Volume 11 Number 1March 2010Editorial 2 Osteoradionecrosis - a review of prevention and management Patients’ and carers’ views of a special care dentistry
general anaesthetic service Establishing a procedure for managing poor standards of oral
care in vulnerable and dependent adults The Mental Capacity Act 2005: implications for primary care
dental services: a summary The Mental Capacity Act 2005: its significance for Special Care
Dentistry and patient care The Mental Capacity Act 2005: implementation within Special
Care Dental services Arthrogryposis Multiplex Congenita: dental findings and treatment
of an 8-year-old child Disability and cultural issues in research – lessons learned
Editorial I am honoured to write an editorial for the Journal of Disability and Oral Health. As a medical doctor with a disability, a past campaigner for the rights of people with disabilities and a non-expert in oral health, it is heartening to see a health journal refer repeatedly in its editorials to both the rights of people with disabilities to receive high quality healthcare and a recognition of the predominance of the social over the medical model of disability. My personal passion is access to healthcare. Previous editorials have addressed the issue of access for people with disabilities. I wish to address the issue of access for those in poverty. The distance between inaccessibility for people in poverty versus with disability is not great. In fact, they are inextricably linked with reports consistently showing disabled people being hugely more likely to end up in poverty than the general population (National Disability Authority, Leonard Cheshire Disability). Tudor Harts Inverse Care Law, which states that the need for healthcare is inversely proportional to the provision of healthcare (or more simply put, those who most need health services are least likely to get them) sadly is persistently and consistently validated. It is my contention that no matter how high its standards of healthcare delivery, an inaccessible healthcare service can lay no claim to being a quality service. It has been demonstrated that lack of access results in patients being less likely to attend a physician, avail of preventive or appropriate diagnostic and therapeutic services, or bring their prescriptions for dispensing (Weinick et al., 1996; Krauss et al., 1998; Newacheck et al., 1998; Baker et al., 2000; Lasser et al., 2006). Prewitt identified continuous access to primary care in inner cities as the primary approach to address health inequalities (Prewitt, 1997). Homeless people suffer from high levels of dental problems (Conte et al., 2006). In Ireland, access to both primary care and dental health services is dependant on having a medical card, a means-tested way of accessing care. Yet in Dublin, it has been shown that 45% of homeless people do not have medical cards (O’Carroll and O’Reilly, 2008). A specialised dental service had been set up in Dublin to provide access to dental services for homeless people was set up, yet it has not had an incumbent for some months for lack of staffing. Thus in the specialised GP clinic we run, we frequently come across homeless people with acute dental pain and no access to any clinic (never mind those requiring non-acute dental treatment). In the UK it has been reported that homeless people find it difficult to access dental services (Dentistry; Homeless Link, 2009) Even if you have a medical card in Ireland it can be difficult to get a dentist to provide treatment. Reports indicate that the case may be similar in the UK with cost deterring many patients from accessing treatment (BBC News, 2007). Marmot, in reviewing the evidence on the effect of having to pay out-of-pocket expenses on the health of middle to low-income earners, comments that this illustrates how health systems perpetuate injustice and social stratification (Marmot and Shipley, 1996). Community and Personal Dental Services offer a route for the provision of specialised services to hard to reach groups such as homeless people. These services seek to deliver services to where the patients feel comfortable. Hard to reach groups find mainstream services difficult to access and intimidating. It is not acceptable in a society that espouses social inclusion that medical or dental care remains unavailable for all. As Martin Luther King said: ‘Of all the forms of inequality, injustice in health is the most shocking and the most inhumane.’
Osteoradionecrosis - a review of prevention and management Mary Burke BDS FDS RCS(Eng)1 and Michael Fenlon MA PhD BDentSc MGDS FDS RCS(Ed)2 1Guy’s and St Thomas’ NHS Foundation Trust, 2King’s College London Abstract It has been long recognised that patients who receive radiotherapy
for cancer of the head and neck area are at risk of developing osteoradionecrosis
(ORN) of the jaws. Guidelines to reduce risk have been written,
based upon the evidence of many studies which have looked at the
incidence of ORN in different groups. Much of the research was carried
out over 20 years ago and more recent analysis of data and consideration
of the changes in radiotherapy raises the question as to whether
modifications to the guidance is now needed. There is a wide variation
in recommendations and a simpler, more unified approach to prevention
of ORN could be developed as well as research on recent management
techniques. Establishing a procedure for managing poor standards of oral care in vulnerable and dependent adults
Vulnerable adults who, for reasons of impairment or disability,
cannot achieve good oral hygiene for themselves may be dependent
on paid carers for their oral care. When this care falls below the
standard necessary to prevent oral disease, their oral and general
health may suffer. If standards fail to improve despite intervention
by the dental team and oral health continues to deteriorate, this
could be seen as neglect and thus become an issue that requires
liaison with the Safeguarding Adults team. This paper describes
the development of a local procedure which aims to establish proper
procedure in such cases, in the absence of national guidelines on
this subject. The Mental Capacity Act 2005 –Implications for primary care dental services: a summary D Mudie BDS LDS MCCD (RCS Eng) 1, S Berman BDS, MSc2, A Kaul BDS MFGDP (UK), MFDS (RCS Eng) 2 1Senior Dental Officer, Adult Special Care; 2Deputy Head of Primary Care Trust Dental Service, Wandsworth Teaching Primary Care Trust, London, UK
The Mental Capacity Act 2005 for England and Wales came into force in October 2007. Prior to its implementation, the law surrounding the provision of care for people unable to give valid consent was based on case law, notions of best practice, and the provision of treatment that was deemed to be in the patient’s best interest. The 2005 Act places the provision of care for such people within a defined legislative framework supported by new systems and statutory bodies. The main provisions of the Act, and the changes in the landscape around consent for the vulnerable adult, are discussed. The Act defines capacity, sets out a test to assess it and describes the responsibilities of those providing care for vulnerable adults. It states the rights of these adults to be as fully engaged as possible with the decision-making process. The application of the Capacity Test is described, together with its implications for patient, carer and clinician. In addition, the Act sets out who should be consulted when decisions about treatment are to be made. Clinicians must now act with due regard to the guidance published
in the Code of Practice which accompanies the Act. Special Care
dentists need a sound working knowledge of the Act, an understanding
of how it impacts on the provision of care for the vulnerable adults
they treat, and must ensure that they comply with their ethical
and legal responsibilities as they treat these patients. The Mental Capacity Act 2005: its significance for Special Care Dentistry and patient care A Kaul BDS MFGDP (UK), MFDS (RCS Eng) 1, D Mudie BDS LDS MCCD (RCS Eng) 1 and S Berman BDS, MSc2, 1Senior Dental Officer, Adult Special Care; 2Deputy Head of Primary Care Trust Dental Service, Wandsworth Teaching Primary Care Trust, London, UK
The Mental Capacity Act 2005 came into force for both England and Wales, and was fully implemented by October 2007 (for Scotland separate legislation exists, which is the Adults with Incapacity Act 2000). Since this time, many Primary Care Trusts in England and Wales have developed guidance on implementing the legislation. However, there has been very little written about the day to day challenges faced by the healthcare professionals who must abide by the Act, and its accompanying Code of Practice. Within Adult Special Care Dentistry, a significant portion of the caseload can consist of vulnerable adults who lack decision-making capacity, or whose decision-making capacity may be in doubt; in these situations, the Mental Capacity Act will be of particular relevance. Composite scenarios based on the authors’ experiences are presented to illustrate some of the challenges that may be faced by the clinician, along with their impact on patient assessment, and oral health care provision. The Act emphasises the need for effective communication within the multi-disciplinary care environment which surrounds many of these potentially vulnerable adults. It is important to raise awareness of the Act and the Code of Practice
amongst all members of the care team, including those who provide
informal care, and support for the patient, and most importantly,
the patients themselves. The Mental Capacity Act 2005: implementation within Special Care Dental services A Kaul BDS MFGDP (UK), MFDS (RCS Eng) 1, D Mudie BDS LDS MCCD (RCS Eng) 1 and S Berman BDS MSc2 1Senior Dental Officer, Adult Special Care; 2Deputy Head of Primary Care Trust Dental Service, Wandsworth Teaching Primary Care Trust, London, UK
There are certain patient groups within Special Care Dentistry for whom the Mental Capacity Act 2005 will have particular relevance. Once the principles and legal implications of the Mental Capacity Act (MCA) have been understood, the dental team must apply and integrate these principles into their patient assessment and oral health care plans. Implementation of the Act will involve raising awareness amongst patients, family, friends and others who provide care for vulnerable adults. Factors that may affect capacity are discussed including how they may impact on the delivery of oral healthcare, and some of the challenges which clinicians may face in assessing capacity. The importance of the Capacity Test and the Best Interest Checklist, along with their documentation is discussed. The role of the Independent Mental Capacity Advocacy Service (IMCAS) and the situations when they may be required are outlined, with particular reference to what may be defined as serious medical treatment within the context of special care dentistry. Arthrogryposis Multiplex Congenita: dental findings and treatment of an 8-year-old child D E Emmanouil DDS MSc PhD, T Roumani DDS MSc and G Petsi DDS Dept. of Paediatric Dentistry, School of Dentistry, University of Athens, Greece Abstract This report describes a case of Arthrogryposis Multiplex Congenita (AMC) with limited mouth opening and dental caries. Conservative dental treatment and physiotherapy exercises were prescribed. The aim of this case report is to describe the method and difficulties in the dental care of this patient and outline the importance of a preventive programme. Disability and cultural issues in research – lessons learned Mili Doshi BDS MFDS RCS (Eng) MSc1, Mary Burke BDS FDS RCS (Eng) 2 and Janice Fiske MBE BDS MPhil FDSRCS (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 Abstract Aim: To discuss the disability and cultural issues, which need
to be considered during the planning and implementation of a study
to investigate the oral health of young adults with a learning disability
and from a minority ethnic group. |