Access to Oral Healthcare for people with Physical and Learning Disability (including Capacity and Consent)

Question 1

What are the barriers in access to oral healthcare for patients at user/carer level?

Answer 1

Physical, mental and cognitive ability required to carry out OH/self care

Diet/sugar based medication

Laxatives

Communication issues- difficulty getting appointment in first place

Fear and anxiety- irregular attendance

Greater need for behaviour management, sedation and GA

Require support to attend appointments (responsibility/pressure on carer)

Knowledge, skills and attitude of carer- may not be priority

Question 2

What are the barriers to professionals providing care for patients with physical and learning disabilities?

Answer 2

Low confidence in new graduates
-> lack of experience

Inadequacies in training

finical constraints due to dental remuneration

Carer/patients belief that they would not want to be seen

Question 3

What are the physical barriers for patients with physical/learning disabilities?

Answer 3

Access
-> physical- stairs, no hoist
-> emotional
-> Financial

Long travelling distance

Need for hospital setting

Question 4

What are the cultural issues which can be a barrier to patients with physical and learning disabilities?

Answer 4

Exacerbated in black minorities

Language barrier

Different attitudes to oral health in different cultures

Gender insensitivities

Lack of communication of need

Question 5

What are the effects that disability can have on patient’s oral health?

Answer 5

Physical impairment can affect ability to perform OH or attend dentist

Multiple medicines can cause dry mouth- increased caries risk

Cariogenic diet advice given from other discipline

Lack of awareness in health and social care setting- overlooked

Question 6

Which trends have been seen in the oral health of patients with learning and physical disabilities in studies?

Answer 6

Higher levels of edentulism
-> worse if on anti-psychotics, or living in more deprived areas

Higher levels of dental pain, long term pain and psychological discomfort

Poorer OH
-> Less people brushing twice per day

More untreated dental disease
-> caries
-> gingivitis/periodontitis

Question 7

What must we consider when deciding where the best place to see a patient with physical/learning disability would be?

Answer 7

Where and when is assessment appropriate?

What treatment is safe and feasible in the different care environments?

What if a medical emergency or complication arises?

Question 8

What are the different places dentists can use to treat patients with physical and learning disability?

Answer 8

 Own home
 Hospital ward
 Primary care- if in patient best interests, in line with needs and wants
 Secondary tertiary care
-> Depends on ASA class
-> if medical emergency arises- can you manage safely

Question 9

What can be done to improve access to dental setting for patients with physical and learning disabilities?

Answer 9

• Ground floor access
• Suitable Car Parking
• Elevators
• Hand rails
• Wide Corridors
• Disabled Toilets

Question 10

What can be done to improve access to dental chair for people with disabilities?

Answer 10

Hoist- requires training or carer
-> required if patient cannot weight bear

Wheel chair tipper

Banana board

Question 11

What can be done to improve access to the mouth of patients who have disabilities?

Answer 11

 Bedishield
 Open wide mouth rests- firm polystyrene
 Toothbrush (2?)- mirroring, training (build up rapport and trust)
 Mirror- non-shatter (possibly not recommended)
 Light
 Gentle head support with consent- if Musculo-skeletal conditions (if everyone agrees and in best interest of patient)

Question 12

Which factors should be considered when deciding the best time to see patients with disabilities?

Answer 12

Medical disease
-> acute- consider delaying
-> chronic- consider prognosis

Social- are they transitioning from child to adult care

Transport- when is the easiest time for patient to attend

Dental

Environmental

Question 13

What are the options when deciding who the right person to treat a patient with physical or learning disability?

Answer 13

Complex case- Dental officer in PDS

Very complex- specialist/senior dental officer

Most complex- consultant

Question 14

In what cases may clinical holding be permitted? What must we remember if we do this practice?

Answer 14

Cannulation in patients with uncontrolled movement
Paediatrics- to avoid GA

-> For support only- must be gentle
-> Must be proportionate- not too forceful or restrictive but enough to make patient and clinician feel safe
-> Consent from everyone in room required

Question 15

What factors should be considered when assessing level of learning disability?

Answer 15

1. Level of understanding and intellectual function
2. Communication
3. Physical and emotional access
4. Co-operation
5. Medical Status
6. Social Status
7. Dental Status

Question 16

What are the signs of pain in people who cannot communicate or reliably report?

Answer 16

• Sleep interruption
• Changes in behaviour
• Rubbing of an area
• Pulling at an area

Ask patient about pain ideally, if not try carer

Question 17

Which conditions are associated with intellectual impairment?

Answer 17

As part of a syndrome with other associated conditions:
* Down syndrome
* Fragile X
* Williams syndrome
* Autistic Spectrum Disorders ( not all people have a L.D.)

Cerebral Palsy ( not all people have a L.D.)

Epilepsy +/- neurological conditions

Diabetes

Question 18

What can be important to consider when assessing a patients dental status if they have physical or learning disabilities?

Answer 18

• Cooperation
• Preventative regime
• Level of support required
• Diet and method of delivery
  -> Swallowing and thickeners if appropriate
• Previous delivery of dental treatment- was it successful

Question 19

What techniques can be used when carrying out an IO exam of patients with physical and learning disabilities?

Answer 19

Multiple brief looks for each quadrant

Use counting- count to 10

Use access aids

Use other people if possible

Question 20

What should we check for when carrying out an intra-oral exam of patients with physical and learning disabilities?

Answer 20

Soft tissues

OH- caries, ask about preventive regime

Periodontal condition- BPE may not be possible
-> use visual assessment, check mobility

Evidence of NCTSL- grinding, medicines, bruxism, diet

Question 21

What dental interventions should be considered for patients with disabilities?

Answer 21

Enhanced Prevention

Modification of oral disease risk factors

Treatment- emergency, short/long term
-> Shared care may be required

Question 22

What must an individual be capable of in order to demonstrate capacity?

Answer 22

• Understand in simple language what the treatment is, its purpose
  and nature and why it is being proposed
• Understand its principle benefits, risks and alternatives
• Understand consequences of not receiving the proposed treatment
• Retain the memory of the decision

-> always assume people have capacity

Question 23

What are the 5 principles of the AWI act?

Answer 23

1. Benefit
2. Least restrictive option- not always doing nothing (single episode of care aka GA may be least restrictive in some cases)
3. Take account wishes of person- less likely for learning disability
4. Consultation with relevant others- welfare guardian, POA, closest carer
5. Encourage use of existing or new skills (residual capacity)

Question 24

What are some examples of augmentative communication aids which can be used for people who cannot communicate verbally?

Answer 24

 Communication board

 Picture boards (not suitable for consent)- eye gaze, pointing

 Talking mats (not suitable for consent)- things that make you happy, unsure, unhappy (can ask patient about choices to help you understand)

 Social stories- shows stages of journey
-> Pictures and words about what is going to happen
-> Give in advance- weeks ahead

-> ask carers what the best method of communication is for patient

Question 25

If a patient presents with what you believe to be a disability, what is the best way of ascertaining what the patient’s condition if they are not forthcoming with information?

Answer 25

Ask open questions
-> does patient need extra support? why?

Other sources- medical/dental records