may trigger allergic reaction.

Does “allergy to adrenaline” (not just to LA) exist? as patient reported this condition? may not be the only myth as adrenaline (LA) solution? always contains some preservatives due to shelf live of adrenaline.

Maximum 15 L/min oxygen flow in case of medical emergency current ERC recommendation  (not 6-7 L/min like in the past)

Always check valve in oxygen mask before putting on patient nose/face. Can be originally faulty due manufacturer problem.

Emerade (Epipen alternative) has got: longer shelf life up to 2 years, and shorter application time in autoinjector (5 mints instead on 10 mints)

Can adrenaline be used in case of severe asthma attack? yes, as a last resort after using first line choice drug, Salbutamol

So called ‘silent myocardial infarction’ may mimick stomach upset.

Non-specific, radiating pain on LHS can be the first sign of cardiac chest pain.

Hypoglycaemia and lack of oxygen can cause seizures

Midazolam buccal liquid should be applied on both sides with ‘cheek massage’ (epileptic seizures)

Detailed questions about insulin intake and meal before eg. extraction

Pulseoximeter (wireless seems to be more handy for special needs patients) should be used more often to monitor patient’s vital signs (HR and O2 Hb saturation)

Contact-less thermometer measuring temperature on forehead may be less reliable compared to in-ear one.

Patient on anti-hypertensive drugs (ACE inhibitors, angiotensine antagonists) are prone to syncope

Wrist-type blood pressure monitor seems to be easier to use compared to traditional ‘arm-cuff’: comfortable, less distressing, no need to remove sleeves. Only disadvantage: technique-sensitive, potentially can be less reliable if used without precise application.

Special precautions re: patient with multiple heart conditions: eg. triple bypasses, HBP, heart failure. In some severe cases is sensible to refer medically compromised patient to oral surgery dep. to get invasive procedure done (eg. surgical extraction) in a safe hospital settings.

What to do if letter from consultant does contain a clinical treatment plan impossible to implement and commence and patient requests to follow specialist advice? Request for revision? Decline treatment as not possible to complete? Difficult dillema…

What kind of restorative treatment outcome would be the optimal for patient with poorly controlled/uncontrolled epilepsy and frequent grand mal fits who lost upper central incisor? To get second professional opinion from Consultant in Restorative Dentistry. Options: 1. no intervention, 2. partial denture, 3. resin bonded bridge(?), 4. single implant installation(?). Due to the high risk of bridge detachment and aspiration/inhalation or acrylic denture fracture during seizures, optimal outcome would be Cr-Co denture with additional anchorages to prevent from dislodgement.

Should buccal midazolam be given straight away when seizures occur? or should 10mg buccal midazolam be given after 5 minutes of seizure activity? (BNF 2015) protocol alteration can be authorised by neurologist

Benefits of bisphosphonates therapy (including IV BP) and risk of osteoporosis complications (fractures) outweigh the risk of complications associated with dental extraction, including osteochemonecrosis (BONJ). Ideally, specialist ought to ask dentist with regards to planned bisphosphonates therapy. From clinical point of view, if any doubts, specialist should start BP despite of anticipated extractions in future.

Brilliant article in Dental Update April 2016 (AE Moore), regarding the above dilemma: “Relevance of Bisphosphonate Therapy in Osteoporosis and Cancer – No Cause for Alarm in Dentistry”

What are the limitations with regards to going ahead or avoiding invasive dental treatment (extractions) in severely medically compromised, frail, and elderly patients with dental problems?

What is the best possible and available scenario in case of highly anxious and phobic patient with social phobia who requires referral to specialist but seems to be unable to travel?

How to justify referral for EUA/dental care under GA/assessment under IV/TM in case of patient with severe/profound learning disability who indicates some dental problems: toothache, ging/perio infections, swelling, etc., but routine initial assessment is not possible due to lack of co-operation? Are eg. troubles with eating, increased agitation, mood change, face touching  sufficient manifestations of some sort of dental problems and putting a patient at risk of GA? Are there any specific criteria to consider acting in the best patient interest? Are there any guidelines, eg. provided by BSDH? Are dental problems outweigh the risk of complications associated with GA, includingmore severe ones? How to explain the lack of justification to parents/carers/support workers/care home managers?How to change their perception regarding ‘routine treatment under GA’ which was pretty common several years ago? Can we just leave it and wait for any obvious symptoms which might justify GA referral? Is it the patient’s best interest decision.

Patient with severe learning disability, nonverbal, uncooperarive and non-compliant, indicates some discomfort within lower facial area, cares report that patient bahaviour changed. Patient lives in a care home, under supervision, but not constantly. Sometimes can  be agitated. Nothing obvious intraorally. Always suspect something ‘more serious than you think’. Not uncommon cases in which on radiograph (OPT or bimolar), mandible fracture can be found. Carers do not remember any accident or patient’s fall.

Are special diagnosic tools, including: temperature measurement, thermographic facial scan, saliva pH, S.mutans count, periodontal saliva markers, etc. helpful to detect acute dental problems in patients with severe/profound learning disability who are not  co-op and do not allow a proper dental  assessment?

C-terminal cross-linking telopeptide (CTX); Biological index to measure bone remodelling and resorption used by some physicians as a screening tool to assess for possible medication-induced (e.g., bisphosphonates) osteonecrosis of the jaw in conjunction with the history and examination (not  validated yet)

 

GDC Standards also contain certain aspects of special care dentistry

Always worth attending sedation courses/trainings. Recently: SAAD BSDH Study Day for Special Care Dentistry. London March 12/2016. Brilliant speakers, great piece of knowledge, opportunity to meet friends. The programm included: Transmucosal sedation, Neuro-disabilty, Medically compromised, Dementia, Propofol, Guidance, training and accreditation, Setting up a sedation service.

SAAD Digest journal – useful source of knowledge about dental sedation

SAADStudyDayProgramme2016March

Stay up-to-date with the latest evidence based data regarding special care dentistry. Trace the latest news from conferences, meetings and study days: IASCD, BSDH, FDI Annusal Congresses. FDI Congress always has a Scientific Session dedicated for Special Dental Care.

fdi