**4.1 A Needs-led specialty**

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 merely treating children.

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 practitioners.

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guidelines for the care and management of people with a disability (http://www.bsdh.org.uk/guidelines.html). Furthermore, through the journal of the association the 'Journal of Disability and Oral health' and helpful publications such as in the British Dental Journal in 2008 (Dougall and Fiske, 2008d, Dougall and Fiske, 2008f, Dougall and Fiske, 2008e, Dougall and Fiske, 2008a, Dougall and Fiske, 2008g, Dougall and Fiske, 2008c, Dougall and Fiske, 2008b, Lewis et al., 2008b, Lewis et al., 2008a), they provide a really helpful basis for practical care of people with learning disabilities. The underlying ethos has a number of key themes and is worth reiterating. First, that people providing care share common values, a commitment to adhere to accepted clinical and professional standards and above all operate within the best interests of the service user. Second, that all individuals have a right to autonomy as far as possible in relation to decisions made about them. Third, good oral health has positive benefits for health, dignity and self-esteem, social

integration and general nutrition as the impact of poor oral health can be profound.

Whilst it is recognised that the advances in Special Care Dentistry are significant, there is much action required to promote oral health of people with learning disabilities, build capacity of the dental team and ensure that there is access to high quality evidence-baed

Dental and oral research amongst people with learning disabilities is much needed to improve our evidence base in promoting oral health and the delivery of patient care, but it is sadly lacking. There is little published evaluation of actions to improve service delivery, patient satisfaction and outcomes. Lack of funding for dental research is a general problem and the challenges of undertaking research, particularly amongst adults because of the challenge of obtaining informed consent. The Mental Capacity Act (UK Parliament, 2005) and subsequent guidance (Department of Health, 2008), provide the opportunity for consultees to be identified for research involving adults who lack the capacity to consent; this can either be a 'personal consultee' or a 'nominated consultee'. Local informants will be identified via local organisations. They will be chosen to reflect the diversity of the local disabled population in relation to sex, cultural and ethnic diversity, age and social status. The consultee may act in place of the person alongside a person with a learning disability or as a substitute. This approach requires high level ethics committee scrutiny and research governance approval and is likely to further add to the time, cost and complexity of the research process. Nevertheless it is very important in supporting people with a learning

There is clear need for methods of assessing the levels of need in this section of the population whether through dental and epidemiological surveys, dental information systems in practices or other means. As dental practice management software becomes more adept at capturing epidemiological data, clinicians should become adept in recording these data during clinical consultations, thus possibly avoiding the need to invest in specific

surveys and providing ongoing monitoring data on oral health (Gallagher, 2005).

**4.3 Future challenges** 

**4.3.1 Research** 

care provided in a timely manner as outlined below.

disability that high quality research is undertaken.

**4.3.2 Monitoring oral health** 

The new specialty was approved by the General Dental Council in 2007 and the specialist list opened in 2008 (General Dental Council, 2008). Initially dentists with relevant expertise were 'grand-parented' onto the specialist list on the basis of their competence.

Impairment and disability were defined in the broadest of terms, thus Special Care Dentistry is concerned with providing and enabling the delivery of oral care for a diverse client-group with a range of disabilities and complex additional needs and includes people living at home, in long stay residential care and secure units, as well as homeless people. Interestingly, in parallel with the creation of the specialty there has been significant emphasis nationally on meeting the needs of *vulnerable* groups such as people with a disability.
