Accessible to all: removing barriers to good oral health

Are you confident in your approach to every patient who enters the surgery? Let Associate Specialist Janet Griffiths introduce you to Special Care Dentistry.

Introduction

Special Care Dentistry 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 these factors’. This is the technical definition which includes visible and hidden disabilities.

Special care includes people with a physical disability, learning disability, autistic spectrum disorders, mental health problems, vision and hearing impairment, communication difficulties, Alzheimer's disease and dementia, and a wide range of complex medical and emotional conditions that limit activities of daily life and present challenges in accessing and delivering oral health care. The list is not exhaustive. In general terms, ‘special care’ covers groups listed under the Disability Discrimination Act (DDA, 1995).

Why do we need Special Care Dentistry?

The DDA applies to people whose disability has a substantial effect on the way the individual can carry out normal day to day activities. Estimates suggest that around 10 million adults are covered by the DDA and this will increase as the Act now includes people with HIV, cancer and multiple sclerosis.

There is no single standard measure of disability. The last UK census reported 9.5 million disabled adults; long term illness limits the lifestyle of more than a third of people aged 65 to 74 and almost half of people aged over 75. Loss of mobility increases with age; the greatest decline is in people aged 75 and over. Sensory impairment is more common with advancing age; visual impairment affects around 80% of people over 60, and 22% have both visual and hearing impairment. The number of people with Alzheimer's disease and dementia will increase as the population ages. One in four adults experience mental distress or a mental health problem. Of the 1.2 million people with a learning disability, 20% are severely or profoundly impaired. More than 300,000 children have a disability; the number of children and adolescents diagnosed with cancer is increasing annually, and 10% of children aged five to 15 have behavioural problems causing mental or emotional distress.

Impairment and disability are common, affecting a large section of the population and all age groups. However, most people requiring Special Care Dentistry are in older age groups. While the oral health of the population has improved over the last three decades, disadvantaged and disabled groups continue to have poorer levels of oral health, and experience barriers to maintaining oral health and accessing dental services. Special Care Dentistry aims to address these inequalities in a growing disabled population.

Addressing the needs

Special Care Dentistry has received considerable publicity since the General Dental Council announced the new specialty in Special Care to address the needs of people with more severe disability and complex additional needs. Many disabled people, despite social and environmental limitations, lead full and active lives and want equal treatment to those without disability in primary care.

The DDA aims to end discrimination against disabled people by removing barriers to their full participation in society. However, it also recognises that disabled people are discriminated against as much by barriers created by an unthinking society as by the attitudes of individuals.

Since 1999, service providers have been required to make reasonable changes to policies, procedures and practices, or provide the service by a reasonable alternative means, for example providing a domiciliary visit. From October 2004, the Act required ‘reasonable steps’ to reduce physical barriers that affect access. This has presented the biggest challenge to service providers but the key to compliance is ‘reasonableness’.

The DDA has put the issue of disability discrimination firmly into the public arena and created pressure to address barriers to oral health care. This is a broad picture of some issues that influenced the need to develop the speciality in combination with Government reports and frameworks for improving the health of the nation, and the demands and growing confidence of disabled people and their families for equitable services, a demand now backed by legislation.

Barriers to oral health

Every patient is an individual with individual approaches to managing their disability therefore a holistic approach to planning care is essential. An ‘ABC’ approach identifies many universal inter-related barriers to oral health (Griffiths and Boyle, 2005). Attitudes, access and ability, barriers and communication can be viewed from the perspective of the patient, carers (family or professional) and the dental team.

Attitudes

Attitudes underpin health behaviour: attitudes to oral health and disease; the need for oral health care and dental attendance; dietary intake; preventive regimes; and the relative value placed on these in the context of the individual's ability to cope with life, and the pressures of caring. Oral health may have a low priority in the daily context of coping with impairment and disability, and the additional cost of living with disability.

The DDA recognises that discriminatory attitudes exist in health services. Many special care patients are referred to secondary care; what they largely want is dental care, in a disability friendly practice, from a sympathetic dental team that understands their specific needs. Lack of confidence, training or expertise in treating disabled people may be factors in the decision to refer. Concerns about the quality of care that can be provided, inadequate remuneration for extra clinical time, need for special facilities, and lack of understanding and experience in dealing with ‘different’ behaviour create barriers to treatment in primary care.

Access

Access to information, transport and services are common barriers to oral health. Impaired mobility leads to social isolation which is itself a barrier to obtaining information, and conditions people over time to have low expectations of services. Information on oral hygiene, preventive care and treatment, the accessibility of dental services, NHS treatment and domiciliary care are important barriers to be addressed.

‘Reasonable changes’ to improve physical access to dental premises should have been addressed by 2004. Where possible, premises should permit unassisted access for wheelchair users and people with walking aids. Entry phones may be a barrier for deaf people. Internal movement should be unrestricted, free of obstacles, with an accessible toilet. Doors with opening devices accommodate people with a range of disabilities. Waiting areas should include seating of different heights and a reception desk accessible to wheelchair users. Signs and notices which are adequately lit and in a suitable sized font help to meet the needs of the visually impaired.

A model surgery would have a hoist, space to treat a patient in their wheelchair, and appropriate transfer aids such as sliding boards and turn-table. However, many simple adaptations and changes in practice can be achieved with little expense. Disabled people are themselves the experts and should be consulted; local Access Groups are a source of informed advice.

Ability

This embraces the individual's physical and cognitive ability for self-care with oral hygiene, and in seeking and accessing services, and carers' ability to provide the required support. Oral hygiene is an integral part of personal care. Techniques for maintaining oral health may be difficult to learn; for others assistance and supervision are essential. Oral health education and practical training in oral hygiene should be mandatory for all professional carers; regrettably this is not the case.

Impaired manual control and dexterity influence standards of oral hygiene. People with severe or profound impairment are dependent on the knowledge and skill of carers for all aspects of oral health care. Aids and adaptations to assist patients and carers with oral hygiene may be required.

The dental team's ability to provide appropriate care and deliver equitable services must be considered. Training in disability confidence, an approach that focuses on a best practice approach to managing disability issues positively in a dental environment, will help address some of the professional barriers.

Barriers to oral health

Barriers are related to the nature, onset and severity of the condition, symptom management and treatment. Dietary changes to manage feeding difficulties and swallowing disorders and improve nutritional status increase the risk of dental caries because of increased oral retention of puréed foods and thickened fluids. High calorie food supplements are frequently prescribed to maintain nutritional status; this is a particular problem in older people with poor appetites who are encouraged to sip small amounts frequently throughout the day. Since a greater proportion of older people are retaining teeth into later life, this presents challenges to maintaining complex restorations affected by recurrent caries.

Oral side effects of medication are a risk factor for oral health. Although these are relatively uncommon, many patients requiring special care are taking a cocktail of medication. The commonest side effect is dry mouth with increased risk of caries, periodontal disease, oral infections and denture problems. Dry mouth (xerostomia) is associated with a wide range of medication, and the cause of significant oral discomfort. Appropriate advice to relieve discomfort and aggressive preventive programmes are essential. As new drugs are developed and side effects are reported, it is essential to check the current British National Formulary.

It is beyond the scope of this article to summarise the commonest conditions in Special Care Dentistry and the impact of long-term medication on oral health. However an assessment of diet and medication are important in assessing risk factors which present barriers to oral health.

Communication

Successful communication — central to all aspects of health care — is based on comprehension, and an essential component of obtaining informed consent. It is the clinician's duty to assess capacity, which is based on ability to understand and retain information relative to treatment, especially as to the consequences of having or not having treatment, and the ability to use and communicate that information in decision making.

Communication impairment does not indicate lack of capacity. Consultation and collaboration with significant persons, family, carers, advocates and health professionals may be required to establish this. If the patient does not have the capacity for informed consent, the responsible clinician will consult significant persons to get agreement for a treatment plan that is in the patient's best interests, and record the outcome of discussion.

The dental team should be familiar with communication techniques.

The dental team should be familiar with techniques to facilitate communication. Face to face conversations, clear speech, jargon free language, short sentences, and closed questions allowing adequate time for a response facilitate communication. Pen and paper, the written word, good lighting for lip reading, gestures and facial expression are helpful for people who are deaf or hearing impaired; texting, email and text-phones are effective for arranging appointments. Signs, gestures and communication charts are helpful for speech loss after stroke or brain injury. Pictures and images are most effective for people with learning difficulties. Organisations such as SIGNALONG, the Stroke Association and the National Autistic Society provide helpful advice on communication techniques.

Special Care Dentistry: accessible to all

An essential component of Special Care Dentistry is about reducing barriers so that good oral health is accessible to all. Disabled people want high quality mainstream dental services, in a universally acceptable environment that does not discriminate, is safely accessible to all, and with the support and advice of expert and specialist services when required. There may be limitations to what can be achieved in changing the physical environment but a simple audit of the environment, current practices and procedures will undoubtedly identify areas for improvement. Domiciliary care must be considered as an alternative for people who encounter problems with physical access or are housebound.

Training the team

‘Disability confidence’ can be developed in the dental team through training in:

• disability discrimination and the relevant legislation

• disability confident language and etiquette

• an understanding of the medical and social models of disability

• an understanding of the impact of different types of impairment.

This provides a foundation for reducing discriminatory barriers in dental practice.

The British Society for Disability and Oral Health (BSDH) has been pivotal in promoting developments in Special Care Dentistry. Membership gives reduced fees at meetings, subscription to the Journal of Disability and Oral Health, and a support network for the dental team. Increased awareness has led to the development of a range of useful resources. BSDH will shortly publish guidance for PCTs and LHBs for commissioning special care dental services in primary care. It now requires the commitment of the dental team to take advantage of the opportunity to redress these inequalities in oral health, and make Special Care Dentistry accessible to everyone.

Dental team resources

• 1 Special Care Dentistry. An interactive learning programme for the dental team. Department of Health, 2006.

• 2 Griffiths J, Boyle S. Holistic Oral Care: a practical approach. UK: Stephen Hancocks Ltd, 2005.

• 3 Making sense of the mouth. (CD, video and illustrated booklet.) UK: Glasgow Dental School, 2001.

• 4 British Society for Disability and Oral Health. www.bsdh.org.uk .

• 5 British National Formulary. www.bnf.org .

Thanks to HANDS and to Cardiff & Vale NHS Trust for images used in this article.