Community and Special Care Dentistry in Sheffield

1. Community and Special Care Dentistry in Sheffield Peter Bateman Clinical director of salaried dental services Specialist in special care dentistry

2. Who are salaried dentists? • Community dentists • Specialists • Access dentists • Dental teachers • Oral health promotion team

3. Who do we treat? • Learning disability • Mental Health • Physical disability • Acquired disability • Frail elderly • Housebound • Medically compromised • Severe dental anxiety • Behavioural problems • Looked after children • Homeless • Migrants • Asylum seekers • Refugees • Substance misuse • Access difficulties

4. What do we do? • Dental clinics in the community • Special care clinics at dental hospital • Special care operating list at Hallamshire hospital • Outreach teaching of dental students • Training of speciality and dental foundation year dentists • Training of dental nurses • Sheffield Oral Health Promotion unit • Dental screening & epidemiology programmes

5. Sheffield SPDCS To be the leading provider of care and education in special Care dentistry for vulnerable groups in Sheffield

6. Today’s lecture • Introduce the speciality of special care dentistry • Describe challenges when treatment planning for special care patients • Pain and anxiety care pathway • Identify key agencies and teams

7. Special Care Dentistry Special Care dentistry is concerned with the improvement of the oral health of individuals and groups in society who have a physical, sensory, intellectual, mental, medical, emotional or social impairment or disability, or a combination of a number of these factors.

8. Commissioning Guidance • Valuing People’s Oral Health. A good practice guide for improving the oral health of children and adults. DoH 2007 • Commissioning tool for Special Care Dentistry. BSDH 2006

9. ‘Some disabled children and adults can present challenges to primary and secondary providers. Delivering a quality service to children and adults who may have poor understanding, uncontrolled movements, limited mouth opening, poor posture or limited mobility, who may experience tiredness during treatment or have medical problems, presents a range of difficulties and barriers’Valuing people’s oral healthDepartment of Health Nov 2007

11. Challenges in special care dentistry • Communication • Co-operation • Medical • Oral risk • Access • Legal and ethical

12. MichaelAge 37Aspbergers syndrome • Referred by GDP resistant to dental care including needles & X-Rays • Needs: time, explanation, further time to make decision • Treatment need :Fillings, one of which large and difficult • Acclimatisation and X-Rays over 2 visits • Simple fillings • Michael initially requested extraction difficult tooth • Next visit changed mind • Further acclimatisation before completed filling • Future arrangement ? Shared care

13. MelanieAge 46History self neglect + ???? • Referred by social care support worker • Came with support worker • Visit 1- waiting room meeting • Visit 2 Just inside surgery door • Failed to attend whenever support worker unavailable • Visit 6 Polished teeth in an upright position • Visit 9 Introduction to local anaesthetic • Visit 15 Completed 3 small fillings, extraction 1 tooth and 7 roots and provision of false teeth • Can now smile....and come to dentist unaccompanied

14. SusanAge 51NeurosarcoidosisInsulin dependent diabeticArthritis/ Osteoporosis/confined to wheelchairMedication includes bisphosphonate/prednisalone • Two man ambulance to access surgery • Root canal treatment of a retained root and sealed • Two teeth cannot be filled or stabilised • Case conference • Full explanation/consent process for extractions • Double steroid and antibiotic cover • Extractions and active follow up

16. LizzieAge 57Severe learning difficultyIn residential care • History of provision of regular scaling and minor fillings with moderate restraint • New carer objected to restraint used and reported back to her manager • Care home cancelled visits and asked for scaling using sedation every 3 months • I visited care home manager and explain clinical needs and that sedation was just as much restraint as was holding • Care home manager visited surgery at Elaine’s next visit • Joint agreement that appropriate physical restraint was being used including recognising the time to stop • Previous programme of regular scaling recommenced

17. Restraint • Clinical holding- Hand holding (5 levels) Head support/ toothbrush Movement restricted Firm hold Considerably stronger hold • Sedation- Gas and air Intravenous • General anaesthetic

18. Not to clean teeth or provide dental care for a person without capacity is Neglect

20. Pain and anxiety pathwayPrinciples • CBT is first choice response for dental phobia/ anxiety • Strict entry criteria • Referrals for sedation to manage phobia/ anxiety not permitted • Sedation only available after CBT failed, unless acute pain • 1 course of treatment with TLC dentist • Back to family dentist

21. Key agencies • Residential care • Mental health care • IMCAs • Child protection • Medical services • Voluntary sector

22. A shared Care modelResidential Oral Care in Sheffield General dental practitioners • Screen residents • Preventive care • Dentures • Simple fillings Salaried service • Carer training • GDP support/training • Complex cases

23. Salaried service referral criteria • Adults and children with a moderate or severe learning difficulty • Adults and children with autistic spectrum disorders that impact on the provision of dental care • An adult currently under the care of a registered mental health practitioner • Children with other special needs affecting the provision of dental care, including those with severe anxiety or other behavioural management difficulty • A patient who for medical reasons cannot receive care in general dental practice • Frail elderly people • An adult who meets the entry criteria for Sheffield’s dental pain and anxiety pathway, and for whom an assessment of their dental anxiety has been completed

24. peterbateman@nhs.net Any Questions? peterbateman@nhs.net