Volume 10, Number 1.       March 2009

Editorial          1

A survey of the quality and quantity of Special Care Dentistry teaching, including Gerodontology, in dental schools of the United Kingdom and Ireland
F Gordon, M Z Morgan and S Thompson 3

Oral health risk assessment of adults with learning disabilities: (1) Current practice
S Turner, T Lamont, H Chesser, L Curtice, K Gordon, S Manton, A Martin, T Welbury and M P Sweeney 11

Oral health risk assessment of adults with learning disabilities: (2) Attitudes of dentists and care staff
S Turner, T Lamont, H Chesser, L Curtice, K Gordon, S Manton, A Martin, T Welbury and M P Sweeney 18

A preliminary investigation into aspects of oral health of Bangladeshi young adults with a learning disability in Tower Hamlets
Mili Doshi, Mary Burke and Janice Fiske 25

Management of exaggerated gag reflex using conscious sedation techniques in endodontic therapy - a pilot study
Harushi Yoshida, Tomoyuki Nogami, Yoshihiko Hayashi and Kumiko Oi 36

Locked-in syndrome: A case report
Sharon Andrea Corinne Liberali 41

Editorial

As we move through the months of the year 2009, the impact of the global economic downturn becomes more evident and nowhere is this felt more keenly than by those groups of people who are marginalised in our societies: the poor, elderly and disabled and so often, these in combination. Towards the end of 2008 it was evident that in some countries, Ireland, Sweden, Italy and Hungary at least, there were moves to cut benefits to people with disabilities as the economic gloom deepened.

As resources become constrained it is also true that the services to marginalised groups become threatened: respite care, teaching assistants, rehabilitation programmes in prisons and comprehensive entitlement to free healthcare by those below the poverty line, which of course includes many people with disabilities.

At a time when the economy is in crisis, there is an ominous sense that those who are vulnerable are left exposed by the consequences of increasing unemployment: heightened self-interest, increasing crime perpetuated towards such sectors of the population and an abandonment of the move towards equity and equality for disadvantaged groups.

At a time like this, governments must hold true to their commitment to vulnerable populations by pursuing a reflationary approach to infrastructure, tax cuts, for example, so that poor, elderly and disabled people can access services and thus contribute to turning around the parlous state in which we now find ourselves.
Oral health care services are not exempt from this. Many working with patients will have for some time now felt the effects of revisions to service plans and budgets, revised downwards as the economic forecasts spelt out less money. In many countries of the world there will be a need for persuasive arguments to make a case for the retention of essential services for those with disabilities; in many countries enabling legislation should ensure that equity is delivered.

It is worth pausing for a moment to underline the differences between equity and equality, terms so often used interchangeably but with distinct differences. What is relevant for people who are marginalised is equity in services, ensuring that services are targeted to allow those most disadvantaged to achieve optimal outcomes, whereas equality implies the same for all, equally distributed. However, equality in healthcare does not produce health for all. Health and socio-economic status are inextricably linked and poverty continues to contribute to poor health and chronic illness, keeping many populations below the poverty line. Health promotion, of which oral health is a part, is governed by the ethical principle of equity of access such that attainment of health should not be hampered for socio-economic reasons or poor health service delivery systems.

Now more than ever we need to keep these principles in sight as the focus stays clearly on efficiencies and economies. Without this not only will the goals for 2010, the European Anti-Poverty Year, not be realised but the Millennium Development Goals for 2015 will not be achieved by those who stand to gain the most.

June Nunn
Editor

A survey of the quality and quantity of Special Care Dentistry teaching, including Gerodontology, in dental schools of the United Kingdom and Ireland

F. Gordon BDS, M. Z Morgan BSc (Hons), PGCE, MPH, MPhil, FFPH , S. Thompson BDS, MPhil, PhD, MSND RDSEd, FHEA

School of Dentistry Cardiff University, Cardiff, UK

Abstract
Aim and objectives: To investigate the Special Care Dentistry educational programmes in undergraduate dental schools of the UK and Ireland, and establish whether courses are adequate in fulfilling the learning outcomes in the General Dental Council (GDC) document 'The First Five Years - A Framework for Undergraduate Dental Education' and statements made by the Quality Assurance Agency (QAA) for Higher Education 'Benchmarking Academic Standards: Dentistry'.
Design: A postal questionnaire survey of 15 dental schools across the UK and Republic of Ireland. Questionnaires were distributed to 1,220 final year students and 15 staff who co-ordinate Special Care Dentistry teaching at each school. The questions explored areas such as teaching methodology and student's clinical confidence with Special Care patients.
Results: Ten dental schools returned student questionnaires and nine returned staff questionnaires. Most did not fulfil GDC or QAA requirements. The amount of didactic teaching and clinical experience varied considerably. Many undergraduates felt they did not receive adequate teaching and 87.9% did not gain sufficient clinical experience. Undergraduates felt ill prepared to treat certain groups of Special Care patients, especially those with mental health problems. Of the students who considered they had enough hands-on experience, only 22.9% felt 'confident' to carry out treatment.
Conclusions: The requirements of the GDC and the QAA are not being met. More clinical experience is required in most dental schools whilst in some schools, undergraduates receive none. Special Care patients are increasingly dentally motivated and many dental undergraduates are not adequately prepared in skills or attitude to provide high quality care.

Oral health risk assessment of adults with learning disabilities: (1) Current practice

S. Turner1, T. Lamont2, H Chesser2, L. Curtice3, K Gordon4, S Manton5, A. Martin6, T. Welbury7 and M.P. Sweeney8

1Dental Health Service Research Unit; University of Dundee; 2Scottish School of Primary Care; 3Scottish Consortium for Learning Disabilities; 4Lothian Salaried Primary Dental Care Service; 5Dundee Dental Hospital and School; 6General Dental Practitioner; Tayside; 7Greater Glasgow Salaried Primary Dental Care Service; 8Glasgow University Dental School

ABSTRACT
Aims: To investigate oral health risk assessment (OHRA) practice for adults with intellectual disabilities in Scotland.
Materials and methods: Two stage postal survey. In Phase 1, Clinical Dental Directors in all 15 Scottish Health Boards were asked to provide any written material pertaining to OHRA for adults with learning disabilities. In Phase 2, dentists and dentally qualified directors and consultants were asked whether a range of 39 OHRA elements were undertaken. These covered the following broad themes: care scale (9 items); risk factors (16 items); follow-up (7 items); and integration (7 items).
Results: In Phase 1, all 15 Health Board areas responded, with eight providing written material. In Phase 2, 179 of 253 dentists (including directors and consultants) gave information on current OHRA practice (response rate: 71%). Items most frequently assessed (i.e. reported by at least 50% of dentists) were: dental treatment needs; both dental and other oral problems; urgency of treatment need; whether examination was incomplete; diet and sugary drinks consumption; brushing adequacy; and consent to treatment issues. Far less frequently mentioned items related to follow-up and the wider integration of OHRA in care planning, carer contact and support. Dentists who saw more adults with learning disabilities tended to report greater coverage of assessment items - particularly of risk factors (r=0.27, n=124, p=0.002). Dentists working in areas which had submitted written material in Phase 1 did not report more comprehensive assessment practice.
Conclusions: Dentists' reports suggest that often OHRA was limited to items of immediate clinical relevance rather than a comprehensive review of risk factors or an ongoing process of risk management in collaboration with other individuals and agencies, and that this practice may have developed from clinician experience rather than guidance.

Oral health risk assessment of adults with learning disabilities: (2) Attitudes of dentists and care staff

S. Turner1, T. Lamont2, H Chesser2, L. Curtice3, K Gordon4, S Manton5, A. Martin6, T. Welbury7 and M.P. Sweeney8

1Dental Health Service Research Unit; University of Dundee; 2Scottish School of Primary Care; 3Scottish Consortium for Learning Disabilities; 4Lothian Salaried Primary Dental Care Service; 5Dundee Dental Hospital and School; 6General Dental Practitioner; Tayside; 7Greater Glasgow Salaried Primary Dental Care Service; 8Glasgow University Dental School

ABSTRACT
Aim: To compare dentists' and care staff attitudes regarding the importance of elements that might contribute to an oral health risk assessment (OHRA) protocol for adults with learning disabilities in Scotland.
Materials and methods: Postal survey of: dentists employed in the Community Dental Service in Scotland, plus consultants and directors as well as general dental practitioners, a sample of Care Home staff, and other care staff. Respondents rated the importance of 39 OHRA elements covering four themes: care (9 items); risk factors (16 items); follow-up (7 items); and integration (7 items).
Results: Response rates were 71% (179/253) for dentists; 69% (36/ 52) for the care home sample, and 31% (10/32) for other social care contacts. A Principle Components Analysis was used to allocate items to four scales covering attitudes towards care issues (e.g. communication problems), risk factors (e.g. swallowing difficulties), follow-up (e.g. named individual responsible for follow-up), and integration (e.g. involvement of other professionals in assessment). Respondents in both the dental and care staff groups tended to rate most items as important. However, care staff placed more importance on elements in the follow-up and integration scales. Care staff also rated the value of an ORHA tool more highly, although again, both groups were generally positive.
Conclusion: Results suggest that care staff were in tune with the aims of current government policy regarding development of comprehensive and shared assessment arrangements, while dentists tended to view assessment as a stand-alone examination. However, the generally positive attitude towards OHRA suggests that there is support for further development of risk assessment as an aid to prevention and treatment planning.

A preliminary investigation into aspects of oral health of Bangladeshi young adults with a learning disability in Tower Hamlets

Mili Doshi BDS, MFDS.RCS (Eng), Msc (SPc)1, Mary Burke BDS, FDS RCS (Eng)2 and Janice Fiske MBE, BDS, MPhil, FDS RCS(Eng)3

1Senior Dental Officer, Tower Hamlets Community Dental Service; 2Associate Specialist in Special Care Dentistry, Guy's and St Thomas' NHS Foundation Trust; 3Senior Lecturer/ Consultant in Special Care Dentistry, King's College London, UK

Abstract
Aim and objectives: To investigate aspects of the oral health, oral health awareness and oral health behaviours of Bangladeshi young adults with a learning disability.
Design: A convenience sample of Bangladeshi young adults with a learning disability was obtained from adult day centres in the London Borough of Tower Hamlets. Structured interviews with 52 individuals (to establish oral health awareness, dental behaviour, perceived needs and dental anxiety) were followed by a standardised oral examination to establish normative dental and treatment needs.
Results: Participants were very aware of different oral health conditions and their social implications. Aesthetics was especially important. The mean caries experience, expressed as DMFT, was 4.49; periodontal treatment was required by 88% of the study population; high levels of tooth wear and dental trauma were found, 48% and 42% respectively; and severe malocclusion was found in 53%. Oral health behaviours were unfavourable with generally poor oral hygiene, high use of betel nut and a trend of symptom-based rather than routine dental attendance. Women were significantly more likely to express dental anxiety than were men, 55% and 25% respectively, and had an overwhelming preference to see a female dentist from their own background (73%).
Conclusion: Bangladeshi young adults with learning disabilities have complex and unmet oral health needs.

Management of exaggerated gag reflex using conscious sedation techniques in endodontic therapy - a pilot study

Harushi Yoshida DDS, PhD1, Tomoyuki Nogami DDS, PhD2, Yoshihiko Hayashi DDS, PhD3, Kumiko Oi DDS, PhD4

1Associate Professor, 2Assistant Professor; Department of Special Care Dentistry, Nagasaki University, Hospital of Medicine and Dentistry, Nagasaki, Japan. 3Professor and Chairperson in Division of Cariology, 4Professor and Chairperson; Division of Clinical Physiology, Nagasaki University, Graduate School of Biomedical Sciences, Nagasaki, Japan

Abstract
Objective: To evaluate the usefulness of inhalation sedation (IS) and intravenous (IV) sedation for gag reflex management in patients undergoing endodontic therapy.
Design: Twelve cases (five mandibular molars, two maxillary and two mandibular premolars, one maxillary canine and two maxillary incisors) of five retching, male patients were studied. Management techniques, complications during treatment, and the characteristics of the root canal obturation were surveyed. The postoperative discomfort was also examined every month for four months up to two years after root canal filling. Results: Two patients each underwent IS and IV sedation, and both management techniques were employed in the other patient. Endodontic treatment was completed without respiratory distress, nausea, vomiting or other complications. Radiographs indicated that the root canals were filled up to 0.5-2mm on the inner portion from the apex in 10 of 12 teeth, although the curved root canals of two mandibular molars showed unfilled space between the ledge and apex. After root canal filling, no postoperative pain / swelling or other discomfort was observed throughout the observation periods.
Conclusion: IS and IV sedation were useful management techniques that facilitated endodontic therapy for problematic gag reflex patients who could not tolerate therapy by behaviour modification.

Locked-in syndrome: A case report

Sharon Andrea Corinne Liberali BDS (Adel.), Grad Dip Clin Dent (Adel.)

Special Needs Unit, Adelaide Dental Hospital, Adelaide, Australia

Abstract
A 33 year old female with a history of a brain stem abscess in 1992 resulting in flaccid quadriplegia, but no residual cognitive deficit, was rendered edentulous in 2006. Dental treatment was complicated by the fact that the patient has 'locked-in syndrome' with her only means of communication via the eye-blink method.

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