11, 12, 13 - Special Needs Dentistry

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SPECIAL NEEDS DENTISTRY

• What is special needs dentistry- The improvement of oral health of individuals and

groups in society who have a physical, sensory, intellectual,

mental, medical, emotional or social impairment or disability or,

more often, a combination of a number of these factors. (JointAdvisory Committee for Special Care Dentistry)

-Special Needs Dentistry (SND) is defined as an area in

dentistry which concerns in the oral health management of

patients adversely affected orally by intellectual or physical

disability and medical or psychiatric issues or, more often, a

combination of a number of these factors, where such conditions

necessitate a modified delivery of oral health care for patients’

total health well-being. ( The Malaysian Dental Journal)

• It is defined by a diverse group of people with:

– a range of disabilities

– complex additional needs

– long stay residential care – people in secure units

– people who are homeless.

• It is important to remember that not everyone with disability

requires SCD, as not all disability limits oral health.

• Also, those people who are ABLE to express need and ABLE to

easily access mainstream dental services, despite disability,

are not in need of SCD.

• Whereas, those people unable to express need or unable to

access care because of disability (for example, due to reduced

communication, fear, inability to co-operate) require SCD.

Group of People Needing Special Care

• The Joint Advisory Committee for Special CareDentistry has identified the population who requirethe services of special care dentistry as:

-'Individuals and groups in society who have a physical, sensory, intellectual, mental, medical,emotional or social impairment or disability or moreoften a combination of a number of these factors.‘

• However, there is no ready made database toprovide figures for the proportion of the populationthat fall within this definition.

Group of People Needing Special Care

Faulks and Hennequin described three groups of people

who require SCD :(Defining the population requiring special care dentistry using the international

classification of functioning, disability and health – a personal view. J Disabil Oral

Health 2006; 3: 143 –152.)

1. People who experience disability due to impairment of oral

function and/or structure and who are limited in their activity

and/or participation directly by their oral status

2. People who have a condition that has direct or indirect

repercussions on their oral health

3. People who are disabled by their social, environmental or cultural

context, which reflects on their oral health.

Scope for This Speciality

• This involves:

1. Diagnosis of orofacial conditions and the provision of

appropriate information to patients of diagnosis, treatment

or management options and their consequences.

2. Removing tooth tissue and/or placing materials for the

purpose of either the temporary or permanent restoration

or replacement of tooth structure or the rehabilitation of the

dentition.

3. Performing procedures on the orofacial complex, teeth,

and the hard and soft tissues surrounding or supporting the

teeth.

4. Extracting teeth.

5. Administration of local analgesia and, or sedative drugs

in connection with procedures on the teeth, jaws and the

soft tissues surrounding or supporting the teeth.

6. Prescribing medicines appropriate to the scope of

practice, the sale or supply of which is restricted by lawto prescription by designated health practitioners.

7. Prescribing special tests in the course of dental

treatment.

8. Using ionizing radiation, for diagnostic purposes, in the

course of the practice of dentistry.

10. Performing procedures on any person preparatory to, or

for the purpose of, the construction, fitting, adjustment,repair, or renewal of artificial dentures or restorative or

corrective dental appliances.

Barriers to Accessing Care

1. Current workforce:

– Most dentists working in the field of SCD are based in the

salaried Community Dental Service.

– General dental practitioners contribute to the overall

picture of SCD, but only a small number of practitioners

have a special interest in this field.

2. Current training:

– On the whole, individuals who have undertaken trainingin SCD have been responsible for their own training,formal and informal.

– It should not be left to the individual dentist to fund theirtraining in SCD.

3. Current delivery of SCD:

–As SCD is not yet an established specialty, the hospital-based services which do exist (often provided by theCommunity Dental Service) depend upon the goodwill ofspecialist and consultant colleagues.

4. Access to the building:

- Despite legislation and the clear expectations of the

Equality and Human Rights Commission (EHRQ), physical

access to dental surgeries continues to be a barrier todental patients.

– Dental clinics which set up which is not ‘elderly

friendly’.

5. Access to the dental surgery:

-Examine the entrance including door width, door

opening, position and design of door handles. Include the

reception and waiting room, looking at the height of the

reception desk, clear signage, non-slip flooring,

communication aids, appropriate seating including chairs

with arm rests, and space for wheelchairs.

- Transportation.

5. Access to the dental chair:

-It is important to consider whether people with physical

disabilities can easily access the preferred dental chair or

whether the same model is available with a 'break-leg'facility to ease transfer.

- When transfer is not straightforward, because the

patient cannot stand or weight bear, 'transfer' or 'banana

boards' can be used. This method requires that thedental chair has a break-leg design and is lifted or

lowered to the same level as the wheelchair. After the

side arm is raised or removed, the smooth curved board

(hence the name 'banana board') is placed between theseats to allow the person to slide from the wheelchair to

the dental chair or vice versa.

-A portable turntable can also be a useful device. It has

the advantage of being able to be used with most wheelchair

and dental chair designs, and can be used in place of a hoist for

some patients with good upper body strength.

-A hoist is the best option for safe and efficient transfer

of patients unable to do so independently, to the dental

chair.

-Recent innovations for patients who should not be

moved from their wheelchairs have included fixed and

portable wheelchair reclining platforms with integrated

head rests.

– The Mun-H-Center in Gothenburg, Sweden, is a National

Resource Centre for oro-facial aids and has developed a set

of four cushions to provide 'non-steady anatomicalsupport' in the dental chair . They can be used individually

or in combination, depending on the needs of the patient.

Philosophy of care• A philosophy of care is a framework of care goals and values

to help you make the best choices for your child and family.

• Special Care Dentistry has a broad based philosophy which

takes a holistic view of oral health and requires specialists to

liaise and work with all those members of an individual's careteam. This is particularly important in the case of people at

the more severe end of the spectrum of disability, where a

greater range of issues needs to be considered.

HUH???

• Reason :so that you are prepared to make

thoughtful decisions when crisis moments

arise; it may be difficult to make decisions in

the moment without a philosophy to guide

WHY???

• -Get your child stable and comfortable as you cannotfind a framework of care if you are focusing onimmediate issues.

-Clear your mind.

-Talk about it!Benefit from the experience of othersby talking with your partner,pediatrician, hospicecounselor, other families, clergy, family and closefriend.

HOW???

• The ethos of Special Care Dentistry (SCD) has always echoed this

philosophy. It is concerned with the improvement of oral health of

individuals and groups in society who have a physical, sensory, intellectual,

mental, medical, emotional or social impairment or disability (or, more

often, a combination of a number of these factors) through this broad-

based, cross-agency, partnership approach. The development of a

Specialty in SCD would provide a better balance between need and

provision, and between prevention and treatment, which is exactly what

the Government is working towards in tackling health inequalities.

Reducing Inequalities

• People with disability are subject to inequality in oral health

both in terms of prevalence of disease and unmet healthcare

needs.

• Over 18% of the global population is living with moderate to

severe functional problems related to disability, and a large

proportion of these persons will require Special Care Dentistry

at some point in their lifetime. (D. Faulks et al; European Journal of

Dental Education ISSN 1396-5883 ; 5 January 2012)

1. Lack of Education:

• Lack of education has been cited as one of the barriers for thepoor awareness of the importance of oral health for people

with disabilities and, subsequently, one of the factors that

impacts in the provision of oral health care for a significant

number of individuals within society.• Education as a possible solution to improve access to oral

health care for the people who needs special health care.

• Undergraduate education:

– Include Special Care Dentistry in undergraduate teaching.

– Centered on demonstrating positive attitudes towards

diversity and included disability awareness, public healthaspects of Special Care Dentistry and relevant ethics and

legislation.

– In 2006, the American Dental Education Association

(ADEA) adopted a resolution to ensure that education

programs include both didactic instruction and clinical

experiences involving treatment of people with special

needs’.

• Postgraduate and specialist education:

- Currently, Special Care Dentistry is recognized as a

registered specialty in four countries: Brazil, Australia,New Zealand and the UK.

• Training of professionals complementary to dentistry:

-Special Care Dentistry is embedded in prequalification

courses for dental nurses, hygienists and therapists in theIreland, the UK and Argentina.

-The Academy of Dentistry for People with Disabilities inthe USA allows hygienists to take the fellowshipexamination and, if successful, to become fellows of the

Academy.

2. Awareness among the public:

– Many people with disability is not registered as a Person

with Disabilities (PWD) with the Social Welfare

Department. Consequently, he does not receive anybenefit or assistance from the JKM (Social Welfare

Department) for disabled people.

• June 02, 2011 14:15 PM

• Most Handicapped People Not Yet Registered With JKM

• By Zulkiple Ibrahim

KUALA LUMPUR, June 2 (Bernama) — Fifty-year-old AbdulRahim (not his full name) had both his legs amputatedbecause of diabetes about a decade ago. Last year, thewheelchair-bound government retiree had his left handamputated due to gangrene.

• However, Abdul Rahim is not registered as a Person withDisabilities (PWD) with the Social Welfare Department.Consequently, he does not receive any benefit or assistancefrom the JKM (Jabatan Kebajikan Masyarakat) for disabledpeople.

• Why did he fail to register with the JKM?

• “Nobody told me to do so. And I really don’t know about anyform of assistance that is available from the government,” hesaid.

Impact of

Health and Social Policy

Services &protection

The Department ofSocial Welfare

Ministry of Women, Family,and Community Development

State Home for Disabled

• Now known as the Taman Sinar Harapan

(Centre of Bright Future or TSH)

• Various types of disabilities such as cerebral

palsy, Down's Syndrome, hydrocephalus,

mental retardation, speech defects and

deafness

Sheltered Workshop (Bengkel Daya)

• Give people with disabilities opportunities

leading to dignity, self worth and socialization

amongst their peers

• Objective: To create employment

opportunities for the disabled and at least to

help the group to be economically

independent.

Bangi Industrial Training and

Rehabilitation Centre

• Provide services for physically disabled peoplewith vocational training and medicalrehabilitation:

IT – ComputerFashion Design & Tailoring

Electronics Prosthetic and Orthotics Multimedia

Wheelchair ManufacturingElectronic Computer Painting

Rehabilitation Ward Physiotherapy

Community-based Rehabilitation Center

• 313 CBR centers established throughout the

country

• Educational programs provided: reading,

writing, social skills, language development,

career guidance, vocational training, religious

and recreational activities

Pusat Pemulihan Dalam Komuniti

Bukit Baru

P P lih D l K i i

Pusat Pemulihan Dalam KomunitiBukit Baru

• Rumah Orang Tua Melarat (Old Folks Home)

• Rumah Bina Diri(Self awareness Home)

counseling, education, vocation, religious

educational and recreational activities.

What is disability?

• A disability is a condition or function judged to

be significantly impaired relative to the usual

standard of an individual or group. The term is

used to refer to individual functioning,including physical impairment, sensory

impairment, cognitive impairment, intellectual

impairment, mental illness, and various typesof chronic disease.

Mobility and physical impairment

Cerebral palsy

• Abnormal oral habits: tongue thrusting,

mouth breathing, drooling

• Difficulty in sucking and eating

Vision disability

Hearing disability

Mouthbreathing

Sign Languages

Learning disability

Attention deficit/Hyperactivity disorder(Atomoxetine)

Psychological disorders

• Schizophrenia

(high DMFT)

Brain injuries/disability

• Autism

Austism spectrum disorder

Autistic disorderAsperger’s

syndrome

Pervasivedevelopmental

disorderRett syndrome

Childhooddisintegrative

disorder

Interlectual disability

• Down syndrome

Down Syndrome in Malaysia

•In an earlier report published in 1989,incidence of Down syndrome in Malaysia is 1

in 950

Incidence classified into 3 major ethnics inMalaysia

Malay - 1 in 981

Chinese - 1 in 940

Indians 1 - in 860

Wh i diff b h h f

What is different about the teeth of

people with DS?

Delayed eruption

Microdontia

Macroglossia

Malocclusion

Gingivitis

Dental caries

Metabolic Diseases

Genetic conditions that result in metabolism

problems

defective gene that results in an enzymedeficiency

• Disabilities can affect people in different ways

Overview of demography of disability

Number of registered People With

Disabilities in Malaysia

Disabilities 2012Visual 27636

Hearing 39303

Speech 180

Physical 106252Learning 117699

Mental 2130

Multiple disabled people 12713

Total 305,640

However, these data are incomplete as registration of persons with

disabilities in Malaysia is not compulsory

Who are eligible?

• Not all patients who fall under the category of

special needs require management by the

specialist in SND.

• Referral to specialist in SND should be limitedto those patients with complex problems

which may, for example, require treatment in

the hospital setting or those with issues ofmultiple problems

• Can be referred to Hospital Kuala Lumpur and

Hospital Serdang for further management co-

morbidities and polypharmacy.

• Strategies such as effective communication,relaxation method, desensitization, and

general anaesthesia are often used in

managing people with special needs receivingoral health care in the surgery.

Current workforce

• Most dentists working in the field of SCD are based in the salaried CommunityDental Service.

• There is a smaller constituent of SCD based in general and teaching hospitals who

are either salaried NHS or university staff.

• General dental practitioners contribute to the overall picture of SCD, but only a

small number of practitioners have a specialist interest in this field.

Service for Children With Special Needs in

Malaysia

• The Oral Health Division has recognized children with special needs as oneof the priority groups. A programme for CHILDREN WITH SPECIAL NEEDS

was launched in 1993 with emphasis given to the disadvantaged group at

outpatient clinics besides some form of treatment given to children at the

institutions.

• Objective: To improve oral health of children with special needs that willcontribute to enhanced quality of life.

• Activities: Inculcating good oral health practices, increasing awareness of

carers of children with special needs and improving skills of dental

personnel.

• This is to ensure that good oral health is achieved through oral healthpromotion, clinical preventive measures and other necessary treatments

in line with Vision 2020 and the Vision for Health towards the

development of a caring society.

Voluntary Organisations

•Collectively and individually, they are a primary source of knowledge and expertise on all aspects oflearning disability.

• Based on British society of disability and oral health guideline of 2012, the range of organisationsinvolved includes:

-Self-advocacy groups, in which people with learning disabilities come together to find strength inunity, explore common problems and share solutions.

-Citizen advocacy groups working in partnership with people with learning disabilities to inform themof their rights, help them assert those rights.

-Parent and carer groups in which members learn from each other’s experiences, and work togetherfor greater success and a diminished sense of isolation.

-Policy-shifting organisations, which advise, campaign, inform and co-operate with others to changenational and local policies and practices.

-Service providing organisations, which provide services, usually under contract from the statutoryagencies, and sometimes with added value from voluntary input.

• In Malaysia , there are 49 Kiwanis clubs across the country, with more than 1300

members. The first club, the Kiwanis Club of Kuala Lumpur was chartered in 1976by the then returning Ambassador to the US, "Bapak Kiwanis" Tan Sri Khir Johari.

The National Autism Society of Malaysia (NASOM) is a non-profit, non-governmental welfare organisation which was formed in

1986 by a group of parents and professionals. It was registered on 3rd March 1987, as a national voluntary charitable organisation

and aims at providing education, help, care and protection for people with autism and their family members. Currently, NASOM

has established 14 Early Intervention Programmes and 3 Vocational Programmes for people inflicted with autism in Malaysia.

PSDNJ started as a small support group of parents who sent their children to Kiwanis’s

Early Intervention Centre. With guidance and support from the Kiwanis members and

teachers, we started to form our society, Down Syndrome Society of Johor. We are

the first association created specifically to support the cause of individuals with Down

syndrome established at the state level. Following from the success of this

organization, there are now currently 8 such State-level associations in Malaysia.

Speech TherapySpeech –language pathologists assess and treat individuals from children to

adults with communication difficulties. These include understanding, expressing,

pronunciation difficulties, voice difficulties, fluency and nasalized speech.

They may also work with people who have feeding and swallowing difficulties.

Speech –language pathologists work collaboratively with patients, families

and related professionals to ensure patient’s needs are been addressed holistically.

Current delivery of SCD

Current delivery of SCD• As SCD is not yet an established specialty, the hospital-based services which do

exist (often provided by the Community Dental Service) depend upon the goodwill

of specialist and consultant colleagues to gain access to facilities such as generalanaesthesia operating lists. This increases the complexity of the services and the

difficulty of coordinating the various agencies involved in an individual's care.

• Specialists work need not, and indeed should not, be restricted to working in

hospitals. Local studies demonstrate that general and community dental services

provide the majority of the currently supplied care for people living in community

settings who are on disability registers.

Skills mix and facilities

• Whereas consultants and a large proportion of specialists have until recently had a strong

hospital focus, there is recognition that not all of them need to be based in hospitals or, if

they are, they may only provide certain aspects of care in a hospital setting. SCD should be

predominantly community based. This would have the effect of reducing inequality in two

• Directly — by improving physical access to a specialist service that is not solely hospital based

• Indirectly — by improving access through support for interested generalists in primary dental

• Hospital services should be closely aligned with specialists in a community setting so that

people who require hospital-based treatment because of medical complications,

multidisciplinary care, and/or care under general anaesthesia, may do so seamlessly.

• Ideally, the dental team will include dental care professionals (DCPs) such as dental therapists

and dental hygienists, and may involve liaison with health promotion services to ensure that

a preventive approach is taken locally to support health care for people with disability. Such

an approach allows a proactive move to reduce and prevent dental disease rather than the

currently common reactive approach of treatment of disease.

Malaysia

MalaysiaSpecial Needs Dentistry (Snd) In Malaysia: A Way Forward

Siti Zaleha Hamzah - Special Needs Dentistry, Hospital Serdang

INTRODUCTION

• Ministry of Health Malaysia (MOH) recently recognised SND as a dental specialty to provide better oral

health needs of the population with disabilities who, due to advances in medicine and improved general

healthcare are surviving much longer into old age.

• In Malaysia, it is predicted that, with an increased number of elderly in the community due to an

improvement in health care delivery and health awareness, the population with disability/ies may also

expand as older people are more likely to develop coincident or consequent disability with ageing. Apartfrom that, it has been reported that the number of Malaysian population suffering from various types of

disability had significantly increased from 132, 655 in 2003 to 197, 519 in 2006. Therefore, the demand in

oral health care for these special needs groups is expected to outstrip the service currently provided. The

same situation is also reported in United Kingdom, Australia and New Zealand.

• Many studies have confirmed that people with disabilities are more likely to have a poorer oral health

condition than those in general population, mainly due to barriers such as limited access to dental service,

financial problems and the complexity of medical conditions from which they suffer.

DEFINITION

• In Malaysia, Special Needs Dentistry (SND) is defined as an area in dentistry which

concerns in the oral health management of patients adversely affected orally byintellectual or physical disability and medical or psychiatric issues or, more often, a

combination of a number of these factors, where such conditions necessitate a

modified delivery of oral health care for patients’ total health well-being.

SERVICE DELIVERY AND PATIENT MANAGEMENT

• SND includes the delivery of oral health care, focusing on individuals with special

needs above 16 years, and it is a hospital-based dental specialty due to the

complexity of the problems that the patients are often presented with.

• Therefore, referral to specialist in SND should be limited to those patients with

complex problems which may, for example, require treatment in the hospital

setting or those with issues of multiple co-morbidities and polypharmacy.

• For the time being, patients with special needs can be referred to Hospital KualaLumpur and Hospital Serdang for further management whereby care provided

includes various types of treatment in general dentistry.

l d l l

Special Needs Dental Surgeons in Malaysia

SND IN THE COMMUNITY DENTAL SETTING

• With the aim to reduce the gap and burden for patients to access oral health

care facilities, the community component in SND would enhance and

encourage knowledge and competence of the community based dental

officers in managing and providing care for patients with special needs

through various strategies and planning.

• The set-up of the SND service in the community is to facilitate the delivery and

provision of oral health management and care for those patients who are

considered having mild to moderate disabilities/medical problems.

CONCLUSION

• More dental practitioners are expected to develop their interest in SND field as thetraining pathway becomes clearer, as well as the initiative of the Ministry of Healthto support the career development of the specialist in SND in line with otherexisting dental specialties in the near future. To ensure a continuing developmentin this rewarding field of dentistry, research in SND should be encouraged andincorporated in planning, development, and monitoring of the specialty.

• Thus, future studies should investigate the oral health status of adults withdisabilities in Malaysia in various aspects, such as caries experience andperiodontal status which is currently lacking.

• There are many ethical issues related to this area of health care and few questionsor problems can be addressed in a yes/no, black or white manner.

• Thus, details investigation and attention are required to explore these areas ofconcern in the future development of SND service in Malaysia.

References

• http://www.hraljournal.com/Page/7%20Kamarulzaman.pdf • http://www.cbrglobal.org/Downloads/PS2a.pdf

• http://www.ijssh.org/papers/447-H10019.pdf

• http://www.pdknet.com.my/web/index.php?module=view_pdk&pdk_id=

• http://www.ncbi.nlm.nih.gov/pubmed/24417495

• http://www.ndss.org/Resources/Health-Care/Associated-

Conditions/Dental-Issues-Down-Syndrome/

• http://www.mdj.org.my/index.php?option=com_content&view=article&id

=141&catid=53&Itemid=133• http://www.disabilitymalaysia.com/about.html

• http://ohd.moh.gov.my/v3/index.php/en/contact-us

• https://www.mah.se/.../Malaysia/.../oral healthcare in malaysia 05.pdf

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