Quartz 4

4. Treatment Planning

8 min read

INTRODUCTION TO SPECIAL NEEDS DENTISTRY

HOW TREATMENT APPROACHES Differ

Special Needs Dentistry?

WHAT IS SPECIAL NEEDS DENTISTRY?

DEFINITION OF SPECIAL NEEDS DENTISTRY

The improvement of oral health of people who have a physical, sensory, intellectual, mental, medical, emotional or social impairment or disability (or commonly a combination of these factors), who require special methods or techniques to prevent or treat oral health problems, or where such conditions necessitate special dental treatment plans.

SPECIAL NEEDS DENTISTRY

Specialists in Special Needs Dentistry provide services and care for the following patient populations:

  • Medically complex: including head & neck cancer, solid organ and stem-cell transplant work-up, bleeding disorders, haematological and solid cancers, immunological disease, cardiac surgery work-up, severe disease of all body systems, and multiple co-morbidities.
  • Disability: including intellectual disability and neurological / neurodegenerative disease
  • Psychiatric conditions and severe dental phobia
  • Geriatric and domiciliary care
  • Other vulnerable populations, e.g. homelessness, drug addition, domestic violence.

Types of care routinely provided by Specialists in Special Needs Dentistry include:

  • Adults requiring complex dental treatment plans modified by their medical and social backgrounds
  • Liaising with all members of an individual’s care team (including dental, medical, allied health, social workers or family/friends) to achieve the most appropriate care plan and treatment through a holistic approach and integrated care pathways.
  • Ensuring oral health is optimised to reduce impact on function, general health and quality of life
  • In-patient hospital dentistry
  • Treatment under general anaesthesia, IV sedation, nitrous oxide and oral sedation
  • Management of anxiety or behavioural issues
  • Understanding of legislation and ethics relevant to consent and clinical holding
  • Use of specialised equipment , including wheelchair tippers/platforms and bariatric services
  • Transition from specialist paediatric dentistry services
  • End-of-life care

POPULATION & WORKFORCE

Population Statistics

Healthy Mouths, Healthy Lives: Australia’s National Oral Health Plan 2015-2024

  • Complex medical conditions: >7 million people have at least one chronic condition in 2004-2005.
  • Disability: 4 million people with a disability in 2009. Over half had two or more intellectual, psychiatric, sensory/speech, ABI or physical/diverse disabilities.
  • Frail older people:
    • By 2021, only 3% of the population will have complete tooth loss (increasing older people retaining their natural teeth)
    • By 2050, >3.5 million older people will access aged care services each year.
  • Mental illness: 45% of people estimated to experience a mental health condition in their lifetime

Workforce: Dental Specialities

  • Special needs dentistry has only 25 practitioners in australia!

Priority Population

Priority Population 4 - People with additional and/or specialised health care needs Goal Improve oral health outcomes and reduce the impact of poor oral health for people with additional and/or specialised health care needs. There are specific groups in Australia for whom poor oral health is only one among a number of other health care issues. This includes people living with mental illness, people with physical, intellectual and developmental disabilities, people with complex medical needs, and frail older people. These groups have a higher incidence of poor oral health.

  • Build workforce capacity and competency in the oral health sector to effectively address the needs of people with additional and/or specialised health care needs

WHERE DO WE START?

BARRIERS TO MAINTAINING ORAL HEALTH

PATIENT ISSUES

  • Medical conditions
  • Medical treatment(s) / medications
  • Physical/fine motor limitations
  • Transport/housing
  • Dietary requirements
  • Intellectual/cognitive/psychiatric
  • Reliance on family/carer
  • Prognosis/life expectancy
  • Quality of life
  • Collation of all medical and social information
  • Involvement of MDT (GP, specialists, allied health)
  • Communication with patient/family/carer
  • Consent (patient, NOK, guardianship board)

DENTIST ISSUES

  • Dentists diagnostic and treatment planning skills
  • Dentists knowledge of health conditions and medical treatments
  • Dentists motivation and capacity to provide ‘simple dentistry’ under ‘complex conditions’
  • Equipment available e.g. wheelchair lift, hoist, sedation, hospital access for GA facilities, portable equipment for provision of care off-site

PROVISION OF DENTAL TREATMENT — OTHER CONFOUNDING FACTORS

  • When to treat and when not to
  • Ideal vs achievable treatment plan
  • Prognosis of dental treatment/maintenance issues
  • Use of chemical restraint — LA/N2O/IV/GA
  • Use of physical restraint/clinical holding

PHILOSOPHY OF CARE AND TREATMENT PLANNING

WHO INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY AND HEALTH

In caring for patients with Special Needs, who may be adolescents, adults or elderly, it is essential that consideration is given to not only the patient’s oral health but also potential environmental, social, medical, physical and cognitive factors which may have an impact on their oral health, oral function, ability to receive dental treatment and also their oral health related quality of life.

ICF

BREAK IT DOWN! — THE INITIAL CONSULT

MEDICAL

  • Medical systems
  • Medications
  • For each condition: diagnosis, date diagnosed, treating physician, how often reviewed
  • Attacks (seizures/asthma/angina): type, triggers, last attack, last hospital admission, stability of medication dose, how long episode lasts, rescue medication
  • Surgical history
  • Allergies

DENTAL

  • Frequency of visits
  • Home oral hygiene maintenance
  • How previous dental treatment is performed
  • Diet

SOCIAL

  • Gender/age, Marital status, Occupation, Dependents
  • Lifestyle habits: smoking/alcohol, recreational drugs
  • Accompanying person
  • Residence
  • Carer support for ADLs
  • Mobility
  • Communication
  • Capacity: time and procedure-specific
  • Behavioural compliance
  • Transport ➡️ Risk Assessment ➡️ Treatment Modifications

TREATMENT MODIFICATIONS — “ACCESS”

Access

  • Access to clinic
  • Timing of treatment
  • Positioning
  • Access to mouth
  • Location/setting

Communication

  • Interpreter
  • Liaison with medical team
  • Patient information leaflets
  • Communication aids
  • Capacity to self-consent
  • Guardianship / ACDs
  • Consent forms
  • Clinical holding
  • Benefits vs risks of procedure
  • Treatment planning and expectations

Education / Prevention

  • Patient and carer
  • Recall intervals
  • Home oral hygiene modifications
  • Patient information leaflets
  • Patient folder or patient report
  • Oral care plan

Surgery

  • Pre-operative
    • Severity: medical condition, dental treatment
    • Liaise with physician
    • Baseline tests: FBC, coag screen, INR, HbA1c/BGL, BMI, LFTs, eGFR, etc
    • Monitoring devices: SpO2, sphygmomanometer, HR
    • ASA grade
    • Emergency medications
    • Supportive care: transfusions, G-CSF, factor / blood product
  • Peri-operative
    • Tissue management
    • Aspiration risk (dysphagia)
    • Mouth props
    • LA/CS/GA
  • Post-operative
    • Haemostasis
    • Instructions
    • Emergency contacts
    • Drugs
    • Who discharged to
    • Prolonged monitoring / overnight stay

Spread of Infection

  • Vertical (within self): antibiotic prophylaxis
  • Horizontal: standard, contact or transmission-based precautions

TREATMENT INTENT/GOALS

RATIONAL DENTAL CARE

SPECIAL CARE IN DENTISTRY

Clinical PRACTICE

  • J Can Dent Assoc 2006; 72(5):441-5
  • ABSTRACT: The concept of “rational dental care” was developed 30 years ago by Ronald Ettinger when it became clear that idealised treatment plans for frail and functionally dependent older adults were often inappropriate.

DETERMINING LEVEL OF CARE

+-----------------------------------------------+----------------------+ | DETERMINING FACTORS | CARE LEVEL | +=============================================+====================+ | Patient desires and expectations | ✓ Very extensive | +-----------------------------------------------+----------------------+ | Type and severity of dental need | ✓ Extensive | +-----------------------------------------------+----------------------+ | Impact on quality of life | ✓ Intermediate | +-----------------------------------------------+----------------------+ | Probability of positive outcome | ✓ Limited | +-----------------------------------------------+----------------------+ | Reasonable treatment alternatives | ✓ Very limited | +-----------------------------------------------+----------------------+ | Ability to tolerate stress of treatment | | | | | | | | +-----------------------------------------------+----------------------+ | Capability to maintain oral health | | | | | | | | +-----------------------------------------------+----------------------+ | Financial and other resources | | | | | | | | +-----------------------------------------------+----------------------+ | Dentist capabilities | | | | | | | | +-----------------------------------------------+----------------------+ | Other issues | | | | | | | | +-----------------------------------------------+----------------------+ Consultation with other health professionals may be imperative for effective decision-making; dentists should refer patients when lacking needed skills and/or equipment. † Boundaries between care levels often are not well-defined; several treatment alternatives may fall within the same level. Berkey et al (1996)

DETERMINING LEVEL OF CARE

Decision Tree: Treatment intent (1) Preventive, (2) Curative, (3) Reconstructive, or (4) Palliative.

ETHICAL ISSUES

  • Autonomy
    • Dentate Patient
    • Patient Seeks Care
    • Family/Care Giver Seeks Care for Patient
  • Perceived Need
    • Dental Problems- None
    • Asymptomatic
    • Symptomatic
  • Assessment of Dependency
    • Autonomy
      • Functionally Independent
      • Frail
      • Functionally Dependent
    • Level of Cognitive Impairment
  • Beneficence
    • Able to Benefit From Treatment
    • Unable to Benefit From Treatment → No Treatment
  • Level of Cooperation
    • Autonomy
      • No Restraint
      • Physical or Chemical Restraint Required
      • G.A.
    • Level of Physical Impairment
  • Beneficence
    • Able to Maintain Hygiene Independently
    • Unable to Maintain Hygiene-Needs Help
    • Unable to Maintain Hygiene - No Help → No Treatment
  • Risk/Benefit of Treatment
  • Informed Consent
    • Informed Consent Possible (Patient)
    • Possible (Significant Other)
    • Not Possible → No Treatment
  • Rational Dental Care
  • Paternalism vs. Patient Autonomy
    • Rehabilitative and Reconstructive (Comprehensive Care)
    • Maintenance and Monitoring (Limited Treatment)
    • Emergency Care (Pain & Infection Control Only)
    • No Treatment Ettinger 2006, 2015

TAKE HOME MESSAGES

SUMMARY — KEY STEPS AT INITIAL CONSULT

  • History
    • Medical history, medication list (including liaising with GP/specialist)
    • Dental history
    • Social history
  • Examination, investigations → diagnoses
    • Risk assessment:
    • Medical, dental, social factors
    • Establish the treatment goal/intent
    • May require a conservative or aggressive treatment planning approach
  • Treatment plan
    • Treatment modifications (ACCESS): access, consent, communication, education/prevention, surgery (pre- peri- post-op), spread of infection

ATTRIBUTES REQUIRED

  • Big ears, big heart, big brain
  • Willingness to grow to know our patients as people
  • Care and compassion
  • Complex treatment planning
    • Extensive knowledge of evidence-based medical and dental guidelines
    • Appreciation of multiple overlying medical/social factors in a compromised oral environment
    • Good understanding of material science and strong clinical expertise
  • Holistic and rational philosophy of care REALITY EQUALITY EQUITY JUSTICE

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