Volume 10 Number 4

December 2009

Editorial 146

Appropriate referrals to special care dentistry: a retrospective study
Najla Akbarali, Carole Boyle and Tim Newton 147

An audit of a protocol for the management of patients with hereditary bleeding disorders undergoing dental treatment
Michael Freedman, Alison Dougall and Barry White 151

Parental perceptions of oral health and access to oral health care services for children with special educational needs in south Bedfordshire
Yee Lee, Chris Dickinson and Meg Skelly 156

Continuing Professional Development Programme 161

Frequency and distribution of gingival bleeding in a population of para-athletes competing at the III Para-Pan-American Games in Rio de Janeiro 2007
P LS Evans, A L S Almeida, Juliana J Rodrigues-da-Silva, R A Andrade, F R Guedes, A M Guedes, J A Grangeiro and E M B Tinoco 163

Retrospective audit of the prescribed systemic medication taken by adults using Salaried Primary Care Dental Services in Warwickshire and implications for dental care
N Ransford, D Tait and C Randall 169

The knowledge and attitudes of north Wales healthcare professionals to bisphosphonate associated osteochemonecrosis of the jaws
D R Masson, E O’Callaghan and M Seager 175

Strategies for the prevention of dental caries in people with disabilities: a review of risk factors, adapted preventive measures and cognitive support
Pia Gabre 184

Editorial

As we close on 2009 and look forward, 2010 is a significant year for those working in the field of Special Care Dentistry, both at home and abroad.

In 2010 the Journal celebrates its 10-year anniversary and the 20th Biennial Congress of the International Association for Disability and Oral Health takes place in Ghent, Belgium. The biennial congress is also a celebration of the 25th anniversary of training in Paediatric and Special Care Dentistry in the University School in Ghent. The programme theme is ‘Caring for Quality of Life’. Keynote presentations will focus on topics as diverse as the Special Smiles program, Ethics and education, Orthodontics, Music therapy, Down syndrome, Sleep apnoea and Xerostomia. Abstract submission is now open at: http://www.iadh2010.be/Abstractsubmission.html

The Congress, as well as the Journal, gives us all the opportunity to appraise the scientific community of our work, an opportunity to invite collaboration and, as importantly, the opportunity to meet with those working in similar areas and to exchange ideas. This showcasing of an emerging speciality also highlights the relative isolation that people working in the area have undertaken in their endeavours on behalf of patients. It is all to easy to be unaware of others working in a related area with whom there is scope to collaborate but also to confer and agree on challenges and the means to address these.

In many respects Special Care Dentistry has come of age; the Journal is about to embark on its second decade and, like IADH is well established and the international voice of the speciality. The Department of Paediatric Dentistry and Special Care in the University of Ghent likewise has earned the respect of the scientific community and has international recognition for the work it does, pioneered by the visionary approach of its Chairman, Professor Luc Martens and his team, in particular Professor Luc Marks.

Having come of age, all those serious about promoting Special Care Dentistry must engage in a determined effort to now move the speciality to the next phase. Much effort in many countries has been focussed on engaging with political decision-makers to establish the credentials of the speciality-for the greater good of patients. Advocacy with other stakeholders has also, to some extent, helped achieve that. We need now, alongside these continuing efforts, to lend credibility to our standing in the scientific community, by adopting a more rigorous approach to our work.

Organisations like IADH and national bodies must give the leadership and direction in areas of scientific research to establish the evidence base that is particular to Special Care Dentistry. Such organisations, as well as individual academic teams, have to phrase the research questions and engage with the wider scientific community; international congresses give us all the opportunity to contribute to that debate and to distil from it what is really important for patients. Notwithstanding the exhilaration of scientific discovery, that is all that matters, not individual accolades or the brilliance of individuals or teams, but patients. That is what we are about. Let us never lose sight of that.

June Nunn. Dublin, November 2009.

Appropriate referrals to special care dentistry: a retrospective study

Najla Akbarali BDS MFDS RCS (Eng)1, Carole Boyle BDS, FDRCS (Eng) MFGDP(UK) MMedSci MSNDRCSEd2and Tim Newton BA PhD3

1Staff Grade Dentist; 2 Consultant, in Special Care Dentistry,
Guy's, King's College and St Thomas' Hospitals, London, UK. 3Professor of Psychology as Applied to Dentistry, King’s College London

Abstract

Aim and Objectives: To assess and identify the appropriateness of patients referred to the Special Care Dentistry Department at Guys Hospital by comparing referral letters to referral guidelines, determining reasons for referral rejections and looking at the initial follow up of patients accepted.
Design: A retrospective study reviewing referral letters using a proforma sent to the Special Care Dentistry Department at Guy’s and St Thomas’ NHS Foundation Trust London over a period of four months. The acceptance / rejection ratio of these referrals and the outcome for the patients accepted were assessed.
Results: 100 referrals were received over a period of four months between 1st November 2007 and 29th February 2008. The overall percentage of patients accepted was 75%. From the patients that were accepted, 27% did not take up the invitation to make an appointment, 64% made an appointment and attended, and 9% made an appointment and failed to attend. From the patients that attended for an assessment, 96% were accepted for treatment. The most common source of referral was from general dental practitioners and the most common reason was complex medical problems. The majority of referrals that were rejected were for patients referred for medical conditions that can be managed in Primary Care.
Conclusions: A high proportion of referrals to the Department of Sedation and Special Care Dentistry are accepted as appropriate, suggesting that there is an understanding of the role of the emerging specialty amongst dental practitioners and other health care professionals. The proportion of appropriate referrals may be improved by structured referral mechanisms and dissemination of information concerning the role of Special Care Dentistry. Certain patient groups with challenging special care needs have higher levels of failure to attend appointments. Patients in these groups require additional support to access dental services.

An Audit of a protocol for the management of patients with hereditary bleeding disorders undergoing dental treatment

Michael Freedman BA, BDentSc, MFD RCSI1, Alison Dougall B.Ch.D, MSc1 and Barry White MD, MSc, MRCPI, MRCPath2

1 Dublin Dental School & Hospital, Lincoln Place, Ireland. 2National Centre for Hereditary Coagulation Disorders, St James’ Hospital, Dublin, Ireland

Abstract

Aim: To design and assess a new protocol for the dental management of patients with hereditary coagulation disorders.
Design: Fifty-two patients with hereditary coagulation disorders undergoing dental treatment in a general hospital were questioned 24 hours and seven days post-operatively about any bleeding, pain or swelling that had occurred when a new protocol for their dental management was followed.
Results: The dental treatments that were performed included supra- and subgingival direct restorations, scaling and exodontia. These were performed under local anaesthesia by infiltration or inferior alveolar nerve block. Two patients reported minor bleeding 24 hours post operatively while no patients reported any bleeding seven days post-operatively.
Conclusions: Given the limitations of the study the protocol was effective in managing the dental needs of the patients studied.

Parental perceptions of oral health and access to oral health care services for children with special educational needs in South Bedfordshire

Yee Lee BDS, MSc, MFDS RCS (Eng)1, Chris Dickinson BDS, MSc, MFDS RCS (Eng), DDPH, LDS RCS (Eng), DipDSed2 and Meg Skelly BDS, FDS RCS (Glasgow), MDS (London), FDS RCS (Eng)2

1Dental Officer, Bedfordshire PCT; 2Consultant, 3Honorary Consultant, Department Sedation and Special Care Dentistry, King’s College London Dental Institute, London

ABSTRACT

Aim: To investigate the perceptions of oral health and barriers to care of parents of children with special educational needs in South Bedfordshire.
Objectives: To undertake a questionnaire study of parents of children in primary and secondary schools in South Bedfordshire in order to investigate parental perception of oral health of their children; analyse the key factors that act as barriers to care and relate the parental oral health perceptions to their views on access to care.
Design: A qualitative, semi-structured questionnaire was devised with the main themes related to perceived oral health and access to oral health care services. There were 21 closed and open-ended questions with the opportunity for additional comments. The questionnaire was answered anonymously.
Results: 451 questionnaires were distributed with 212 returned (47%). Parental perception underestimated the level of oral health and there was a reported lack of oral health education provided by the dental profession. Although the majority of children with special educational needs attended a dentist, parents were more likely to experience difficulties accessing oral health care services.
Conclusions: The level of oral health of children with special educational needs in South Bedfordshire is underestimated by parents. The Disability Discrimination Act (2005) aims to reduce inequalities but parents still experience barriers when accessing oral health care services.

Frequency and distribution of gingival bleeding in a population of para-athletes competing at the III Para-Pan-American Games in Rio de Janeiro 2007

P LS Evans MS1, A L S Almeida DDS2, Juliana J Rodrigues-da-Silva DDS3, R A Andrade MS1,
F R Guedes PhD4; A M Guedes PhD4, J A Grangeiro MS5 and E MB Tinoco Ph.D1,6

Department of 1Periodontology, 2 Orthodontics, 3 Dentistry, 4 Radiology; State University of Rio de Janeiro, UERJ; 5 Brazilian Olympic Comittee, COB, Rio de Janeiro; 6 Unigranrio, School of Dentistry, Department of Periodontology, Duque de Caxias, Brazil

Abstract

Aim: prevalence of gingivitis is high in most populations and physical impairments may jeopardise oral hygiene skills, leading to gingival bleeding. This cross-sectional randomised study aimed to evaluate the frequency and distribution of gingival bleeding among para-athletes.
Design: Invitations were sent to over 1,300 para-participants of the III Para-Pan-American Games, 95(78.51%) males, with mean age 32.6(sd±9.6). A modified version of the Eastman Interdental Bleeding Index (EIBI) was adopted to assess gingival inflammation (Modified EIBI). Individuals were separated according to their physical impairments: GI– visually-impaired, with 2 subgroups: GI-a- with late-acquired-visual-impairment and GI-c- with either congenital or early-acquired-visual-impairment; G-II- with impaired upper-limbs; with 1 subgroup: G-II-t- with bilateral impairment or absent limbs; G-III, with lower limbs disabilities. The frequency and distribution of interdental bleeding were calculated and compared between groups.
Results: 121 individuals were examined: 29 individuals (23.97%) and 66 sites (3.03%) showed interdental bleeding. Frequencies were: G-I (8.12%+2.94); G-I-a (5.56%+2.45); G-I-c (10.7%+3.4); G-II (1.1%+0.4); G-II-t (0%); GIII (1.7%+0.7). Significant differences were found in G-I>G-III (p=0.0002); G-I-c>G-I-a (p=0.042). Males showed higher frequency of bleeding (3.6%+1.7) than females (0.8%+0,5%), p<0.01.
Conclusions: Interdental bleeding is a common condition in this population with special needs and is influenced by different physical impairments. The EIBI is a valuable tool for screening large populations and can be easily used for assessing gingival health conditions among athletes with physical disabilities. The modified-EIBI is also a valuable tool for screening large populations at major sports events, and can be easily used to assess gingival health conditions among individuals with special needs.

Retrospective audit of the prescribed systemic medication taken by adults using Salaried Primary Care Dental Services in Warwickshire and implications for dental care

N Ransford BDS, MSc, DSCD RCS (Eng) 1, D Tait BDS, MSc, MSND RCS (Ed)2 and
C Randall BPharm, MRPharmS3

1Clinical Director; 2Senior Dental Officer; Warwickshire PCT Special Care Dental Service; 3Senior Medicines Information Pharmacist, North West Medicines Information Centre

Abstract

Objectives: To identify the most commonly prescribed systemic medications being taken by patients attending Salaried Primary Care Dental Services (SPCDS) in Warwickshire and to consider the clinical and service commissioning implications.
Design: A retrospective analysis of 516 case records taken from the 12 SPCDS clinics in Warwickshire over a one month period. A standardised data sheet was used to record information on medical conditions and prescribed medications. Results: 72% of patients were taking prescribed medications, with 36% taking four or more. Antiepileptics, antipsychotics and antidepressants were the most frequent groups involved.
Conclusions: The high levels of medication use and polypharmacy suggest a need for familiarity with the most commonly taken medications in order to aid the assessment of patients’ medical status and maintain vigilance regarding adverse drug reactions. This has implications for the continuing professional development of clinicians. In addition, the relative medical complexity of this patient group requires recognition in commissioning policy.

The knowledge and attitudes of North Wales healthcare professionals to bisphosphonate associated osteochemonecrosis of the jaws

D R Masson BDS1, E O’Callaghan BDS1 and M Seager BDS2

1Dental General Professional Trainee, 2Senior Dental Officer / GPT Tutor; North Wales Community Dental Service
Abstract

Aim and objectives: The purpose of this study was to ascertain the level of knowledge of, and the attitudes to, bisphosphonate related osteochemonecrosis of the jaws (BRONJ) amongst healthcare workers in North Wales. The frequency with which patients undergoing bisphosphonate therapy are seen by these healthcare professionals was also to be established.
Design: A self-administered, postal questionnaire was sent to 26 community dentists, 132 general dental practitioners, 120 general medical practitioners and 60 pharmacists.
Results: The results indicated that patients using bisphosphonates are seen on a regular basis by many healthcare professionals, most commonly for the treatment of osteoporosis. Although the vast majority of the healthcare professionals approached claim to be aware of the side-effects of theses drugs, very few have knowledge of osteochemonecrosis as an issue in this patient population. However, the vast majority of healthcare professionals requested further guidance on this issue. There are currently no guidelines on the effective treatment of osteochemonecrosis.
Conclusions: Knowledge among many healthcare professionals; GMPs, GDPs and pharmacists about bisphosphonates and the oral/dental consequences of patients prescribed these drugs is poor. As a result of this project, advice leaflets have been produced for dentists, general medical practitioners, pharmacists and patients.

Strategies for the prevention of dental caries in people with disabilities: a review of risk factors, adapted preventive measures and cognitive support

Pia Gabre, DDS, PhD

Department of Preventive Dentistry, Public Dental Health Services, Uppsala County Council, Sweden and Department of Cariology, Sahlgrenska Academy at Göteborg University, Göteborg, Sweden

Abstract
Aim: Individuals with disabilities have an increased caries risk mainly owing to impaired oral clearance, inappropriate food choices, difficulties in oral hygiene routines including use of fluorides, and low overall understanding of healthy behaviour. Although individuals with disabilities have an urgent need of effective preventive measures, their ability to accomplish such measures themselves is severely limited.
Objectives: This paper reviews methods and products adapted to cognitive, intellectual and physical disabilities intended to prevent dental caries.
Results: Training programmes that stimulate oral motor function and oral sensory perception can improve oral clearance. Frequency of meals and choices of food can be influenced by increased knowledge among care staff and the individuals themselves. Different kinds of cognitive support can also enable people with disabilities to independently make healthy food choices, and cognitive support and assistive devices can facilitate oral hygiene and use of fluorides. Impaired oral clearance leads to increased caries risk but, at the same time, increases the effect of fluorides. Tooth brushing with toothpaste is a population-based strategy used by most people. When supplemental fluoride is needed more frequent use of tooth brushing with fluoridated toothpaste or a higher concentration of fluoride becomes a useful method, well known by people with disabilities and care staff.
Conclusions: Adaptation of products and methods to the individual impairment accords with people’s rights to autonomy and independence, and implies empowerment for people with disabilities.

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