Things to remember

The patient should be considered ‘in the bigger context’, including general medical condition, cooperation, physical mobility, ability to give a valid and informed consent,  social issues, relatives care, etc

Patient-centered approach is paramount

Long-term assessment of caries risk, risk of periodontitis and any other oral health problems, including oral cancer screening

Individual treatment plan which can be significantly altered, modified and adjusted depending on patient cooperation, mood, ability to consent or withdrawing consent for any reason

Seek further advice from senior colleagues, do not hesitate to discuss complex cases with them. Be assertive, say ‘I cannot do it’ if some requests/referrals/treatment plans do not seem to be optimal solution for the patient, considering health factors.

Discuss non-standard treatment plans with others, get another opinion regarding complex cases, but remember: any clinical decision belongs ultimately to operator.

Oral hygiene screening and provision is crucial, with the close support of the dental hygienist, dental therapist and oral health promotor Demonstrate proper OH for carers and support workers, encourage them to maintain a regular TB Advise of other medical and dental professionals highly recommended and valuable, including physicians, hospital consultants, specialists, colleagues.

Dentist with special interest in special care dentistry must have a substantial knowledge in general medicine, including complex medical conditions and medications.

The use of BP monitor, pulseoximeter, HgA1c glucose level and INR check (AccuCheck) should be available in dental surgery.

Careful decision-making process regarding dental treatment under general anaesthesia provision or conscious sedation

If any doubts, it is wise to ‘step back’ and say: ‘ hold on, stop for a second, we need to need to make sure that…’ or ‘ hold on, stop for a second, it is not safe to proceed further as I am really concern about….’

It is nothing wrong of being assertive and not to go straight ahead with non-urgent treatment complex plan as patient demands

Complex comorbidities, unstable conditions may prevent from proceeding forward with and elective  dental care

Dental care for medically compromised patients is getting more and more complex and challenging due to  various medical conditions ‘overlapping’ at the same time, gross needs for restorative care in elderly patients, multi-drug therapies and age factor.

Patient health and safety first – general rule, do not undertake procedures with high risk of complications, eg. surgical exodontia without radiographs, especially during GA or domiciliary care

Prevent from medical emergency situation by: careful MH check, appropriate referral, wise tx planning and avoid over-treatement when appropriate.

Joint meetings regarding the decision about the dental intervention always must take into account the best interest of patient in order to secure his/her oral health, relief pain, discomfort and make them ‘dentally fit’.

Keep away all distractions during dental treatment in clinic, GA and domiciliary care, concentrate and stay calm

Demonstrate a professional attitude all the  time. Do not loose calmness even if patient asking eg. strange/difficult questions, making some jokes, being sarcastic or impatient (eg. autistic, with Asperger’s syndrome)

Patients with mental health often very emotional, in tears, with ‘swinging’ mood.

‘Breaks from treatment’ if any elective care left may help to regain patient’s confidence. Avoid over-treatment.

Some patients with mental health problems may obsessively focus on one aspect  of their dental problems, eg. crowns, gums, etc. They may demonstrate a vast amount of the knowledge  related to those problems, including, aetiology, causative factors etc.

Toothpaste dispenser helps  a lot for patient’s with manual dexterity problems.

Do not underestimate any complaints and  statements from patient, even if they sound ‘unreal’. Example 1 – patients with serious mental health problems for many years c/o a ‘discharge’ inside the nose. No further  investigation  was advised for many years. ENT specialist exam and CT scan revealed completely radiopaque sinus. Example 2 – patients c/o a problems with swallowing and ‘itchy throat’. Endoscopy revealed suspicious ‘lump’ inside a pharynx which required further HP investigation re: SCC.

Tentative diagnosis initially helps to establish the potential treatment pathways as in difficult cases it may not be possible to get a definite clinical answer regarding the causative factor.

Seek for all potential dental problems which might be the causative factors if the patient with additional requirements is unable to indicate, express and localize eg. the source of pain/discomfort. This is particularly relevant for non-odontogenic problems such as: sinusitis, salivary glands diseases, trigeminal neuralgia, oral medicine.

Be ‘cautiously vigilant’ while dealing with special needs patients: undiagnosed trauma, fractures, malignant condition’s.

Dental care may be provided from a variety of clinic premises, including mobile clinics, and may involve domiciliary visits where appropriate Patients in wheelchairs may require special facilities, including wheelchair recliner and the use of hoist

Bariatric patients may require bariatric dental chair, considering maximum weight limit

Elderly patients with complex medical conditions and dental needs may not tolerate time-consuming procedures, including RCT, crown prep, etc. More preventative and step-wise approach, periodical breaks, not ‘too intense’ Tx plan.

Weigh of electric wheelchair plus obese patient may be even above the maximum limit of specially dedicated bariatric platform! (max 50 Stones) Better to carry on with dental treatment with the bariatric patient staying on his/her reclining, electric chair. Much more comfortable, options depend on the type of electric chair, no need for hoisting (some patients really dislike being hoisted)

Be aware that obese patient with chest problems (COPD, Asthma) laying down on dental chair may experience a drop of O2 saturation as more upright position preferable.

Constant pulseoximetry monitoring recommended.

Be aware of serious risk of adrenal crisis if patient is on prolonged corticosteroids therapy (eg. acromegalia, endocrine disturbances). Patient should bring eg. hydrocortisone injection in case of any signs of AC as life-threatening condition. To consider double dose of steroids prior invasive procedure (extraction) following getting a specialist opinion.   Surgical procedures, eg. impacted third molars extractions, retained roots removal can be well managed  in primary care using IS or IV sedation. Some surgical procedures can be also carried out under GA.

The impacted and angulated third molars may be potentially a causative factor of eg. external root resorption of second molars and subsequent further complications

Electric pulp test with the use of Pulp Tester very useful in cases when patient who suffers from bruxism and chronic sinusitis co: poorly defined, atypical facial pain/discomfort and unable to localize the problems. Particularly in case of suspicious posterior upper teeth which are not TTP and do not reveal any obvious periapical pathologies on PA radiographs. Helpful to distinguish odontogenic and non-dental origin of the pain.

Patient with mental health problems, fibromyalgia and polymyalgia and chronic facial/head pain (neurotic pain, neuralgia) may be on gabapentin or carbamazepine. Patient with mental health problems can be reluctant to have any teeth extracted but may well embrace a restorative option.

For phobic patients who cannot tolerate the high speed hp noise the ‘speed-increasing slow hand-piece’ (with the red strip) can be the optimal solution for conservative dental treatment.

Recently introduce fully aesthetic, zirconia-based preformed crowns for deciduous teeth are potentially a viable alternative for SS crown, when patient or parent is unable to accept ‘non aesthetic metalic appearance’ of SS crowns.

Keep it as simple as possible, clear and concise, do not over complicate. Remember that dental appointment cancellation may trigger an emotional instability in certain patients with special needs, including ‘crisis-team’ meeting, particularly if patient is in pain.

To avoid cancellations as much as possible, if it happened – patient needs explanations, another appointment ASAP and lots of reassurance. Alternative date n the earliest possible time, including booking a patient on emergency slot. Never underestimate patient’s opinions/statements/complaints.

Some unxplained dental problems may indicate something truly sinister, eg. oral/pharynx/sinus cancer.

Be aware of MUS – Medically Unexplained Symptoms with the differential diagnosis including: atypical facial pain, TMJ disorder, migraine, neuralgia, mental health disorder, depression, hormonal imbalance, etc.

If patient complaints of constant ‘facial’ discomfort, practical tip: to encourage him/her to write and daily notes about pattern, location, severity, etc. using his/her own words  and thoughts about potential dental problems. Up to a few weeks time, patient should bring it for a review appointment in a month time.

With regard to risk of osteoradionecrosis following head and neck radiotherapy: “A total radiation dose of <55 Gy should not be regarded as low risk, because the risk of developing ORN cannot be determined by radiotherapy dose alone” (Journal of DOH, 2013, 14/2, 53p).

Topical Benzocaine safer than lidocaine! as is not absorbing via mucosa. Lidocaine gets to system therefore lidocaine dose needs to be calculated with regards to weight.

Is it true that vasoconstrictor (adrenaline) in LA reduces LA active substance toxicity? According to some research, there is no massive difference between epinephrine concentration 1:80000, 1:100000, and 1:200000 re: systemic toxic effect. More important is slow LA administration than adrenaline concentration, particularly in case of accidental intravascular LA administration!

Topical LA usually do not work on palatal mucosa which is keratinised. Cotton wool palat or ideally transmucosal adhesive patch for longer time (eg. 0 sek) with LA would be a better option.

Stretching soft tissue with finger (not dental mirror, as dental students learn) and gentle rubbing with finger: less painful and distraction.

‘Vibro’ devices may help to achieve more comfortable injection.

Duraphat varnish contains carbohydrate saccharin – according to patient’s with poorly controlled diabetes type 1 – after applications of topical F varnish patient became unwell, Hb glucose level elevated significantly which subsequently required hospitalization

Intraosseous dental anaesthesia rather not suitable for patients with special needs (should be treated only as “rescue anaesthesia”)

Electronic dental anaesthesia (EDA) and needless LA (eg. Injex) not recommended for patients with special needs.

AMSA, PSA local anaesthetic techniques with CCLAD systems reduce the problem with prolonged lip numbness, which can be particularly beneficial in patients with special needs and children.

Is Citanest 3% with felypressin vasocontrictor really safer option in pregnancy? Not entirely true (myth?) as felypressin is crossing placenta.

In cardiac, pregnant and medically compromised patients, articaine with lower concentration of adrenaline better than Citanest. In Germany, there is available articiane with 1:400000 adrenaline concentration which would be the best option for medically compromised patients (not registered in UK yet).

Generally, up to 1.7 ml of LA should ‘do the job’ and 2.2 ml cartridge is not really necessary for a single infiltration LA.

Myth: articaine cannot be administered for IANB.

Do not repeat IDB twice with the same needle as it does bend and deflect. Less comfortable for a patient second time.

Better not to apply only buccal infiltration for lower molars whilst providing invasive dental care. Only 40% success,it means that patient may feel discomfort/pain which might discourage him from further dental appointments.

LA with articaine more suitable for medically compromised patients, with liver dysfunction and alcohol problems due to the fact that articaine has got a short half life (45-60 mints) and is breaking down by plasma enzymes, not in the liver like lidocaine is. However, there is a genetic condition with these enzymes deficiency.

A new drug Soliris (Eculizumab, FDA approved, Alexion Pharm) is dedicated for patients with myasthenia gravis, a condition affecting acetyl choline receptors at neuromuscular junction.