**2.3.3 Consent for care**

In addition to the barriers listed above, there is the issue of 'capacity to consent' to treatment to consider (Dougall and Fiske, 2008c). The Mental Capacity Act (UK Parliament, 2005) introduced a broad *diagnostic* threshold to determine whether a person has capacity to make a particular decision. The Act identified that a person lacks capacity where: '…at the material time, he is unable to make a decision for himself in relation to a matter because of an impairment of or disturbance in the functioning of the mind or brain' (section 2(1). 'The impairment may be temporary or permanent' (section 2(2)).

A person is considered unable to make a decision if (s)he is unable to:


#### (UK Parliament, 2005)

The principles of consent remain the same whether or not people have full capacity to consent. Informed consent is based on freewill, capacity and knowledge (Dougall and Fiske, 2008c). This means that there are certain key stages which clinicians need to work through with patients, from an introduction of self and the purpose of the visit and establishing what is already understood, right through to giving and obtaining informed consent:


(King, 2001, Dougall and Fiske, 2008c)

Disability and Oral Health 349

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

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).

> From six months of age infants should be introduced to drinking from a cup and from age on year feeding from a

As soon as teeth erupt in the mouth brush them twice daily

Sugar should not be added to weaning foods

Fluoride Use only a smear of fluoride toothpaste containing at least

Parents should brush or supervise brushing

and the use of fluoride to strengthen teeth as shown in Table 2.

This will involve cleaning teeth and/or dentures effectively.

Tooth brushing

**Children 0-3 years Dental caries** Diet Breast feeding provides the best nutrition for babies

1,000ppm fluoride

bottle should be discouraged

Medicines Sugar-free medicines should be recommended

**3.1 Evidence-based self care** 

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