Access to Oral Healthcare for people with Physical and Learning Disability (including Capacity and Consent) Flashcards
What are the barriers in access to oral healthcare for patients at user/carer level?
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
What are the barriers to professionals providing care for patients with physical and learning disabilities?
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
What are the physical barriers for patients with physical/learning disabilities?
Access
-> physical- stairs, no hoist
-> emotional
-> Financial
Long travelling distance
Need for hospital setting
What are the cultural issues which can be a barrier to patients with physical and learning disabilities?
Exacerbated in black minorities
Language barrier
Different attitudes to oral health in different cultures
Gender insensitivities
Lack of communication of need
What are the effects that disability can have on patient’s oral health?
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
Which trends have been seen in the oral health of patients with learning and physical disabilities in studies?
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
What must we consider when deciding where the best place to see a patient with physical/learning disability would be?
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?
What are the different places dentists can use to treat patients with physical and learning disability?
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
What can be done to improve access to dental setting for patients with physical and learning disabilities?
- Ground floor access
- Suitable Car Parking
- Elevators
- Hand rails
- Wide Corridors
- Disabled Toilets
What can be done to improve access to dental chair for people with disabilities?
Hoist- requires training or carer
-> required if patient cannot weight bear
Wheel chair tipper
Banana board
What can be done to improve access to the mouth of patients who have disabilities?
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)
Which factors should be considered when deciding the best time to see patients with disabilities?
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
What are the options when deciding who the right person to treat a patient with physical or learning disability?
Complex case- Dental officer in PDS
Very complex- specialist/senior dental officer
Most complex- consultant
In what cases may clinical holding be permitted? What must we remember if we do this practice?
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
What factors should be considered when assessing level of learning disability?
- Level of understanding and intellectual function
- Communication
- Physical and emotional access
- Co-operation
- Medical Status
- Social Status
- Dental Status
What are the signs of pain in people who cannot communicate or reliably report?
- Sleep interruption
- Changes in behaviour
- Rubbing of an area
- Pulling at an area
Ask patient about pain ideally, if not try carer
Which conditions are associated with intellectual impairment?
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
What can be important to consider when assessing a patients dental status if they have physical or learning disabilities?
- 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
What techniques can be used when carrying out an IO exam of patients with physical and learning disabilities?
Multiple brief looks for each quadrant
Use counting- count to 10
Use access aids
Use other people if possible
What should we check for when carrying out an intra-oral exam of patients with physical and learning disabilities?
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
What dental interventions should be considered for patients with disabilities?
Enhanced Prevention
Modification of oral disease risk factors
Treatment- emergency, short/long term
-> Shared care may be required
What must an individual be capable of in order to demonstrate capacity?
- 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
What are the 5 principles of the AWI act?
- Benefit
- Least restrictive option- not always doing nothing (single episode of care aka GA may be least restrictive in some cases)
- Take account wishes of person- less likely for learning disability
- Consultation with relevant others- welfare guardian, POA, closest carer
- Encourage use of existing or new skills (residual capacity)
What are some examples of augmentative communication aids which can be used for people who cannot communicate verbally?
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
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?
Ask open questions
-> does patient need extra support? why?
Other sources- medical/dental records
