# INTRODUCTION TO SPECIAL NEEDS
# DENTISTRY
# HOW TREATMENT APPROACHES DIFFER
**11th July 2025**
**UWA DMD2 Lecture**
**Dr Jee-Yun Leung**
BDSc(Hons) MSc(SCD) DSCD(RCSEng) DClinDent(SND) MRACDS(SND) FANZASND
Specialist, Special Needs Dentistry
Senior Lecturer, The University of Western Australia
Consultant, Maxillofacial and Dental Surgery Department, Fiona Stanley Hospital
**Special Needs Dentistry?**
Let's set the scene...
Two images showing individuals in wheelchairs receiving dental care.
<mark style="background-color: rgb(255, 255, 255);">MEDICALLY COMPLEX</mark>
**CASE EXAMPLE**
**Chief concerns:**
* Extensive caries teeth 25 & 36
* Mobile tooth 24
* Poor oral hygiene
**MEDICAL HISTORY**
* Neurocognitive Disorder (Dementia)
* Multifactorial - likely due to alcohol abuse, TBI from MVA (hit by taxi in Thailand), subdural/subarachnoid haemorrhage (falls x2 when intoxicated)
* Neurosyphilis excluded, HIV considered
* HIV +ve
* Biktarvy (bictegravir, emtricitabine, tenofovir, alafenamide)
* History of alcohol dependence
* Memory impairment
* Alcoholic steatohepatitis, currently undergoing investigations for liver cirrhosis → rosuvastatin
* Oxazepam (control alcohol withdrawal syndrome)
* History of syphilis
* COPD
* Smoker
* Dyspnoea: salbutamol, glycopyrronium, budesonide/formoterol
* Infective exacerbations requiring weaning prednisolone
* Depression
* Desvenlafaxine
* Schizophrenia and mood disorder
* Sodium valproate, risperidone, olanzapine
**SOCIAL HISTORY**
* Residence:
* 2010-2014: Bangkok
* 2015: Lived with sons in Adelaide, then by himself, then supported accommodation.
* Jan-Feb 2016: homeless, prolonged hospital admission (escalating alcoholism), social crisis
* Mar 2016: supported accommodation
* May 2018: residential aged care facility
* ADLs: dependent on others
* Behaviour:
* Feels angry/anxious when does not feel in control of situations.
* Will verbally refuse care, and staff must return later to complete these tasks.
* Reduced insight into own safety and abilities.
* Capacity:
* Able to understand questions/information and able to communicate decisions.
* Able to weigh up risks and benefits for simple treatment decisions
* Questionable whether he would be able to for more complex treatment decisions
**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.**
<p style="text-align: center;">SPECIAL NEEDS DENTISTRY</p>
<p>
<span style="color: #bc501e;"><b>Specialists in Special Needs Dentistry</b></span>
provide services and care for the following patient populations:
</p>
<ul>
<li>
<span style="color: #6d6d6d;"><b>Medically complex:</b></span>
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.
</li>
<li>
<span style="color: #6d6d6d;"><b>Disability:</b></span>
including intellectual disability and neurological / neurodegenerative disease
</li>
<li>
<span style="color: #6d6d6d;"><b>Psychiatric conditions</b></span>
and severe dental phobia
</li>
<li>
<span style="color: #6d6d6d;"><b>Geriatric</b></span>
and domiciliary care
</li>
<li>
<span style="color: #6d6d6d;"><b>Other vulnerable populations,</b></span>
e.g. homelessness, drug addition, domestic violence.
</li>
</ul>
SPECIAL NEEDS DENTISTRY
**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
**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**
**Table 4.1 Dental practitioners - dental speciality by state or territory**
**Speciality**
**ACT** **NSW** **NT** **QLD** **SA** **TAS** **VIC** **WA** **No PPP** **Total**
Dento-maxillofacial radiology
1
9
1
5
16
Endodontics
7
51
42
15
4
49
17
6
191
Forensic odontology
2
5
1
2
2
2
2
4
20
Oral and Maxillofacial Pathology
4
4
4
1
2
3
1
19
Oral and maxillofacial surgery
7
62
2
58
19
5
55
21
6
235
Dental Board
Ahpra
Oral medicine
1
10
7
14
11
2
45
Oral surgery
40
8
1
7
1
3
60
Orthodontics
16
189
2
121
54
9
155
68
20
634
Paediatric dentistry
2
45
27
16
1
44
22
6
163
Periodontics
8
67
1
54
17
5
65
32
5
254
Prosthodontics
4
69
43
28
56
23
8
231
Public health dentistry
(Community dentistry)
5
1
1
8
1
16
Special needs dentistry
5
4
6
8
1
1
25
Total
47
553
6
380
162
28
466
209
58
1,909
https://www.dentalboard.gov.au/About-the-Board/Statistics.aspx
<p style="text-align: center;">POPULATION</p>
<br>
<img src="image_0.png" style="width: 100%; max-width: 300px; float: left; margin-right: 20px;">
<p>
<b>Priority Population 4 - People with additional and/or specialised</b><br>
<b>health care needs</b>
</p>
<p>
<span style="background-color: #3770A8; padding: 5px; display: inline-block;">
<span style="color: white; font-weight: bold;">Goal</span>
<span style="color: white;">Improve oral health outcomes and reduce the impact of poor oral health for people</span>
<span style="color: white;">with additional and/or specialised health care needs.</span>
</span>
</p>
<p>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.**</p>
<p>Being a relatively new specialty, there were only 17 registered specialists in Special Needs Dentistry in Australia in 2014, with limited or no availability in some states and territories. A lack of dentists with adequate skills in Special Needs Dentistry was the most frequently reported problem for carers from family homes and community houses, followed by a lack of dentists willing to treat people with disabilities, resulting in long waiting lists. Carers from family homes and community houses were more likely to report problems in obtaining dental care than those at institutions.<sup>122</sup></p>
<p><b>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</b></p>
<p>Consumers with very complex needs will be treated by dental specialists including specialists in Special Needs Dentistry. However, most dental care for people in these groups will have to be provided by general dental practitioners.</p>
<p style="text-align: center;">WHERE DO WE START?</p>
**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
**MEDICO-LEGAL ISSUES**
* 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**
International
Classification of
Functioning,
Disability
and
Health
Short version
Health Condition (Disorder/Disease)
Body Functions &
Activities
Participation
Structures
(Limitation) (Restriction)
(Impairment)
Capacity Performance
Environmental
Personal
Factors
Factors
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
**Consent**
* Capacity to self-consent
* Guardianship / ACDs
* Consent forms
* Clinical holding
* Benefits vs risks of procedure
* Treatment planning and expectations
TREATMENT MODIFICATIONS – “ACCESS”
**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
[WHAT IS THE IDEAL DENTITION?](
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**RATIONAL DENTAL CARE**
**SPECIAL CARE IN DENTISTRY**
**Full Access**
Geriatric dental curriculum and the needs of the elderly
RONALD L. ETTINGER DOS, MDS, JAMES D. BECK PHO
First published: September 1984 |
https://doi-org.proxy.library.adelaide.edu.au/10.1111/j.1754-4505.1984.tb00189.x | Citations 55
**Clinical Decision Making in the Dental Treatment of the Elderly¹**
Ronald L. Ettinger D.D.S., M.S.D.
Article first published online: 28 JUL 2006
DOI: 10.1111/j.1741-2358.1984.tb00367.x
Issue
Gerodontology
**Gerodontology**
Volume 3, Issue 2, pages
157-165, July 1984
Volume 4 Issue 5
September 1984
Pages 207-213
**Clinical**
**PRACTICE**
Rational Dental Care: Part 1.
Has the Concept Changed in 20 Years?
Related
Information
**ABSTRACT**
**J Can Dent Assoc 2006; 72(5):441-5**
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****
**Patient desires and expectations**
**Type and severity of dental need**
**Impact on quality of life**
**Probability of positive outcome**
**Reasonable treatment alternatives**
**Ability to tolerate stress of treatment**
**Capability to maintain oral health**
**Financial and other resources**
**Dentist capabilities**
**Other issues**
**CARE LEVEL**'
✓ **Very extensive**
✓ **Extensive**
✓ **Intermediate**
✓ **Limited**
✓ **Very limited**
**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
Dental Problems-
None
**Perceived Need**
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
<p style="text-align: center; color: black; font-size: 29.8px; margin: 310px 0;">BACK TO THE CASE…</p>
CASE I
**MEDICAL HISTORY**
* Neurocognitive Disorder (Dementia)
* Multifactorial - likely due to alcohol abuse, TBI from MVA (hit by taxi in Thailand), subdural/subarachnoid haemorrhage (falls x2 when intoxicated)
* Neurosyphilis excluded, HIV considered
* HIV +ve
* Biktarvy (bictegravir, emtricitabine, tenofovir, alafenamide)
* History of alcohol dependence
* Memory impairment
* Alcoholic steatohepatitis, currently undergoing investigations for liver cirrhosis -> rosuvastatin
* Oxazepam (control alcohol withdrawal syndrome)
* History of syphilis
* COPD
* Smoker
* Dyspnoea: salbutamol, glycopyrronium, budesonide/formoterol
* Infective exacerbations requiring weaning prednisolone
* Depression
* Desvenlafaxine
* Schizophrenia and mood disorder
* Sodium valproate, risperidone, olanzapine
**SOCIAL HISTORY**
* Residence:
* 2010-2014: Bangkok
* 2015: Lived with sons in Adelaide, then by himself, then supported accommodation.
* Jan-Feb 2016: homeless, prolonged hospital admission (escalating alcoholism), social crisis
* Mar 2016: supported accommodation
* May 2018: residential aged care facility
* ADLs: dependent on others
* Behaviour:
* Feels angry/anxious when does not feel in control of situations.
* Will verbally refuse care, and staff must return later to complete these tasks.
* Reduced insight into own safety and abilities.
* Capacity:
* Able to understand questions/information and able to communicate decisions.
* Able to weigh up risks and benefits for simple treatment decisions
* Questionable whether he would be able to for more complex treatment decisions
* Family
# DENTAL HISTORY
## History
* Irregular dental attender
* Deterioration in ADLs, loss of dexterity, pain in hands with gripping action.
* Requires assistance for care, but often refuses this
## Diet
* Sugar exposure: unknown (pt usually brought in by someone not involved in his regular care, pt is unreliable historian, RACF staff difficult to contact)
* Acid exposure: hx of alcoholism (quantity unknown)
## Fluoride
* Brushes teeth with non-fluoridated toothpaste (CHX-based)
* Drinks tap water, but minimal quantities
## Saliva
* Polypharmacy & medications associated with dry mouth (COPD inhalers, desvenlafaxine, olanzapine, risperidone, cetirizine)
* Dehydrated appearance to oral mucosa
EXAMINATION
**Tooth 24:** Previous RCF, grade II mobile, likely chronic apical periodontitis
**Tooth 25:** carious retained root, chronic apical periodontitis
**Tooth 34:** buccal caries
**Tooth 36:** carious retained root
**Gingival tissues:** generalised moderate biofilm-induced gingivitis
**Periodontal tissues:** stage I-II generalised grade A periodontitis
Here is the extracted text from the image, using the PDF text for context and aiming to match formatting:
<br>ACTIVITY</br>
<br>• **Risk Assessment**</br>
<br> • Medical</br>
<br> • Dental</br>
<br> • Social</br>
<br>• **Treatment Modifications**</br>
<br> • Access</br>
<br> • Consent</br>
<br> • Communication</br>
<br> • Education/Prevention</br>
<br> • Surgical</br>
<br> • Spread of infection</br>
RISK ASSESSMENT
**MEDICAL**
* Oxygenation: dyspnoea upon mild exertion
* Positioning: dyspnoea, chronic pain
* Bleeding: unknown whilst undergoing liver investigations
* Drug metabolism: unknown whilst undergoing liver investigations
* Aspiration pneumonia: significant plaque accumulation on background of COPD & immunocompromise
* HIV control: liability to infection and impaired healing
**DENTAL**
* Dry mouth: medications, reduced fluid intake, inhalers, mouth breathing
* Low fluoride exposure
* Poor oral hygiene and motivation for self-care
* Low dexterity
* Liability to oral thrush: inhalers, poor oral hygiene, HIV positive
* Smoking
* Hx of alcoholism
**SOCIAL**
* Impaired mobility and falls risk
* Capacity to consent
* Poor short-term memory
* Reliance on 3rd party for ADLs and to attend appointments
* Refuses personal care provided by RACF staff
<br>
<p align="center">TREATMENT PLAN</p>
<p><b>Treatment approach:“Maintenance and monitoring”</b></p>
<p>Control Phase</p>
<p>1) Tooth 34 buccal RMGIC</p>
<p>2) Periodontal debridement and oral hygiene instruction</p>
<p>3) Extraction of teeth 24, 25 and 36</p>
<p>Restorative Phase</p>
<p>1) Will not proceed with upper denture fabrication since aesthetics are not a
concern, patient is already struggling with oral hygiene, denture will add to
the plaque accumulation risk, and add complexity to his daily oral hygiene.</p>
<p>Maintenance Phase</p>
<p>1) Recalls 3-4 monthly initially</p>
<p>2) Periodontal maintenance and reinforce oral hygiene instruction</p>
**TREATMENT MODIFICATIONS**
**Consent:**
* Find out consent arrangements
* no appointed guardian for health and welfare decisions
* RACF informed able to self-consent
* Involved NOK in supported decision-making process.
* Confirm with patient he is happy for discussion of sensitive topics in front of NOK
* Discuss limitation of dental care and treatment approach
* If declines treatment →increased risks/difficulty in future as health deteriorates
* Short-term memory loss
* record of written consent to act as reminder for patient
* trusted NOK involved in discussion
* Mood changes: if patient refuses care, re-discuss at another appointment
TREATMENT MODIFICATIONS
**Access to Care:**
* Appointments: suitable days for both RACF and NOK
* Mobility: wheelchair availability for long corridors due to fatigue, dyspnoea. Supervise when transferring from
wheelchair to dental chair
* Positioning: Treat upright or only slightly reclined. Frequent breaks.
* Location: Dental clinic facilitates best standard of care. May need to plan for access to domiciliary care in
future as health declines.
**Communication:**
* Maintain patient’s dignity.
* Address patient primarily (rather than NOK)
* Speak slowly and clearly in non-complex language
* Oral care assessments and oral care plan included into patient’s Personal Care Plan
**TREATMENT MODIFICATIONS**
**Education/Prevention:**
* High concentration fluoride toothpaste (e.g. Neutrafluor 5000), tooth mousse
* Rinsing mouth with water after inhaler use
* Bicarbonate of soda mouth rinses
* Increase water intake
* Oral hygiene product modification (e.g. electric toothbrush, large toothbrush handle to aid grip)
**TREATMENT MODIFICATIONS**
**Surgical:**
* Check baseline tests: complete blood examination, CD4 count / viral load, coagulation screen, biochemistry
serology (indicators for HIV control, liver and renal function)
* Salbutamol and oxygen easily accessible prior to treatment in case of emergency
* Drug doses
* Bleeding: Local haemostasis techniques (LA with vasoconstrictor, atraumatic procedure, haemostatic agent,
suture, if required TXA 5% MW).
RECALL EXAMINATION
Significant health
deterioration
**Treatment**
**approach:**
**“Emergency care**
**only”**
TAKE HOME MESSAGES
<p style="text-align: center;">SUMMARY – KEY STEPS AT INITIAL CONSULT</p>
<ul>
<li>History</li>
<ul>
<li>Medical history, medication list (including liaising with GP/specialist)</li>
<li>Dental history</li>
<li>Social history</li>
</ul>
<li>Examination, investigations &rarr; diagnoses</li>
<li>*Risk assessment:</li>
<ul>
<li>Medical, dental, social factors</li>
</ul>
<li>*Establish the <b>treatment goal/intent</b></li>
<ul>
<li>May require a conservative or aggressive treatment planning approach</li>
</ul>
<li>Treatment plan</li>
<li>*Treatment modifications (ACCESS): access, consent, communication, education/prevention, surgery (pre- peri- post-op), spread of infection</li>
</ul>
**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**
THANK YOU!
Any questions?
Jeeyun.leung@uwa.edu.au
