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SPECIAL NEEDS DENTISTRY

SPECIAL NEEDS DENTISTRY


What is special needs 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. (Joint
Advisory Committee for Special Care Dentistry)

-Special Needs Dentistry (SND) is defined as an area in


dentistry which concerns in the oral health management of
patients adversely affected orally by intellectual or physical
disability and medical or psychiatric issues or, more often, a
combination of a number of these factors, where such conditions
necessitate a modified delivery of oral health care for patients
total health well-being. ( The Malaysian Dental Journal)

SPECIAL NEEDS DENTISTRY


It is defined by a diverse group of people with:

a range of disabilities
complex additional needs
long stay residential care
people in secure units
people who are homeless.

SPECIAL NEEDS DENTISTRY


It is important to remember that not everyone with disability
requires SCD, as not all disability limits oral health.
Also, those people who are ABLE to express need and ABLE to
easily access mainstream dental services, despite disability,
are not in need of SCD.
Whereas, those people unable to express need or unable to
access care because of disability (for example, due to reduced
communication, fear, inability to co-operate) require SCD.

Group of People Needing Special Care


The Joint Advisory Committee for Special Care
Dentistry has identified the population who require
the services of special care dentistry as:
-'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.

However, there is no ready made database to


provide figures for the proportion of the population
that fall within this definition.

Group of People Needing Special Care


Faulks and Hennequin described three groups of people
who require SCD :
(Defining the population requiring special care dentistry using the international
classification of functioning, disability and health a personal view. J Disabil Oral
Health 2006; 3: 143152.)

1. 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.

Scope for This Speciality


Special Needs Dentistry Specialists practices in the
branch of dentistry that is concerned with the oral
health care of people adversely affected by
intellectual disability, medical, physical or psychiatric
issues.
Special Needs Dentistry Specialist is undertaken by a
dental practitioner who possesses additional
postgraduate qualifications, training and
experiences.

Scope for This Speciality


This involves:
1. Diagnosis of orofacial conditions and the provision of
appropriate information to patients of diagnosis, treatment
or management options and their consequences.
2. Removing tooth tissue and/or placing materials for the
purpose of either the temporary or permanent restoration
or replacement of tooth structure or the rehabilitation of the
dentition.
3. Performing procedures on the orofacial complex, teeth,
and the hard and soft tissues surrounding or supporting the
teeth.

Scope for This Speciality


4.

Extracting teeth.

5.

Administration of local analgesia and, or sedative drugs


in connection with procedures on the teeth, jaws and the
soft tissues surrounding or supporting the teeth.

6.

Prescribing medicines appropriate to the scope of


practice, the sale or supply of which is restricted by law
to prescription by designated health practitioners.

Scope for This Speciality


7.

Prescribing special tests in the course of dental


treatment.

8.

Using ionizing radiation, for diagnostic purposes, in the


course of the practice of dentistry.

10.

Performing procedures on any person preparatory to, or


for the purpose of, the construction, fitting, adjustment,
repair, or renewal of artificial dentures or restorative or
corrective dental appliances.

Barriers to Accessing Care


1. Current workforce:
Most dentists working in the field of SCD are based in the
salaried Community Dental Service.
General dental practitioners contribute to the overall
picture of SCD, but only a small number of practitioners
have a special interest in this field.

Barriers to Accessing Care


2.

Current training:
On the whole, individuals who have undertaken training
in SCD have been responsible for their own training,
formal and informal.
It should not be left to the individual dentist to fund their
training in SCD.

3. Current delivery of SCD:


As SCD is not yet an established specialty, the hospitalbased services which do exist (often provided by the
Community Dental Service) depend upon the goodwill of
specialist and consultant colleagues.

Barriers to Accessing Care


4.

Access to the building:


- Despite legislation and the clear expectations of the
Equality and Human Rights Commission (EHRQ), physical
access to dental surgeries continues to be a barrier to
dental patients.

Barriers to Accessing Care


Dental clinics which set up which is not elderly
friendly.

Barriers to Accessing Care


5.

Access to the dental surgery:


-Examine the entrance including door width, 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 flooring,
communication aids, appropriate seating including chairs
with arm rests, and space for wheelchairs.
- Transportation.

Barriers to Accessing Care


5.

Access to the dental chair:


-It is important to consider whether people with physical
disabilities can easily access the preferred dental chair or
whether the same model is available with a 'break-leg'
facility to ease transfer.

- When transfer is not straightforward, because the


patient cannot stand or weight bear, 'transfer' or 'banana
boards' can be used. This method requires that the
dental chair has a break-leg design and is lifted or
lowered to the same level as the wheelchair. After the
side arm is raised or removed, the smooth curved board
(hence the name 'banana board') is placed between the
seats to allow the person to slide from the wheelchair to
the dental chair or vice versa.

-A portable turntable can also be a useful device. It has


the advantage of being able to be used with most wheelchair
and dental chair designs, and can be used in place of a hoist for
some patients with good upper body strength.

-A hoist is the best option for safe and efficient transfer


of patients unable to do so independently, to the dental
chair.

-Recent innovations for patients who should not be


moved from their wheelchairs have included fixed and
portable wheelchair reclining platforms with integrated
head rests.

The Mun-H-Center in Gothenburg, Sweden, is a National


Resource Centre for oro-facial aids and has developed a set
of four cushions to provide 'non-steady anatomical
support' in the dental chair . They can be used individually
or in combination, depending on the needs of the patient.

Philosophy of care
A philosophy of care is a framework of care goals and values
to help you make the best choices for your child and family.
Special Care Dentistry has a broad based philosophy which
takes a holistic view of oral health and requires specialists to
liaise and work with all those members of an individual's care
team. This is particularly important in the case of people at
the more severe end of the spectrum of disability, where a
greater range of issues needs to be considered.

HUH???

Reason :so that you are prepared to make


thoughtful decisions when crisis moments
arise; it may be difficult to make decisions in
the moment without a philosophy to guide
you.
WHY???

-Get your child stable and comfortable as you cannot


find a framework of care if you are focusing on
immediate issues.
-Clear your mind.
-Talk about it!Benefit from the experience of others
by talking with your partner,pediatrician, hospice
counselor, other families, clergy, family and close
friend.

HOW???

The ethos of Special Care Dentistry (SCD) has always echoed this
philosophy. It is concerned with 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) through this broadbased, cross-agency, partnership approach. The development of a

Specialty in SCD would provide a better balance between need and


provision, and between prevention and treatment, which is exactly what
the Government is working towards in tackling health inequalities.

Reducing Inequalities

People with disability are subject to inequality in oral health


both in terms of prevalence of disease and unmet healthcare
needs.

Over 18% of the global population is living with moderate to


severe functional problems related to disability, and a large
proportion of these persons will require Special Care Dentistry
at some point in their lifetime. (D. Faulks et al; European Journal of
Dental Education ISSN 1396-5883 ; 5 January 2012)

Reducing Inequalities
1. Lack of Education:
Lack of education has been cited as one of the barriers for the
poor awareness of the importance of oral health for people
with disabilities and, subsequently, one of the factors that
impacts in the provision of oral health care for a significant
number of individuals within society.
Education as a possible solution to improve access to oral
health care for the people who needs special health care.

Reducing Inequalities
Undergraduate education:
Include Special Care Dentistry in undergraduate teaching.
Centered on demonstrating positive attitudes towards
diversity and included disability awareness, public health
aspects of Special Care Dentistry and relevant ethics and
legislation.
In 2006, the American Dental Education Association
(ADEA) adopted a resolution to ensure that education
programs include both didactic instruction and clinical
experiences involving treatment of people with special
needs.

Reducing Inequalities
Postgraduate and specialist education:
- Currently, Special Care Dentistry is recognized as a
registered specialty in four countries: Brazil, Australia,
New Zealand and the UK.

Training of professionals complementary to dentistry:


-Special Care Dentistry is embedded in prequalification
courses for dental nurses, hygienists and therapists in the
Ireland, the UK and Argentina.
-The Academy of Dentistry for People with Disabilities in
the USA allows hygienists to take the fellowship
examination and, if successful, to become fellows of the
Academy.

Reducing Inequalities
2. Awareness among the public:

Many people with disability is not registered as a Person


with Disabilities (PWD) with the Social Welfare
Department. Consequently, he does not receive any
benefit or assistance from the JKM (Social Welfare
Department) for disabled people.

June 02, 2011 14:15 PM


Most Handicapped People Not Yet Registered With JKM
By Zulkiple Ibrahim
KUALA LUMPUR, June 2 (Bernama) Fifty-year-old Abdul
Rahim (not his full name) had both his legs amputated
because of diabetes about a decade ago. Last year, the
wheelchair-bound government retiree had his left hand
amputated due to gangrene.
However, Abdul Rahim is not registered as a Person with
Disabilities (PWD) with the Social Welfare Department.
Consequently, he does not receive any benefit or assistance
from the JKM (Jabatan Kebajikan Masyarakat) for disabled
people.
Why did he fail to register with the JKM?
Nobody told me to do so. And I really dont know about any
form of assistance that is available from the government, he
said.

Impact of
Health and Social Policy

Services &
protection
The Department of
Social Welfare
Ministry of Women, Family,
and Community Development

State Home for Disabled


Now known as the Taman Sinar Harapan
(Centre of Bright Future or TSH)
Various types of disabilities such as cerebral
palsy, Down's Syndrome, hydrocephalus,
mental retardation, speech defects and
deafness

Sheltered Workshop (Bengkel Daya)


Give people with disabilities opportunities
leading to dignity, self worth and socialization
amongst their peers
Objective: To create employment
opportunities for the disabled and at least to
help the group to be economically
independent.

Bangi Industrial Training and


Rehabilitation Centre
Provide services for physically disabled people
with vocational training and medical
rehabilitation:
IT Computer
Fashion Design & Tailoring
Electronics Prosthetic and Orthotics Multimedia
Wheelchair Manufacturing
Electronic Computer Painting
Rehabilitation Ward Physiotherapy

Community-based Rehabilitation Center


313 CBR centers established throughout the
country
Educational programs provided: reading,
writing, social skills, language development,
career guidance, vocational training, religious
and recreational activities

Pusat Pemulihan Dalam Komuniti


Bukit Baru

Pusat Pemulihan Dalam Komuniti


Bukit Baru

Rumah Orang Tua Melarat (Old Folks Home)


Rumah Bina Diri(Self awareness Home)
counseling, education, vocation, religious
educational and recreational activities.

What is disability?

What is disability?
A disability is a condition or function judged to
be significantly impaired relative to the usual
standard of an individual or group. The term is
used to refer to individual functioning,
including physical impairment, sensory
impairment, cognitive impairment, intellectual
impairment, mental illness, and various types
of chronic disease.

Mobility and physical impairment


Cerebral palsy
Abnormal oral habits: tongue thrusting,
mouth breathing, drooling
Difficulty in sucking and eating

Vision disability

Hearing disability
Mouthbreathing

Sign Languages

Learning disability
Attention deficit/Hyperactivity disorder
(Atomoxetine)

Psychological disorders
Schizophrenia
(high DMFT)

Brain injuries/disability
Autism

Austism spectrum disorder


Autistic disorder

Aspergers
syndrome

Pervasive
developmental
disorder

Rett syndrome

Childhood
disintegrative
disorder

Interlectual disability
Down syndrome

Down Syndrome in Malaysia


In an earlier report published in 1989,
incidence of Down syndrome in Malaysia is 1
in 950
Incidence classified into 3 major ethnics in
Malaysia
Malay - 1 in 981
Chinese - 1 in 940
Indians 1 - in 860

What is different about the teeth of


people with DS?
Delayed eruption
Microdontia
Macroglossia
Malocclusion
Gingivitis
Dental caries

Metabolic Diseases
Genetic conditions that result in metabolism
problems
defective gene that results in an enzyme
deficiency

Metabolic Diseases
Hurler syndrome (abnormal bone structure and
developmental delay)
Niemann-Pick disease (difficulty feeding, and nerve
damage)
Tay-Sachs disease (progressive weakness, progressing
to severe nerve damage; the child usually lives only
until age 4 or 5)
Fabry disease (pain in the extremities in childhood,
with kidney and heart disease and strokes in
adulthood; only males are affected)
Krabbe disease (progressive nerve damage,
developmental delay in young children)

Disabilities can affect people in different ways

Overview of demography of disability

Overview of demography of disability

Number of registered People With


Disabilities in Malaysia
Disabilities
Visual
Hearing
Speech
Physical
Learning
Mental
Multiple disabled people
Total

2012
27636
39303
180
106252
117699
2130
12713
305,640

However, these data are incomplete as registration of persons with


disabilities in Malaysia is not compulsory

Who are eligible?


Not all patients who fall under the category of
special needs require management by the
specialist in SND.
Referral to specialist in SND should be limited
to those patients with complex problems
which may, for example, require treatment in
the hospital setting or those with issues of
multiple problems

Can be referred to Hospital Kuala Lumpur and


Hospital Serdang for further management comorbidities and polypharmacy.
Strategies such as effective communication,
relaxation method, desensitization, and
general anaesthesia are often used in
managing people with special needs receiving
oral health care in the surgery.

Current workforce

Most dentists working in the field of SCD are based in the salaried Community
Dental Service.

There is a smaller constituent of SCD based in general and teaching hospitals who
are either salaried NHS or university staff.

General dental practitioners contribute to the overall picture of SCD, but only a
small number of practitioners have a specialist interest in this field.

QP

Service for Children With Special Needs in


Malaysia
The Oral Health Division has recognized children with special needs as one
of the priority groups. A programme for CHILDREN WITH SPECIAL NEEDS
was launched in 1993 with emphasis given to the disadvantaged group at
outpatient clinics besides some form of treatment given to children at the
institutions.
Objective: To improve oral health of children with special needs that will
contribute to enhanced quality of life.
Activities: Inculcating good oral health practices, increasing awareness of
carers of children with special needs and improving skills of dental
personnel.
This is to ensure that good oral health is achieved through oral health
promotion, clinical preventive measures and other necessary treatments
in line with Vision 2020 and the Vision for Health towards the
development of a caring society.
QP

Voluntary Organisations

Collectively and individually, they are a primary source of knowledge and expertise on all aspects of
learning disability.

Based on British society of disability and oral health guideline of 2012, the range of organisations
involved includes:
-Self-advocacy groups, in which people with learning disabilities come together to find strength in
unity, explore common problems and share solutions.
-Citizen advocacy groups working in partnership with people with learning disabilities to inform them
of their rights, help them assert those rights.
-Parent and carer groups in which members learn from each others experiences, and work together
for greater success and a diminished sense of isolation.
-Policy-shifting organisations, which advise, campaign, inform and co-operate with others to change
national and local policies and practices.
-Service providing organisations, which provide services, usually under contract from the statutory
agencies, and sometimes with added value from voluntary input.

QP

Voluntary Organisation
Many of the larger organisation produce specific information on oral care.
-Mencap has an oral care leaflet in a number of ethnic minority languages;
it also produces training material dealing with oral care and diet for use
with parents of people with profound and multiple disabilities.
-PAMIS (Profound and Multiple Impairment Service) provides training
programmes on dental care and oral health specifically for people with
profound and multiple learning disabilities.

QP

In Malaysia , there are 49 Kiwanis clubs across the country, with more than 1300
members. The first club, the Kiwanis Club of Kuala Lumpur was chartered in 1976
by the then returning Ambassador to the US, "Bapak Kiwanis" Tan Sri Khir Johari.

QP

The National Autism Society of Malaysia (NASOM) is a non-profit, non-governmental welfare organisation which was formed in
1986 by a group of parents and professionals. It was registered on 3rd March 1987, as a national voluntary charitable organisation
and aims at providing education, help, care and protection for people with autism and their family members. Currently, NASOM
has established 14 Early Intervention Programmes and 3 Vocational Programmes for people inflicted with autism in Malaysia.

QP

PSDNJ started as a small support group of parents who sent their children to Kiwaniss
Early Intervention Centre. With guidance and support from the Kiwanis members and
teachers, we started to form our society, Down Syndrome Society of Johor. We are
the first association created specifically to support the cause of individuals with Down
syndrome established at the state level. Following from the success of this
organization, there are now currently 8 such State-level associations in Malaysia.

QP

Speech Therapy
Speechlanguage pathologists assess and treat individuals from children to
adults with communication difficulties. These include understanding, expressing,
pronunciation difficulties, voice difficulties, fluency and nasalized speech.
They may also work with people who have feeding and swallowing difficulties.
Speechlanguage pathologists work collaboratively with patients, families
and related professionals to ensure patients needs are been addressed holistically.

QP

Current delivery of SCD

As SCD is not yet an established specialty, the hospital-based services which do


exist (often provided by the Community Dental Service) depend upon the goodwill
of specialist and consultant colleagues to gain access to facilities such as general
anaesthesia operating lists. This increases the complexity of the services and the
difficulty of coordinating the various agencies involved in an individual's care.

Specialists work need not, and indeed should not, be restricted to working in
hospitals. Local studies demonstrate that general and community dental services
provide the majority of the currently supplied care for people living in community
settings who are on disability registers.

QP

Skills mix and facilities

Whereas consultants and a large proportion of specialists have until recently had a strong
hospital focus, there is recognition that not all of them need to be based in hospitals or, if
they are, they may only provide certain aspects of care in a hospital setting. SCD should be
predominantly community based. This would have the effect of reducing inequality in two
ways:
Directly by improving physical access to a specialist service that is not solely hospital based
Indirectly by improving access through support for interested generalists in primary dental
care.
Hospital services should be closely aligned with specialists in a community setting so that
people who require hospital-based treatment because of medical complications,
multidisciplinary care, and/or care under general anaesthesia, may do so seamlessly.
Ideally, the dental team will include dental care professionals (DCPs) such as dental therapists
and dental hygienists, and may involve liaison with health promotion services to ensure that
a preventive approach is taken locally to support health care for people with disability. Such
an approach allows a proactive move to reduce and prevent dental disease rather than the
currently common reactive approach of treatment of disease.

QP

QP

Malaysia
Special Needs Dentistry (Snd) In Malaysia: A Way Forward
Siti Zaleha Hamzah - Special Needs Dentistry, Hospital Serdang

INTRODUCTION

Ministry of Health Malaysia (MOH) recently recognised SND as a dental specialty to provide better oral
health needs of the population with disabilities who, due to advances in medicine and improved general
healthcare are surviving much longer into old age.

In Malaysia, it is predicted that, with an increased number of elderly in the community due to an
improvement in health care delivery and health awareness, the population with disability/ies may also
expand as older people are more likely to develop coincident or consequent disability with ageing. Apart
from that, it has been reported that the number of Malaysian population suffering from various types of
disability had significantly increased from 132, 655 in 2003 to 197, 519 in 2006. Therefore, the demand in
oral health care for these special needs groups is expected to outstrip the service currently provided. The
same situation is also reported in United Kingdom, Australia and New Zealand.

Many studies have confirmed that people with disabilities are more likely to have a poorer oral health
condition than those in general population, mainly due to barriers such as limited access to dental service,
financial problems and the complexity of medical conditions from which they suffer.

QP

DEFINITION

In Malaysia, Special Needs Dentistry (SND) is defined as an area in dentistry which


concerns in the oral health management of patients adversely affected orally by
intellectual or physical disability and medical or psychiatric issues or, more often, a
combination of a number of these factors, where such conditions necessitate a
modified delivery of oral health care for patients total health well-being.

QP

SERVICE DELIVERY AND PATIENT MANAGEMENT

SND includes the delivery of oral health care, focusing on individuals with special
needs above 16 years, and it is a hospital-based dental specialty due to the
complexity of the problems that the patients are often presented with.

Therefore, referral to specialist in SND should be limited to those patients with


complex problems which may, for example, require treatment in the hospital
setting or those with issues of multiple co-morbidities and polypharmacy.

For the time being, patients with special needs can be referred to Hospital Kuala
Lumpur and Hospital Serdang for further management whereby care provided
includes various types of treatment in general dentistry.

QP

REFERRAL PROCESS

During the referral process, it is crucial for referring clinician to state clearly in the referral letter the reason
for referral, such as for consultation and examination regarding a specific condition or a particular area in
patients care, for urgent treatment in managing a specific complaint or condition or for further
management when the overall medical conditions or oral health problems requires care from specialists.
The patients have to be reminded to bring their valid PWD/ OKU card authorized by the Social Welfare
Department if they have one, or guarantee letter as well as the referral letter.

It is the responsibility of the referring clinician to complete a referral letter or form which contains details
information about the patient which include patients full name, address details and phone number,
copies of relevant radiographs if available, access and consent issues as well as special requirements, any
diagnostic test result, a brief medical history including current medications and allergies and indication of
disability and state clearly the contact details (including phone no and/or email) of the patients general
practitioners/ specialist medical practitioners if applicable. The last but not least is the contact details of
the referring clinician including phone no and/or email address.

All of this information would facilitate and reduce the time spent by patient in the specialist facilities.

QP

Special Needs Dental Surgeons in Malaysia

QP

SND IN THE COMMUNITY DENTAL SETTING

With the aim to reduce the gap and burden for patients to access oral health
care facilities, the community component in SND would enhance and
encourage knowledge and competence of the community based dental
officers in managing and providing care for patients with special needs
through various strategies and planning.

The set-up of the SND service in the community is to facilitate the delivery and
provision of oral health management and care for those patients who are
considered having mild to moderate disabilities/medical problems.

QP

CONCLUSION

More dental practitioners are expected to develop their interest in SND field as the
training pathway becomes clearer, as well as the initiative of the Ministry of Health
to support the career development of the specialist in SND in line with other
existing dental specialties in the near future. To ensure a continuing development
in this rewarding field of dentistry, research in SND should be encouraged and
incorporated in planning, development, and monitoring of the specialty.

Thus, future studies should investigate the oral health status of adults with
disabilities in Malaysia in various aspects, such as caries experience and
periodontal status which is currently lacking.

There are many ethical issues related to this area of health care and few questions
or problems can be addressed in a yes/no, black or white manner.

Thus, details investigation and attention are required to explore these areas of
concern in the future development of SND service in Malaysia.

QP

THANK
YOU!

QP

References

http://www.hraljournal.com/Page/7%20Kamarulzaman.pdf
http://www.cbrglobal.org/Downloads/PS2a.pdf
http://www.ijssh.org/papers/447-H10019.pdf
http://www.pdknet.com.my/web/index.php?module=view_pdk&pdk_id=
6
http://www.ncbi.nlm.nih.gov/pubmed/24417495
http://www.ndss.org/Resources/Health-Care/AssociatedConditions/Dental-Issues-Down-Syndrome/
http://www.mdj.org.my/index.php?option=com_content&view=article&id
=141&catid=53&Itemid=133
http://www.disabilitymalaysia.com/about.html
http://ohd.moh.gov.my/v3/index.php/en/contact-us
https://www.mah.se/.../Malaysia/.../oral_healthcare_in_malaysia_05.pdf

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