Special Care Flashcards
What is special care dentistry?
concerned with providing and enabling the delivery of oral care for people with an impairment or disability
What is the aim of special care dentistry?
The improvement of oral health of individuals and groups in society who have a physical, sensory, intellectual, mental, medical, emotional or social impairment or disability or, more often, a combination of a number of these factors
Name the 3 groups who require special care dentistry (SCD)?
- People who experience disability due to impairment of oral function and/or structure and who are limited in their activity and/or participation directly by their oral status 2. People who have a condition that has direct or indirect repercussions on their oral health 3. People who are disabled by their social, environmental or cultural context, which reflects on their oral health.
Is SCD continious or sporadic for pateints?
There is also a temporal factor, in that SCD may be required at certain periods or points of an individual’s life and not at others
How are treatment plans devised for SCD patients?
Tailored to meet their specific needs, is through an integrated care pathway developed through liaison with all those members of that individual’s care team
Name the 4 principles of dentistry?
- All individuals have a right to equal standards of health and care, including oral health• All individuals have a right to autonomy in relation to decisions made about them• Good oral health has positive benefits for health, dignity and self-esteem, social integration, and general nutrition,and • The impact of poor oral health can be profound
Total number of disabled patients in the UK?
Between 8.6 and 10.8 million people1/4 of us
Inequalities in SCD - Do they occur? How do they occur?
Pateint’s with disabilities whom have the same avaliability for treatment, seemingly still have worse OH and are reccomended for extractions over indirect restorations or fillings. Overall, they are treated differently to the rest of the population.
Department of Health document detailing changes to dentistry which encompasses pateints with disabilities?
Valuing people’s oral health, a good practice guide for improving the oral health of disabled children and adults (2007)
Valuing people’s oral health, a good practice guide for improving the oral health of disabled children and adults (2007) - what is included? summary? conclusion?
- recognises the need for the provision of equitable and responsive oral healthcare services for people with disability- The document is designed to support primary care trusts (PCTs) and their advisers in their needs assessment and commissioning of preventive oral health services rather than considering treatment provision. - ‘it is important to value and develop competence in provision of oral healthcare to people with disability through research, consistent advice, professional training and provision of specialist care’.- It acknowledges the treatment of preventable dental diseases is costly to the PCTs and specialist services and to patients and their carers. It states that carers may have to take time from work and fund transport to accompany disabled people for treatment, but takes no account of the emotional, psychological, social or financial cost to the disabled person, who may also need to take time from paid employment1
What’s wrong with the current NHS contract 2006, UDA system?
- in terms of ‘units of dental activity’ (UDAs) that were being provided in the test period of the development of the new contract. This remuneration system is based on average time taken to carry out various procedures rather than on the needs of individual patients. It takes no account of the complexity of care, such as the provision of oral care for someone with a learning disability, which may involve dealing with their inability to consent for care- UDAs have also been introduced into the contracts of the salaried (formerly known as personal and community) dental services, which have always been a safety net service for people with disability unable to receive care in mainstream general dental services. The new contract has not taken account of the skewed practice profile of complexity of care within salaried dental services and, not surprisingly, there has been anecdotal evidence of the difficulties this has caused in continuing the appropriate provision of care for people with disability. - in some areas, because of initial uncertainty of how to approach the issue, rather than rolling on contracts for domiciliary care, none were commissioned thus reducing access to care for vulnerable older people- Now, without additional commissioning of services by the PCT, any further domiciliary care provided by a practitioner is disincentivised as it will be paid in UDAs, with no recognition of the additional time or skills required.
What is the case-mix model?
allows objective assessment of the complexity of the provision of care for people with disability through a structured matrix.
Name the 6 criterion in which the case mix model is based upon?
- Ability to communicate 2. Ability to co-operate 3. Medical status 4. Oral risk factors 5. Access to oral care 6. Legal and ethical barriers
Name the type of factor considered for - Ability to communicate?
Need for interpreter or other means of communication; degree of learning disability or dementia
Name the type of factor considered for - Ability to co-operate
Additional appointment time or acclimatisation visits required; need to use sedation or GA
Name the type of factor considered for - Medical status
Treatment modification required; degree of impact of medical or psychiatric condition on the provision of care
Name the type of factor considered for - Oral risk factors
Ability to carry out oral hygiene; dietary conditions, eg PEG feeding, severe xerostomia
Name the type of factor considered for - Access to oral care
Support of carer required to get to the surgery; use of wheelchair recliner or hoist; need for domiciliary care
Name the type of factor considered for - Legal and ethical barriers
degree of capacity to consent; need to consult with other professionals or carers; need to hold best interest meeting or case conference
The Disability Discrimination Act 1995 - What did it include? update?
terms of alterations to buildings and surgeries and changes to service delivery which may be reasonably expected of the general dental practitioner2004
The Equality and Human Rights Commission 2007 - what did it include?
Can use its new enforcement powers where necessary to guarantee equality to all.Damages that can be awarded by them to a disabled person who has been discriminated against are seemingly limitless.
The Disability Equality Duty 2006 - what did it include? name the 4 main categories?
It requires that any public body (including service providers) needs to look actively at ways of ensuring that disabled people are treated equallynsuring better physical access to oral care for disabled patients can be divided into four key areas: • Access to the building • Access to the dental surgery • Access to the dental chair • Access to the mouth.
How to adapt practice to improve access to the building?
In many cases simple rails and ramps will provide building access for most people with a disability, and major alterations to buildings are only required to provide full access where they are considered reasonable.the dentist’s duty of care requires them to organise alternative arrangements for treatment which are reasonable and acceptable to the patient.
How to adapt practice to improve access to the dental surgery?
practice of ongoing and documented disability awareness training for all staff1. Ask people with disabilities for their opinions, and 2. Undertake an access audit.Look at potential problem areas such as the approach to the premises (parking, kerbs, ramps, lighting, signage, etc). Examine the entrance including door width, level threshold, door opening, position and design of door handles. Include the reception and waiting room, looking at the height of the reception desk, clear signage, non-slip fl ooring, communication aids, appropriate seating including chairs with arm rests, and space for wheelchairs. Check there are no obstructions or clutter in the corridors or surgeries. Consider the design and layout of the surgeries to give wheelchair access and manoeuvrability. Check toilet facilities, including space, transfer bars, raised seat and alarm; and consider means of emergency escape from the premises including signage, visual alarms and accessible exits.
How to adapt practice to improve access to the dental chair?
Aim, if possible, for the surgery to be arranged in such a way that there is room for a wheelchair to be brought alongside the dental chair to aid easier transfer by the patient into the dental chair. This layout also allows for the possibility of treating the patient in their own wheelchair using a variety of headrest attachmentsAs a general rule it is always prudent to ask the patient how much or little help they require and not to assume that they need helpWhen transfer is not straightforward, because the patient cannot stand or weight bear, ‘transfer’ or ‘banana boards’ can be usedA hoist is the best option for safe and efficient transfer of patients unable to do so independently, to the dental chairThe base unit offers the option of a dental mounting joint for either a removable dental chair or most commercially manufactured manual wheelchairs. Once attached, either option can be tilted, raised and lowered with no compromise to posture for either the dental nurse or the dentist whilst allowing patients to receive dental treatment in a safe and comfortable position
How to adapt practice to improve access to the mouth?
To achieve the best position in the dental chair, the patient’s body should be well supported and joints and muscles should be in the rest position.for more complex patients she advocates the use of cushions or beanbags to aid in patient positioning and comfort.safe-guarder’leg-relaxer’bite support on finger for sporadic bitterssturdier instrumentsempathy for extreme gaggers
When thinking about the facilitators and barriers to special care, other than the physical environment, what else is there?
Capacity• Financial• Societal expectation• Psychological/anxiety• Medical history• Communication• Patient knowledge and attitude• Professional knowledge and attitude – dental, medical, social care
Describe the SEAMLESS acroynm?
- S eamless● E ducation and training● A ccess● M ultidisciplinary working● L iaison and linkwork● E mpowerment● S pecial care dentistry● S ervice provision and development
What is SEAMLESS?
Network to provide seamless care between different elements of dental services• E.g. paediatrics to adult services, regular dentist to GA service
What factors can aid the SEAMLESS network?
Prevention to patient• Carer training (Caring for Smiles, Open Wide)• Undergraduate, Postgraduate, Continuing ProfessionalDevelopment• NEBDN Certificate in Special Care Dental Nursing• Training for the dental team - Medical emergencies - Manual handlingMultidisciplinary Working• Development of networks with other health and social careprofessionals• Sharing of information• Eases anxiety if the correct information can be sought quickly• i.e how to access emergency care
How can empowerment aid dentistry?
Patient centred care planning● Many patients have personal health record which has information regarding likes,dislikes, communication, every day needs● Can also have oral care plan and tooth brushing
How to overcome the barriers in Dentistry?
Service Provision and Development• Required if barriers to seamless care are to be overcome• Some want to use mainstream services, others specialisedservices• Shared care model between GDS and Special Care Dentistry• Multi-agency working
Act relating to consent?
Adults with Incapacity (Scotland) Act (2000)
What to discuss when trying to achieve informed consent for a patient?
Understand what the treatment is• Benefits, risks and alternatives• Consequences of not having the treatment• Retain the information• Communicate the decision to others• Hold the decision consistently
What is the definition of in/capacity?
AWI defines capacity as when a person is incapable of:1. Acting2. Making decisions3. Communicating decisions4. Understanding decisions5. Retaining the memory of decisions
How can capacity be affected?
Capacity may be diminished temporarily or permanently, partially ortotally• Remember – the law in Scotland presumes all adults 16 years and olderhave sufficient capacity to decide on their own medical treatment
What factors can influence a person’s ability of capacity?
- Previous experiences• Information• Communication• Pain, medications etc• Conditions such as pneumonia, UTI, delirium• Support• Other people• Adult Support and Protection (Scotland) Act (2007)
What does the Adults with Incapacity (Scotland) Act (AWI) cover?
• Whole act covers welfare, property, financial and medical• Proxy decision makers• Managing affairs in the future should capacity to make decisions lost
Name the 5 principles of AWI?
- Any action taken on behalf of the person must benefit the person2. Any action must be the least restrictive option that will achieve the desired effect3. Before making a decision on behalf of a person, account should be taken of the person’s past and present views and preferences4. Account should be taken of the views of specific persons such as guardian, attorney, relatives and any other person appearing to have an interest in the person5. Anyone acting under the act must encourage the adult to develop and exercise as much skill as possible in making decisions or taking actions.All steps must be taken to enhance the person’s decision making ability.
How to determine incapacity?
• Is capable of making and communicating their choices• Understands the nature of what is being asked and why• Has memory abilities that allow retention of information• Is aware of any alternatives• Has knowledge of the risks and benefits• Is aware that the information is of personal relevance to them• Is aware of the right to refuse as well as the consequences of refusal• Has ever expressed their wishes relevant to the issue when greater capacity existed• Is expressing views consistent with their previously preferred moral, cultural, family and experientialbackground• Is not under the influence from a relative, carer or other third party
What is Power of Attorney?
Power of Attorney – a person(s) granted the authority to make decisions on behalf of a person who becomes incapable of making decisions on their own• The same way as a person creates a will• Usually with legal help• 2 types - Continuing Attorney - Welfare Attorney
What is the definition of a Continuing Power of Attorney?
Can only manage the finances and property of another person• Powers can start immediately after the agreement signed• The Granter can specify the powers should start only when they have lost capacity to manage their own finances• Example of dental relevance – elderly resident of a nursing home having denture made as a dom, consent to treatment but not costs
What is the definition of a Welfare Power of Attorney?
Have the power of a person’s personal welfare (the things that affect the person’s physical and emotional well being)• Medical care and treatment, choice of diet, personal care, clothing, meaningful social contact with friends and family• Can only start making decisions, on behalf of the person, once the person has been assessed and it is agreed they no longer have capacity
What is the defintion of a Guardinship Order?
Can only be applied for when the person is assessed as not having capacity to make decisions• Can cover property and financial matters or personal welfare including health or a combination of all of these• Anyone with an interest in the person may apply e.g family member, local authority (social work)• The decisions an Attorney or Guardian can make will be specified in the order granted, may not be all decisions
What is the definition of an Intervention Order?
Gives permission for one-off decisions which the person does not have capacity to make:• Welfare intervention order may be relevant when a person is assessed as not being able to consent to complex medical treatment, although they can still make most other decisions• Example of dental relevance – patient with complex psychiatric history requiring full mouth clearance under GA due to extensive caries and multiple periapical areas and recurring abscesses
Explain Part 5 of the AWI act?
Amended in 2005 to include dentists, nurses and ophthalmic opticians• Must have relevant qualifications, experience and competence• Can only authorise treatment in own speciality• Practitioner allowed to share the authority to treat others involved in the person’s care and treatment• Example of dental relevance – dentist authorises treatment plan to include scaling carried out by therapist and oral health instruction by the oral health educators
Explain Part 5, Section 47 of the AWI act?
Grants the practitioner the general authority to give medical treatment to an adult who lacks capacity to give or refuse consent• Decision regarding capacity to consent should be based on assessment at the time rather than then existence if the adult’s diagnosis or disability• Capacity to consent must be considered with respect to a specific decision and for a given moment in time
AWI flowchart?
look at it
What must a patient hold to prove Incapacity?
Adult with Incapacity Certficate
What must a valid AWI Act Certificate include?
Should it be deemed that the person does not have capacity to consent the Certificate of Incapacity under Section 47 of AWI (Scotland) Act 2000 is completed• Must state how long it is valid for and must be signed and dated- Treatment specific: - it’s length should reflect this e.g. one day for dental GA, 3-6 months for restorative treatment plan, 3 years for examination, prevention (including OHI) and scaling• Maximum period is 3 years• Can be cancelled altogether or cancelled and changed should a person’s condition or circumstances change• Good practice to attach a written treatment plan• If the person who does not have capacity and there is a proxy, they can give consent on behalf of the person but a S47 certificate must still be completed• If a proxy refuses consent, treatment cannot go ahead and practitioner must contact the Mental Welfare Commission for a 2nd opinion
Whom can give the Adults with Incapacity Certificate?
Dentists that have had the added training to gauge their capacity- limited to the current treatment plan
What to do during an AWI emergency? Only Scotland
Identify whether the situation is an emergency? YesOver 16? YesDo they have capacity? NoDo they have a welfare guardian? Yes, contact themIf non-contactable, must try and relieve pain, but is mainly reversible
3 emergencies of dentistry?
HaemorrhageFacial SwellingTrauma
What happens if 2 welfare guardians can’t agree?
Must get a second opinionMust find a consensus for the treatment
Welfare guardian vs PoA? Differences
Welfare guardian - patient has never had capacityPoA - patient have had capacity in the last
What is the defintion of cerebral palsy?
Wide spectrum of non progressive neurological and physical disabilitiesDevelopmental or as a result of peri natal insult suxh as hypoxia, trauma or infection
Name the 3 types of cerebral palsy?
SpasticAtaxic Dyskinetic
Describe spastic cerebral palsy?
Muscles appear stiff and tightArises from motor cortex damageMost common
Describe dyskinetic cerebral palsy?
Involuntary movementsArises from basal ganglia damage
Describe ataxic cerebral palsy?
Shaky movements. Affexts balance and sense of positioning in spaceCerebellum damage
Name the 4 types of coverage for cerebral palsy?
MonoplegiaHemiplegiaParaplegiaQuadraplegia
What are the dental features for a patient with cerebral palsy?
Higher level of untreated diseaseDevelolmebtsl abnormalitiesMalocclusionUncontrolled movementsBruxismDroolingPeriodontal diseaseCaroes
