Setting up dental sedation services for special care and medically compromised patients

Abstract

Special Care Dentistry (SCD) is defined as “an improvement of oral health of the individuals and groups in society who have a medical, physical, mental, psychological, social, intellectual, emotional, or sensory impairment or disability or, more often, a combination of a number of these factors” (Fiske, 2006). It tends to assess the oral health needs of people who have medically compromised conditions, are taking multiple medications, or have poor access to dental care (Abed, 2017). In 2008, SCD was recognised by the General Dental Council (GDC) as a specialty in the United Kingdom (General Dental Council, 2012). On 12th of March 2016, a symposium run by the Society for the Advancement of Anaesthesia in Dentistry (SAAD) and the British Society for Disability and Oral Health (BSDH) in the United Kingdom delivered suggestions about “Setting up Dental Sedation Services for Special Care Patients.” It discussed six possible barriers that any health organization might face while setting up dental sedation services for special care patients. Why do these patients need this kind of special services? What are the barriers and the solutions? Also, how could these services be established and delivered positively? Is it possible to deliver different types of dental treatment such as dental extractions, scaling and root planing, restorations, root canal treatment and prosthodontics with reasonable cost for both health organizations and patients? Special Care Dentistry is a new dental field that needs a multidisciplinary team (MDT) to develop an integrated care pathway between multiple medical fields. Such tools are not always available for people with special needs for a number of possible reasons, ranging from access issues to lack of facility or knowledge about the treatment. The two disability discrimination Acts, the Disability Discrimination Act 1995 (DDA) and the Special Educational Needs and Disability (Northern Ireland) Order 2005 (SENDO), give people with disabilities important rights not to be discriminated in healthcare (Disability Discrimination Act, 1995). Thereby, dental care providers have to make suitable adjustments in their services to provide equal standards of dental treatment. It is widely reported that the number of special care patients is increasing dramatically as a result of increased life expectancy and medical advancements that improve quality of life for these individuals, which means that there will be more challenges for their families and the healthcare system. Therefore, maintaining good oral hygiene is an important issue for special care patients as it has a positive effect on self-esteem, general health and life quality (Scambler et al., 2011). Historically, delivering dental treatment for special care patients has been conducted under general anaesthesia due to difficulties accessing the mouth and teeth. Although general anaesthesia is useful and essential for certain cases, it is not without problems (Messieha, 2009). Post-anaesthetic side effects can be divided into common, uncommon, and rare. Common side effects affect 1 in 10 to 1 in 100 patients such as nausea, vomiting, sore throat, dizziness, shivering, headache, confusion, memory loss, bruising, soreness, and post-injection pain. Uncommon side effects affect 1 in 1000 to 1 in 10,000 patients such as damage to teeth, lips, tongue, and eyes. Rare side effects affect 1 in 10,000 to 1 in 100,000 patients such as serious allergy, anaphylaxis shock, equipment failure, and death (1 in 200,000) (Vicente et al., 2003). The causes of death with the administration of general anaesthesia are aspiration, hypoxia, inadequate airway management, anaphylaxis, human error, and equipment failure (Sykes, 1992). Advanced periodontal diseases, difficult root canal treatment, and complex restorations requiring multiple visits cannot always be provided under general anaesthesia. At present, with the development of conscious sedation techniques, all aspects of dentistry could be done as an alternative treatment of teeth extraction under general anaesthesia. However, setting up such services is not an easy task. The first barrier to establish dental sedation services for special care patients is transitioning from a practice of providing general anaesthesia to a practice of providing conscious sedation. It is crucial to show that sedation is an alternative method of behaviour management to general anaesthesia for a large number of special care patients (Gallagher and Fiske, 2007). It is also cost-effective and safer than general anaesthesia. This requires a high level of support (logistically and financially). Moreover, it requires a great deal of patience and representative clinical governance that may be different from one country to another. Understanding the patients’ needs and their rights to seek health services to achieve equilibrium between all individuals might be used to eliminate this conflict. Furthermore, training staff in the management of people with special needs, starting with dentists, nurses, and sedationists, will help to solve this barrier. The second barrier is the anaesthesia team, which is one of the big challenges for the dental team. For example, differences in the doses of sedative drugs, patient monitoring, and the use of antidote medicine are the common difficulties. Understanding the role of each member is the golden standard protocol for successful results. Dental care providers have to accept that there will be differences of opinion and they have to show their ​competency. Besides, both teams have to work together to deliver effective care and success in every case. The third barrier is finding a good sedation nurse! All dental practitioners understand that expert nurses lead to high standards of successful treatment. In the field of Conscious Sedation and Special Care Dentistry, the dental nurse has a very proactive role in delivering safe and effective treatment via organization and forward thinking. They could regularly assist with sedation by attending a practical training course. The fourth barrier is ensuring the patient and his/her caregiver understand the treatment plan and evaluate risks and benefits via verbal and written consent form. The differences between general anaesthesia and conscious sedation—advantages and disadvantages—have to be listed to avoid medico-legal issues. The dental team has to be open, with positive and negative aspects. Special care dentists and oral surgeons have a similar scope of practice, which might be the fifth barrier and should be considered during strategy development. Health organizations have to outline clear acceptance criteria between special care dentists and oral surgeons regarding their role in managing patients with special needs. The sixth barrier is when things do not go to plan! Special care dentists have to prepare for the failure of sedative cases. They should have regular training for advanced medical emergencies. How will the practice manage such a situation with patients, caregivers, and people of high authority? In conclusion, developing dental sedation services for special care and medically compromised patients needs a lot of support, teamwork, patience, and clinical consideration. Conflict of interest The authors declared that there is no conflict of interest.