Volume 8, Number 2. August 2007Contents Referral patterns and access to dental services of people affected by homelessness in Dublin, Ireland An audit of patient assessment and treatment outcomes in anxious patients referred for conscious sedation Barriers to oral health care access among socially vulnerable groups: a qualitative study Guillermo Machuca, Emilia Nieves, Antonio F. Sánchez, Carmen Machuca and Pedro Bullón 73 The value of training doctors in the diagnosis of oral manifestations of HIV Student evaluation of clinical outreach teaching in Community Special Care Dentistry Preaxial acrofacial dysostosis (Nager Syndrome): a case report Book review 95 Diary 96
Pushing Boundaries 2007 is another significant year for the Journal. We have consolidated our move to three issues a year with an impressive array of original research from an international group of authors. For the first time, subscribers can access the Journal online at www.jdohonline.org, with a paper copy, or both, opening up access to many more readers. This is a distinct member advantage, allowing the subscriber not only the access to the current issue but to the archive of previously published material. In addition, this online facility enables members to access CPD online and if they wish, to set up their own CPD account for recording all their CPD without cost. At a time when Special Care Dentistry is expanding rapidly as a recognised specialty in many countries, a resource is required that is contemporary, peer-reviewed and authoritative. More and more countries are establishing education and training programmes in the speciality and access to the innovative, to good practice and to seminal papers in the discipline is essential. This is not only for the student but for the established practitioner as part of their continuing professional development. The decision of the Executive of the International Association for Disability and Oral Health to take up online membership for its members is therefore timely and to be applauded for its far-sightedness. Investing in its members is a benefit that will reach out and embed knowledge and good practice for special care patients worldwide. Pushing out the boundaries is essential for many reasons but two are especially important. In many countries professionals in emerging specialities often work in isolation and without access to publications like this and thus are unaware of the opportunities that they might bring to their patients. As well, encouraging the novice academic, the innovator in their field, the experienced clinician with a cautionary tale to tell, are important functions of a scientific journal. We have a responsibility through our stringent peer review mechanism to bring the very best to the readership whilst at the same time cultivating and supporting those for whom scientific writing is a new endeavour. In time, papers in the Journal will come to be viewed as seminal; for example, the paper in the December 2006 issue on defining the population requiring Special Care Dentistry using the World Health Organisation’s International Classification of Functioning, Disability and Health. If Dentistry, let alone Special Care Dentistry, is to be recognised for the important role it has to play in overall health, then we need to push back the boundaries of how we work to be included. For too long Dentistry has argued that it needs to be considered different and must be a special, separate case, without using the opportunities we have to be part of the wider healthcare team and work towards the ‘common risk’ approach; to put oral healthcare in context. Papers like this give us the framework to do that. It is imperative that, for our patients at least, we take up this challenge.
June Nunn, Dublin July 2007
Referral patterns and access to dental services of people affected by homelessness in Dublin, Ireland Ruth Gray BDS, MDPH Senior Dental Officer, Community Dental Service, Lisburn Health Centre, Abstract Aims: To assess the accessibility of a dental service in a dental clinic and a homeless drop-in centre in Dublin for people affected by homelessness, evaluate current referral patterns and investigate the level of methadone use in the population and corresponding use of drug services. Material and methods: A review was conducted of a comprehensive database of all 237 patient dental records using simple inclusion criteria. Comparisons were made with data from a general survey of homeless people in Dublin. Results: Showed 163 men and 74 women had attended, with a modal age range of 25-34 years. Only 16% of patients were over 40 years of age, of which only 6% were females. The main source of referral was from the homeless drop-in centre, in which the clinic is situated (39%); hostels referred 19% and day centres 12%. Previous input from the dental team into the centres through education, health promotion or screening improved the number of referrals. 61% of the patients were attending for treatment in methadone clinics. Conclusions: As the homeless population is not homogenous the targeting of services to certain sub-sets of this population is necessary, such as people over 40 years of age and women with families in bed and breakfast accommodation. Health education and screening can promote access to dental services. Finally, an interdisciplinary approach is essential so that an oral health assessment can be included in the initial assessments made by community welfare officers, hostel staff and drug centre workers.
An audit of patient assessment and treatment outcomes in anxious patients referred for conscious sedation R B Smith BDS, MScD, MFGDP and S A Thompson BDS MPhil, PhD, MSND RCS Ed. Unit of Conscious Sedation and Special Care Dentistry, Department of Adult Dental Health, Cardiff University School of Dentistry, Heath Park, Cardiff CF14 4XY, UK
Abstract
Barriers to oral health care access among socially vulnerable groups: a qualitative study Jacques N Vananobbergen DDS, PhD1, Ruth Van Der Beken M Soc.2, Leen Gyssels M Soc3, Leen De Roo M Soc4,5 and Sara Willems MA Soc, PhD5 1Department Community Dentistry and Dental Public Health, Ghent University, Belgium, 2District Health Care Centres ‘De Sleep’, 3‘Brugse Poort’, 4‘Botermarkt’, 5 Department of Family Medicine and Primary Health Care, Ghent University, Belgium.
Abstract Objectives:To identify perceptions and underlying causes of important barriers to access for oral health care among socially vulnerable groups. Methods:In a qualitative approach, focus group discussions were organised to gather information concerning barriers to oral health care. The study was undertaken in the city of Ghent, one of the major capitals in Flanders. 150 participants with different backgrounds participated in 13 focus group discussions. Group moderators were experienced health care workers. A discussion guide based on a ‘domino’ game was developed especially for use in this study. The discussions were tape-recorded and transcribed verbatim. QSR Nudist software was used to organise the data. The health belief model was the main theoretical approach for the study. Results:From the users, the overall knowledge on preventive health care and on available dental care services and costs were limited. The importance of oral hygiene was well known but difficult to put into practice, the importance of the primary dentition was underestimated and tooth-unfriendly dietary habits were common. This was strengthened by cultural beliefs. Fear of pain and dental treatment, uncertainty about dental treatments, language barriers and out-of-pocket costs were reported. For the suppliers, the lack of information and negative experiences concerning dentists’ lack of responsiveness to patient concern were expressed. Conclusion: An important commitment, based on these results, consists of information and motivation of the target group. The framework reported in this study offers guidance for estimating barriers experienced by the target group and for evaluating the outcome of interventions to reduce these barriers.
Descriptive study of factors modifying the periodontal status of a population of people with a learning disability in Spain Guillermo Machuca MD DMD1, Emilia Nieves DMD 2, Antonio F. Sánchez MD DMD3, Carmen Machuca MD DMD MSD3 and Pedro Bullón MD DMD4 1Professor, 2Honorary Associate Lecturer, 3Associate Lecturer; Department of Patients with Special Needs and Periodontics: 4Professor, Department of Oral Medicine and Periodontics; Faculty of Dentistry, University of Seville, Spain. Abstract Objectives: To evaluate, for institutionalised people with a learning disability: their periodontal status, periodontal treatment needs, the influence of social and demographical factors, behaviour, dental maintenance and malocclusions on their periodontal state. Subjects: 143 adults (17.5±3.5 years) with a learning disability in residential care. Design: Data were recorded relating to age, gender, illness, difficulties in behavioural management, residential status (resident/non-resident), previous contacts with dentists, and oral hygiene. The Community Periodontal Index of Treatment Needs (CPITN), periodontal treatment needs (TN) and malocclusion (WHO: 0, 1 and 2), were registered in accordance with the criteria of the World Health Organisation (WHO). Results: 24.3% had a congenital learning disability and 20.8% were diagnosed with Down syndrome. 79.0% of subjects were non-resident; 77.6% had a dental management issue; for 61.1% it was their first dentist contact; 41.9% brushed their own teeth. For malocclusion; 10.5% had none, 15.4% had mild and 74.1% moderate/advanced. For periodontal health; 4.2% had good health, 4.1% had bleeding, 59% calculus, 25.7% moderate pockets and 7% deep pockets. None of the patients was totally edentulous. Periodontal disease increased with age (p<0.001) and women had better periodontal health (p<0.01). Patients who had their teeth brushed by their carers had better periodontal health (p<0.05). 4.2% require no treatment, 95.1% required instruction in oral hygiene, 91% instruction and calculus removal; 6.3% advanced periodontal treatment. Treatment needs increased with age (p<0.001), with difficulty in management (p<0.001), and whether they brushed their own teeth (p<0.05). Conclusions: A high level of mild/moderate periodontal disease was observed in the sample. This increased with age, with the presence of malocclusions and with unsupervised brushing.
The value of training doctors in the diagnosis of oral manifestations of HIV C R Vernazza, BDS MFDS RCS Ed1, B N Mayanja MBChB2, J O Mugisha MBChB MSc Epid2, L Van der Paal MD MSc Epid 2, C J Young BDS3, P G Robinson BDS, LDS RCS, MSc, PhD, FRACDS, ILTM4 1Clinical Fellow in Child Dental Health, School of Dental Sciences, Newcastle University, UK; 2Medical Officer and Clinical Epidemiologist MRC/UVRI Research Council Programme on AIDS, Entebbe, Uganda; 3Dental Surgeon, Northamptonshire, UK; 4Professor of Dental Public Health, School of Dentistry, University of Sheffield, UK.
Abstract Objectives: To assess the effectiveness of a training intervention on doctors’ diagnoses of oral manifestations of HIV infection in an outpatient medical clinic in rural Uganda. Methods: Didactic teaching, seminars and calibration with participants were given to doctors by dental students. After the intervention, doctors’ and dental students’ diagnoses were compared against participants’ HIV status in the same 79 patients. Then, for three months doctors’ diagnoses only were compared against participants’ HIV status. Outcome measures: Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) and likelihood ratios (LR) using HIV status as gold standard. Results: Immediately after the intervention, agreement between doctors’ and dental students’ diagnoses was 0.71 (k) for the same 79 participants (44 HIV positive): Over the next three months, the doctors did not diagnose any further lesions in a sample of 259 participants, (111 were HIV positive) (sensitivity, PPV and LR all fell to 0). This reduction in sensitivity was significant (p<0.001) (Fisher’s exact test). Conclusions: Doctors can be trained in the diagnosis of oral manifestations of HIV infection but diagnostic validity decreases with time from training. Further and sustained increases in diagnostic validity may be possible with increased or more effective training and if oral diagnosis forms an integral part of participants’ health care, rather than part of a research project.
Student evaluation of clinical outreach teaching in Community Special Care Dentistry Liana Zoitopoulos BDS MCDH MHSM PhD1, Theodore Papadakis DDPH RCS MDentSci DIPDS2, Yogesh Tanna BDS MSc2 Stephen Dunne BDS FDSRCS PhD3 1Consultant in Special Care Dentistry/ Honorary Senior Lecturer and Head; 2Senior Dental Officer, Department of Community Special Care Dentistry; 3Head of Primary Dental Care: King’s College London Dental Institute, London, UK
Abstract Aim: To describe the content of an outreach teaching programme in Community Special Care Dentistry (CSCD) and assess the students’ feedback. Design and subjects: The content and operational arrangements of the outreach programme are described. A random sample of 120 student evaluation sheets from a three-year period was analysed for recurring comments. Information collected on student attendance and number and type of patients seen were also reviewed. Results: A high atttendance rate was noted throughout the three-year period. An average number of six patients was seen by each pair of students, per day. The percentage of special care patients as opposed to vulnerable (high caries) groups increased each year. The majority (81%) of student evaluation forms had positive comments only, with the most commonly recurring items being the tutors’ skills, the chance to get an insight into CSCD and the range of patients treated. Conclusion: The programme has been both well attended and received by students. There are inevitably, limitations on extrapolating this information, based as it is, on students’ perceptions.
Preaxial acrofacial dysostosis (Nager syndrome): a case report A Da Silveira DDS MS PHD1, A S Joshi MDS M(ORTH)RCS2 and M Shahani MD3 1Chief of Orthodontics and Assistant Professor, 2Orthodontic Research Fellow, 3Director of Pediatric Services and Assistant Professor, The Craniofacial Center and Department of Pediatrics, University of Illinois, Chicago, Illinois, USA. Abstract This case report describes the surgical and dental management of a 12-year-old girl with preaxial acrofacial dysostosis also known as Nager syndrome. It highlights the importance of multidisciplinary treatment at an early age and the effect of parental noncompliance on the overall physical and psychological development of a medically compromised patient.
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