**3. Disability and oral care**

'Valuing people's oral health' (Department of Health, 2007), is a national policy concerned with improving the oral health of children and adults with a disability. It is a good example of health promoting public health action in support of the oral health of people with a disability. The policy document recognises that disabled children and adults have the same right to good oral health as the rest of the population (Department of Health, 2007). Oral health may depend on a whole series of factors, some of which are relevant across the population, and which include the following which include oral care:

*Personal predisposing factors* 


#### *Health systems factors*


Sources: (BSDH et al., 2001, BSDOH, 2009, Dougall and Fiske, 2008a, Dougall and Fiske, 2008b, Dougall and Fiske, 2008c, Dougall and Fiske, 2008e, Dougall and Fiske, 2008f, Lewis et al., 2008a, Lewis et al., 2008b)

The legal framework and basis for obtaining consent will vary from country to country; however, the principles above should prove helpful whatever the context. The big challenge exists in relation to adults who are unable to provide informed consent. This clearly has implications for many people with moderate to severe learning disabilities and has led to the introduction of 'best interest meetings' to ensure that the patient is fully represented where they are not able to fully participate in their own right and the most appropriate care

'Valuing people's oral health' (Department of Health, 2007), is a national policy concerned with improving the oral health of children and adults with a disability. It is a good example of health promoting public health action in support of the oral health of people with a disability. The policy document recognises that disabled children and adults have the same right to good oral health as the rest of the population (Department of Health, 2007). Oral health may depend on a whole series of factors, some of which are relevant across the

programme for the individual is agreed (Dougall and Fiske, 2008c).

population, and which include the following which include oral care:

• Nature and severity of the individual's learning disability

• Previous dental history including attendance pattern

• Importance placed on oral health by carers whether family or paid

• Ability to undertake regular oral hygiene procedures or receive care from others

• Access to local dental services: regular, specialist and emergency dental care

• Nature of local dental services: willingness and skills of the dental team to treat people

• Access to sedation or general anaesthetic services in conjunction with the provision of

• Location and mode of delivery of care: domiciliary, mobile surgery, routine dental

• Processes in place to achieve agreement on dental care plans where the individual is

Sources: (BSDH et al., 2001, BSDOH, 2009, Dougall and Fiske, 2008a, Dougall and Fiske, 2008b, Dougall and Fiske, 2008c, Dougall and Fiske, 2008e, Dougall and Fiske, 2008f, Lewis et al., 2008a, Lewis et al.,

**3. Disability and oral care** 

*Personal predisposing factors* 

• Psychological status • Socio-economic status • Behavioural risk factors

• Medications

*Health systems factors* 

2008b)

• Presence of co-morbidities

• Capacity to consent to oral care

with learning disabilities

dental care (If required)

surgery/office, dental hospital

• Support to access care: transport, carers, etc

unable to provide informed consent

• Age

#### **3.1 Evidence-based self care**

Good oral health starts in infancy with a supportive environment including the active support of parents and/or carers. Personal care and a healthy lifestyle are fundamental to having and maintaining good oral health, but this can be more challenging to people with a disability. As already highlighted, the pathology of oral diseases is well understood, particularly in relation to tooth decay which is the most prevalent dental conditions in children worldwide; so too is the evidence base for prevention. Much of the contemporary evidence base is outlined in 'Delivering Better Oral Health: an evidence–based toolkit for prevention' (Department of Health and British Association for the Study of Community Dentistry, 2009). It outlines appropriate health behaviour at a population and an individual level from birth onwards. It highlights what is should be emphasised by the dental team for the population in general and what additional preventive care is appropriate for those of giving special concern. In all categories there is an emphasis on a healthy diet, good hygiene and the use of fluoride to strengthen teeth as shown in Table 2.

Tooth decay is prevented by minimising the volume and frequency of sweet food and drink. As soon as teeth appear, around the age of six months, they ought to be brushed regularly with a smear of fluoride toothpaste. It is really important to avoid non-milk extrinsic sugars include adding sugar to bottles of milk and prolonged night time feeding. From the age of one year, it is good to progress to using a trainer cup; however children with learning disabilities may take longer to do so. Once children are old enough to begin brushing teeth themselves, parents should continue to supervise brushing until the child is able to undertake thorough cleaning themselves and a 'pea-sized' amount of toothpaste should be used. It is very important to clean teeth last thing at night and at one other time during the day with familystrength fluoride toothpaste (1450-1500ppm fluoride) and to spit out excess toothpaste without rinsing away the fluoride toothpaste. Many people are not aware that rinsing with lots of water after tooth-brushing dilutes the effect of fluoride in toothpaste and is not advised.

Where clients are cared for in institutions it is very important that there is an oral health assessment incorporated into their general assessment on entry to a care home to inform their daily regimen or 'care plan'. Standards for daily oral hygiene should be agreed and care givers trained in the provision of daily oral care (Fiske et al., 2000, BSDH et al., 2001). This will involve cleaning teeth and/or dentures effectively.


Disability and Oral Health 351

In looking at professional dental care it is important to understand that within the UK there has been a significant shift in the provision of social care for people with learning disabilities and this has had implications for oral healthcare. Tiller et al (2001) outline how adults with learning disabilities were largely cared for in residential establishments until the 1980's when a process of 'normalisation' resulted in adults with a learning disability moving from residential homes to live in the community over the subsequent decade or two. Many moved to live in residential homes in the community, supported by carers. Tiller et al (2001) undertook a study to compare the oral health of adults remaining in residential homes with those still living in the community. It provided dramatic insight to the fact that adults living in the community in the Sheffield area of the North of England were particularly disadvantaged. Despite the fact that people living in residential care were significantly older than those based in the community, both groups had similar levels of caries experience; however, adults living in the community had significantly more untreated decay and poorer oral hygiene than their counterparts in residential care. In contrast, adults in residential care had significantly more missing teeth. Stanfield in another study across settings demonstrated that compared with institutionalised people with learning disabilities, attendance patterns were less regular for residents in the community; furthermore, individuals in the community were also less likely to receive operative dental treatment (Stanfield et al., 2003). There is evidence from south east London that amongst adults with learning disabilities the prevalence of plaque, calculus and gingivitis were high, however those living in with their families had less untreated disease (Naidu et al., 2006). A study conducted about the same time involving structured interviews of 257 learning disabled adults and/or carers in Lambeth, Southwark & Lewisham (Pratelli and Gelbier, 2000). The majority (63%) reported no difficulty in obtaining dental care for people with learning disabilities, with general dental services (40%), community (36%) and hospital services (15%) being the main providers. Subjects with a history of difficulty in obtaining an appointment were more likely to perceive an unmet treatment need and have a greater professionally defined need for treatment at time of interview than their counterparts. This was also for case for those with higher levels of disability or requiring assistance with cleaning. Almost half of subjects perceived a need for care, only 30% of whom had obtained a dental appointment. Support systems to facilitate access to dental care, identified for and by this client group, were advocated including good information systems across health and

It is salutary to note that a review of access to healthcare across the lifespan of people with learning disabilities (Alborz et al., 2004) highlighted the dearth of research on access to dental care and that the published material at that time, which only related to first line services, did not include access to specialist care. In a review of the five studies available Alborz et al (2004) also reported that adults with learning disabilities living in informal family settings in the community were found to have higher levels of tooth decay than those living in more formal residential settings. They were reported as less likely to see a dentist

All of the above research raises two key questions. First, how often should people attend for dental care; and, second, where should they seek care? Guidance, from the National Institute for Clinical Excellence on dental recalls recommends that children should attend a

regularly, or to have no dentist, and only seek care when experiencing pain.

**3.2 Professional care through dental services** 

social care (Pratelli and Gelbier, 2000).


Source: Delivering Better Oral Health (Dept of Health & BASCD, 2009)

Table 2. Prevention of oral disease for those at high risk of developing oral disease

**Dental caries** Diet Sugars should not be consumed more than four times per day

consumed, when limited to mealtimes

Sugary food and drink should be reduced and when

If over 7 years of age, and giving concern, use a fluoride mouth-rinse daily (0.05%NaF) at a different time to brushing

Any supplements containing sugar and glucose polymers at mealtimes when possible unless clinically directed otherwise)

If giving concern, use a fluoride mouth-rinse daily (0.05%NaF)

Brush teeth systematically with either a manual brush with a small head and round end filaments, a compact angled arrangement of long and short filaments and a comfortable

A powered toothbrush with an oscillating/rotating head Clean interdentally using inter-dental brushes or floss

Brush last thing at night and on one other occasion

Sugary food and drink should be reduced and when

Brush last thing at night and on one other occasion

Brushing should be supervised by an adult Spit out after brushing and do not rinse

Fluoride Use a pea-sized amount of toothpaste containing 1,3500-1,500

**Children over 3 years** 

Medication Ensure medication is sugar-free

**Adults** 

handle OR

Tobacco Do not smoke

Tobacco Do not smoke

Source: Delivering Better Oral Health (Dept of Health & BASCD, 2009)

and not last thing at night.

**Dental caries** Diet Sugars should not be consumed more than four times per day

at a different time to brushing

Alcohol Limit alcohol to moderate levels (if drunk)

fruit or vegetables per day

Table 2. Prevention of oral disease for those at high risk of developing oral disease

Diet Maintain balanced healthy diet with at least five portions of

Brush twice daily

consumed, when limited to mealtimes

Fluoride Use a toothpaste containing at least 1,3500ppm fluoride

Brushing should be supervised by an adult Spit out after brushing and do not rinse

ppm

Tooth brushing

Dietary supplements

Tooth brushing

Tooth brushing

**Periodontal (gum) diseases** 

**Oral (mouth) cancer** 

In looking at professional dental care it is important to understand that within the UK there has been a significant shift in the provision of social care for people with learning disabilities and this has had implications for oral healthcare. Tiller et al (2001) outline how adults with learning disabilities were largely cared for in residential establishments until the 1980's when a process of 'normalisation' resulted in adults with a learning disability moving from residential homes to live in the community over the subsequent decade or two. Many moved to live in residential homes in the community, supported by carers. Tiller et al (2001) undertook a study to compare the oral health of adults remaining in residential homes with those still living in the community. It provided dramatic insight to the fact that adults living in the community in the Sheffield area of the North of England were particularly disadvantaged. Despite the fact that people living in residential care were significantly older than those based in the community, both groups had similar levels of caries experience; however, adults living in the community had significantly more untreated decay and poorer oral hygiene than their counterparts in residential care. In contrast, adults in residential care had significantly more missing teeth. Stanfield in another study across settings demonstrated that compared with institutionalised people with learning disabilities, attendance patterns were less regular for residents in the community; furthermore, individuals in the community were also less likely to receive operative dental treatment (Stanfield et al., 2003). There is evidence from south east London that amongst adults with learning disabilities the prevalence of plaque, calculus and gingivitis were high, however those living in with their families had less untreated disease (Naidu et al., 2006). A study conducted about the same time involving structured interviews of 257 learning disabled adults and/or carers in Lambeth, Southwark & Lewisham (Pratelli and Gelbier, 2000). The majority (63%) reported no difficulty in obtaining dental care for people with learning disabilities, with general dental services (40%), community (36%) and hospital services (15%) being the main providers. Subjects with a history of difficulty in obtaining an appointment were more likely to perceive an unmet treatment need and have a greater professionally defined need for treatment at time of interview than their counterparts. This was also for case for those with higher levels of disability or requiring assistance with cleaning. Almost half of subjects perceived a need for care, only 30% of whom had obtained a dental appointment. Support systems to facilitate access to dental care, identified for and by this client group, were advocated including good information systems across health and social care (Pratelli and Gelbier, 2000).

It is salutary to note that a review of access to healthcare across the lifespan of people with learning disabilities (Alborz et al., 2004) highlighted the dearth of research on access to dental care and that the published material at that time, which only related to first line services, did not include access to specialist care. In a review of the five studies available Alborz et al (2004) also reported that adults with learning disabilities living in informal family settings in the community were found to have higher levels of tooth decay than those living in more formal residential settings. They were reported as less likely to see a dentist regularly, or to have no dentist, and only seek care when experiencing pain.

All of the above research raises two key questions. First, how often should people attend for dental care; and, second, where should they seek care? Guidance, from the National Institute for Clinical Excellence on dental recalls recommends that children should attend a

Disability and Oral Health 353

care is delivered and the information needs of patients and carers (BSDH et al., 2001, Gallagher and Fiske, 2007, Department of Health, 2007). One of the challenges for dental practitioners in providing dental care for people with disabilities relates to the physical setting. Many dental practices were established in buildings which are not ideal in relation to the disability legislation outlined in Section 2.2 and they may not have appropriate car parking facilities (Baird et al., 2008). Whilst some modifications can be made, it is important for carers to find the practices in an area which are easily physically accessible. This is where local planners and policymakers, together with professional leaders, can ensure that there is good local information on the availability of dental services and how best they may be

Although general dentists are the main providers of dental care, not all care can, or should, be provided by general dentists or even in a primary care setting. Patients and carers may also need to negotiate their way through to specialist services, and possibility hospital specialist services either as a one-off process, because of a particular need or condition, or on

In the UK, patients do not normally have direct access to specialist services and primary dental care practitioners refer those patients who are beyond their skill and competence to manage. There are now 13 dental specialties including Paediatric Dentistry and Special Care Dentistry (see Section 4 below). Paediatric Dentistry is concerned with the care of children who require specialist care and this includes children with learning difficulties. Special Care Dentistry (SCD) is concerned with the improvement in oral health of individuals and groups in society who have a physical, sensory, intellectual, mental, medical, emotional or social impairment or disability or, more often, a combination of a number of these factors (JACSCD, 2003). The focus on providing care for adults and ideally often take over the care of teenagers with a learning disability from their paediatric colleagues, particularly when patients require additional skill and expertise which is beyond the competence of a general

Management of people with disabilities may range from simple care in a complex patient through to complex care in patients who do not find it a challenge to receive care. Specialists are able to manage the medical, legal, social and clinical health issues that arise in patient care. They also have access to a range of facilities and agencies to support care. Special Care Dentistry is often provided across community and hospital settings so that care may be provided in the location most appropriate for the patient. For example if general anaesthetic is required this must be done in hospital, whereas the use of sedation as well as local anaesthetic for clinical care may be provided in a community setting, providing it is equipped and staffed to do so. Careful assessment and treatment planning are crucial for patients. A cross-sectional study of 210 children, with varying degrees of disability and attending special schools in three inner London boroughs, provides insight to treatment planning and patient management. It revealed that 67% required treatment and amongst the 52% of children who required a combination of treatment procedures, 64% could be treated in a primary care setting without sedation and the remaining 36% would require sedation (27%), or a general anaesthetic (9%), because of inability to comply with care (Taylor et al.,

an ongoing basis if their needs and/or management are complex.

accessed.

**3.2.2 Specialist care** 

dental practitioner.

2001).

dentist for a check-up at least once a year and that the equivalent period for adults is at least once every two years (NICE, 2004). The recommendation is based on assessment of an individual's risk of developing further disease and should ideally be discussed, and agreed, by the patient and health professional. It is recognised the some people with learning disabilities may be at higher 'risk' of oral disease and may therefore need to be seen more frequently by the dental team. Exactly, 'where patients with a learning disability may most appropriately seek care' will vary depending on a number of factors including their oral health needs and the complexity of their condition as outlined in the following sections.

#### **3.2.1 Primary dental care**

Within the UK, the majority of dental care is provided by general dental practitioners in their 'dental practice' or 'office'. This is the case for dental care in general and for people with learning disabilities. Primary dental care practitioner's act as the 'gatekeeper' to specialist services, which are only used when required. Historically a much smaller salaried dental service, known as the 'community dental service' played an important role in providing primary dental care for hard to reach groups such as people with learning disabilities. As outlined in Sections 3.2.2 and 4, much of this service is becoming more specialised with the emergency of a new specialty of 'Special Care Dentistry'.

The policy documents on learning disabilities (Department of Health, 2001; 2007) advocate 'choice' and 'inclusion'; however, this may require further work on the part of clinicians in line with principles for holistic care and ensuring patient empowerment (Owens et al., 2010).

Contemporary evidence-based oral health care, where-ever it is received, involves much more than just treating disease. There are many interventions for children and adults who give cause for concern and are at higher risk of developing oral disease. Following an indepth case history and examination, this includes:


(Department of Health and British Association for the Study of Community Dentistry, 2009)

Much of the above preventive care can be effectively provided by other members of the dental team such as dental therapists and dental hygienists on prescription from a dentist. There is evidence that dental hygienists could make a greater contribution to the care of people with a disability (Christensen et al., 2005). Carers play such an important role in healthcare and require regular support from the dental team. Valuing people's oral health recognises that it is good practice for personnel involved in the care of disabled children and adults to receive appropriate training and for them to be provided with information about services available and preventive actions that work (Department of Health, 2007). It is therefore important for carers to ensure that they receive the appropriate information and guidance to help support and maintain oral health (Dougall and Fiske, 2008d).

Several reviews and policy documents have identified issues relating to physical access to dental care, issues relating to clinicians' understanding of people with a disability and how

dentist for a check-up at least once a year and that the equivalent period for adults is at least once every two years (NICE, 2004). The recommendation is based on assessment of an individual's risk of developing further disease and should ideally be discussed, and agreed, by the patient and health professional. It is recognised the some people with learning disabilities may be at higher 'risk' of oral disease and may therefore need to be seen more frequently by the dental team. Exactly, 'where patients with a learning disability may most appropriately seek care' will vary depending on a number of factors including their oral health needs and the complexity of their condition as outlined in the following sections.

Within the UK, the majority of dental care is provided by general dental practitioners in their 'dental practice' or 'office'. This is the case for dental care in general and for people with learning disabilities. Primary dental care practitioner's act as the 'gatekeeper' to specialist services, which are only used when required. Historically a much smaller salaried dental service, known as the 'community dental service' played an important role in providing primary dental care for hard to reach groups such as people with learning disabilities. As outlined in Sections 3.2.2 and 4, much of this service is becoming more

The policy documents on learning disabilities (Department of Health, 2001; 2007) advocate 'choice' and 'inclusion'; however, this may require further work on the part of clinicians in line with principles for holistic care and ensuring patient empowerment (Owens et al., 2010). Contemporary evidence-based oral health care, where-ever it is received, involves much more than just treating disease. There are many interventions for children and adults who give cause for concern and are at higher risk of developing oral disease. Following an in-

• Regular application of a small amount of fluoride varnish to susceptible tooth surfaces • Prescription of high fluoride toothpaste, fluoride supplements or fluoride mouthwash • Providing fissure sealants on newly erupted teeth to reduce the risk of tooth decay • Ensuring timely and appropriate advice and support on diet and other health

Much of the above preventive care can be effectively provided by other members of the dental team such as dental therapists and dental hygienists on prescription from a dentist. There is evidence that dental hygienists could make a greater contribution to the care of people with a disability (Christensen et al., 2005). Carers play such an important role in healthcare and require regular support from the dental team. Valuing people's oral health recognises that it is good practice for personnel involved in the care of disabled children and adults to receive appropriate training and for them to be provided with information about services available and preventive actions that work (Department of Health, 2007). It is therefore important for carers to ensure that they receive the appropriate information and

Several reviews and policy documents have identified issues relating to physical access to dental care, issues relating to clinicians' understanding of people with a disability and how

(Department of Health and British Association for the Study of Community Dentistry, 2009)

guidance to help support and maintain oral health (Dougall and Fiske, 2008d).

specialised with the emergency of a new specialty of 'Special Care Dentistry'.

depth case history and examination, this includes:

behaviours such as tooth-brushing.

**3.2.1 Primary dental care** 

care is delivered and the information needs of patients and carers (BSDH et al., 2001, Gallagher and Fiske, 2007, Department of Health, 2007). One of the challenges for dental practitioners in providing dental care for people with disabilities relates to the physical setting. Many dental practices were established in buildings which are not ideal in relation to the disability legislation outlined in Section 2.2 and they may not have appropriate car parking facilities (Baird et al., 2008). Whilst some modifications can be made, it is important for carers to find the practices in an area which are easily physically accessible. This is where local planners and policymakers, together with professional leaders, can ensure that there is good local information on the availability of dental services and how best they may be accessed.

Although general dentists are the main providers of dental care, not all care can, or should, be provided by general dentists or even in a primary care setting. Patients and carers may also need to negotiate their way through to specialist services, and possibility hospital specialist services either as a one-off process, because of a particular need or condition, or on an ongoing basis if their needs and/or management are complex.

#### **3.2.2 Specialist care**

In the UK, patients do not normally have direct access to specialist services and primary dental care practitioners refer those patients who are beyond their skill and competence to manage. There are now 13 dental specialties including Paediatric Dentistry and Special Care Dentistry (see Section 4 below). Paediatric Dentistry is concerned with the care of children who require specialist care and this includes children with learning difficulties. Special Care Dentistry (SCD) is concerned with the improvement in oral health of individuals and groups in society who have a physical, sensory, intellectual, mental, medical, emotional or social impairment or disability or, more often, a combination of a number of these factors (JACSCD, 2003). The focus on providing care for adults and ideally often take over the care of teenagers with a learning disability from their paediatric colleagues, particularly when patients require additional skill and expertise which is beyond the competence of a general dental practitioner.

Management of people with disabilities may range from simple care in a complex patient through to complex care in patients who do not find it a challenge to receive care. Specialists are able to manage the medical, legal, social and clinical health issues that arise in patient care. They also have access to a range of facilities and agencies to support care. Special Care Dentistry is often provided across community and hospital settings so that care may be provided in the location most appropriate for the patient. For example if general anaesthetic is required this must be done in hospital, whereas the use of sedation as well as local anaesthetic for clinical care may be provided in a community setting, providing it is equipped and staffed to do so. Careful assessment and treatment planning are crucial for patients. A cross-sectional study of 210 children, with varying degrees of disability and attending special schools in three inner London boroughs, provides insight to treatment planning and patient management. It revealed that 67% required treatment and amongst the 52% of children who required a combination of treatment procedures, 64% could be treated in a primary care setting without sedation and the remaining 36% would require sedation (27%), or a general anaesthetic (9%), because of inability to comply with care (Taylor et al., 2001).

Disability and Oral Health 355

As already intimated, carers have an important role in initiating dental treatment whether routine or emergency. It may not always be clear that an individual client has a dental problem but it should be one of the considerations when someone is out of sorts and there is no obvious cause, particularly in clients who have difficulty in expressing their needs. Carers need to have easily accessible information on the range of local services and how

Increasingly there needs to be clear pathways to care which are easily understood and widely available to inform access to dental care. Care should also be seamless across the years, where possible (Dougall and Fiske, 2008f, Lewis et al., 2008b, Lewis et al., 2008a, Dougall and Fiske, 2008g). Care pathways should build on the principles outlined in 'Valuing Peoples Oral Health', outlined in Section 2.2, whereby primary dental care practitioners provide the majority of dental care, mainly in their dental surgery but they may also undertake domiciliary care in people's own homes or in residential institutions. Some interested dental practitioners are now commissioned to provide dental care in this way and they may well, over time, become Dentists with a Special Interest in Special Care Dentistry in future (Department of Health et al., 2009). All institutions which have the care of people with learning disabilities whether care homes or homes within the community should have access to both emergency and routine dental care for their clients. Furthermore,

it may be appropriate to have regular screening sessions or dental checkups on site.

Specialist

Dentist with a special Interest

> Primary dental care practitioners

they may be accessed (Frenkel, 1999).

**Integrated Special Care Dentistry**

Fig. 1. Integrated network of care

In addition to the above, oral healthcare may be delivered to people with learning disabilities on a domiciliary basis, i.e. carried out in an environment where a patient is resident, either permanently or temporarily, because of frailty, dementia, or disorientation (BSDOH, 2009). It may be provided in an individual's home, a care home or community house or in a day centre or hospital. The type of care that may be provided on this basis and in these settings is often more limited than can be provided in a normal dental surgery; however, with medical advances increasingly sophisticated care is possible. The British Society for Disability and (oral) Health (2009) provide publically accessible guidelines on the provision of domiciliary care. Another option is to provide dental care in a mobile caravan, which is fully equipped as a dental surgery and this provides the opportunity to treat groups of individuals at a school, day centre or residential home and reduces barriers to care.

#### **3.2.3 Integrated Care pathways**

Access may be defined as the 'fit between clients and services' (Penchansky and Thomas, 1981). There are five key areas for practical action to facilitate access and reduce barriers to care outlined in Table 3. It is important that people with a disability are facilitated to access oral healthcare and therefore greater work is required by planners and providers to make services more accessible to patients, thus 'improving the fit'. Bringing services to patients in a mobile or domiciliary service outlined above are good examples of practical action to improve availability and accessibility of services; however, it is important that mainstream services are similarly accessible.


Adapted from Penchansky & Thomas, 1981

Table 3. Access: 5 As

In addition to the above practical issues, psychosocial barriers to care must also be recognised as fear is a general barrier to dental care (Finch et al., 1988, Kelly et al., 2000), and thus anxiety management must be part of care provision. Adjuncts to behavioural management include sedation and general anaesthetic for anxious or restless patients (Boyle et al., 2000, Manley et al., 2008, Department of Health and Faculty of GDPUK, 2008, Glassman et al., 2009).

In addition to the above, oral healthcare may be delivered to people with learning disabilities on a domiciliary basis, i.e. carried out in an environment where a patient is resident, either permanently or temporarily, because of frailty, dementia, or disorientation (BSDOH, 2009). It may be provided in an individual's home, a care home or community house or in a day centre or hospital. The type of care that may be provided on this basis and in these settings is often more limited than can be provided in a normal dental surgery; however, with medical advances increasingly sophisticated care is possible. The British Society for Disability and (oral) Health (2009) provide publically accessible guidelines on the provision of domiciliary care. Another option is to provide dental care in a mobile caravan, which is fully equipped as a dental surgery and this provides the opportunity to treat groups of individuals at a school, day centre or residential home and reduces barriers to

Access may be defined as the 'fit between clients and services' (Penchansky and Thomas, 1981). There are five key areas for practical action to facilitate access and reduce barriers to care outlined in Table 3. It is important that people with a disability are facilitated to access oral healthcare and therefore greater work is required by planners and providers to make services more accessible to patients, thus 'improving the fit'. Bringing services to patients in a mobile or domiciliary service outlined above are good examples of practical action to improve availability and accessibility of services; however, it is important that mainstream

**Available** in a geographic area, both real and perceived (Where do dentists

**Accessible** Location, eg transport/walking/parking, physical, e.g. disabled

**Acceptable** feel welcome, treated professionally, treated as an individual,

costs/ understanding of costs **Accommodating** opening hours: evenings, weekends, drop-in service vs

**Affordable** costs of care (direct) and cost of attending (indirect), information on

In addition to the above practical issues, psychosocial barriers to care must also be recognised as fear is a general barrier to dental care (Finch et al., 1988, Kelly et al., 2000), and thus anxiety management must be part of care provision. Adjuncts to behavioural management include sedation and general anaesthetic for anxious or restless patients (Boyle et al., 2000, Manley et al., 2008, Department of Health and Faculty of GDPUK, 2008,

like to set up practices? Low availability may suppress demand)

language, waiting areas, quality of care appropriate (posh/shabby)

care.

**3.2.3 Integrated Care pathways** 

services are similarly accessible.

**5As Descriptor** 

Adapted from Penchansky & Thomas, 1981

Table 3. Access: 5 As

Glassman et al., 2009).

access

appointments

As already intimated, carers have an important role in initiating dental treatment whether routine or emergency. It may not always be clear that an individual client has a dental problem but it should be one of the considerations when someone is out of sorts and there is no obvious cause, particularly in clients who have difficulty in expressing their needs. Carers need to have easily accessible information on the range of local services and how they may be accessed (Frenkel, 1999).

Increasingly there needs to be clear pathways to care which are easily understood and widely available to inform access to dental care. Care should also be seamless across the years, where possible (Dougall and Fiske, 2008f, Lewis et al., 2008b, Lewis et al., 2008a, Dougall and Fiske, 2008g). Care pathways should build on the principles outlined in 'Valuing Peoples Oral Health', outlined in Section 2.2, whereby primary dental care practitioners provide the majority of dental care, mainly in their dental surgery but they may also undertake domiciliary care in people's own homes or in residential institutions. Some interested dental practitioners are now commissioned to provide dental care in this way and they may well, over time, become Dentists with a Special Interest in Special Care Dentistry in future (Department of Health et al., 2009). All institutions which have the care of people with learning disabilities whether care homes or homes within the community should have access to both emergency and routine dental care for their clients. Furthermore, it may be appropriate to have regular screening sessions or dental checkups on site.

Fig. 1. Integrated network of care

Disability and Oral Health 357

leading chronic diseases which are the major cause of death in high income countries: cardiovascular diseases, cancer, chronic respiratory diseases and diabetes. The risk factors include unhealthy diet, tobacco, and alcohol. Poor oral hygiene is also a risk factor. This highlights the importance of working on these common risk factors in support of health in

**4. Special Care Dentistry - how UK addressed this professional challenge** 

Within the past decade in the UK, the dental specialty of 'Special Care Dentistry' came into being. It is an interesting example of a public health approach to planning and implementation of a new specialty. In the early decades of the UK National health Service, i.e. from 1948 onwards, dental surgeons and then oral surgeons, provided extraction services for people with a disability in hospitals. From the 1980's onwards interested dentists in the community and salaried dental services, began to provide care for people with learning disabilities in community clinics as health policy expanded their remit beyond

A Working Group for Special Care Dentistry was established by the Dean of the Faculty of Dental Surgery in one of the Royal Colleges to explore the need for a specialty of Special Care Dentistry in the UK and reported in 1999. They wrestled with both the arguments for creation of a specialty and with the process for achieving change. The need to formalise the care for more vulnerable sections of society that had traditionally been provided by a relatively small number of socially committed dentists was overwhelming. Furthermore, there was clear evidence that services for disabled children within the UK were much better than those for adults and that that the transition to adult care was a particular challenge for healthcare in general (JACSCD, 2003). Children with more extreme disabilities tended to have been managed by paediatric consultants and thus got into difficulties when they had to move to routine services as they reached 16 or 18 years of age and were no longer under the remit of paediatric services. The process of achieving change involved the establishment of a 'Joint Advisory Committee for Special Care Dentistry' in 2000 to build a case, lobby for change, and commence formal training for a new specialty. The case of need for the specialty was used to influence key players such as the Department of Health and the General Dental Council (JACSCD, 2003, Gallagher and Fiske, 2007); it examined the demography of the patient base, oral health inequalities, inequalities in access and models of good practice including how the specialty would work with primary care practitioners in providing care for the spectrum of disabilities. Existing models of good practice reveal that established clinicians working in this field have a patient base of between 850 and 1,500 patients per year and work across primary care and hospital settings, liaising with colleagues in health, social services and the voluntary sector to ensure integrated health care planning. The arguments outlined in a paper in the British Dental Journal focused on it being a professional challenge to ensure better access, outcomes and oral health of individuals and groups who have a physical, sensory, intellectual, medical, emotional or social impairment or disability (Gallagher and Fiske, 2007). On this basis, a conservative estimate of 133 specialists was suggested for the future, working in networks with Dentists with a Special Interest in Special Care Dentistry and primary dental care

general.

**4.1 A Needs-led specialty** 

merely treating children.

practitioners.
