Integrating special care dentistry into your general dental practice

As medical care has markedly advanced worldwide, there are an expanding number of people with special needs in the population. One such group would be geriatric individuals. Changing demographic trends demonstrates that the number of elderly individual is increasing. In 2024 from the Department of Statistics Malaysia data, there are 3,949 900 elderly out of the total population of 34,058 800. This counts for 11.6% of the population. It is expected that Malaysia will become an ageing nation by 2030 when 15% of the population comprises of elderly.

Chronicity of illness and disease status cannot be considered in isolation as several significant factors are impacted by oral health status and must be considered in order for comprehensive care to be achieved. More individuals are retaining their teeth longer and the population of ageing patients with special needs is also increasing. This increase potentiates the demand for special care dentistry in a dental practice to manage the complexities associated with these patients’ disabilities, medical and social conditions. Understanding that patients’ general health can be compromised by poor oral health is critical for adequate management.

However, not all patients with disabilities require specialist care and management because not all disabilities prevent oral hygiene practice. This entirely depends on the type and severity of the patient’s disability. In addition, oral hygiene status is also related to whether patients live dependently or independently and at home or in an institution. Furthermore, if patients with disabilities can access dental services and are able to communicate details of their dental problems (without compromised verbal communication, cognitive impairment or behavioural problems), they can actually seek dental care from the mainstream dental setting i.e: your dental practice. The ability to identify and understand psychological or behavioural problems associated with special needs patients is considered one of the integral components in management and care for this group. Unfortunately, this is something that cannot be entirely taught in an undergraduate dental training program. Clinical experience plays a major and important role in identifying and managing this problem. Effective communication provides reassurances, attention and moral support for these patients These skills may be learnt after years of clinical experiences.

Essentially there are several ways to overcome the challenges in managing patients with special needs. A proper preparation for the dental management should be considered. An understanding of the patient’s condition certainly helps for the preparation. For example, a patient with intellectual disability and behaviour challenge comes into your dental clinic due to a toothache.

• Treat the patient as a person not the intellectual disability.
• You can begin with small talk and makes the patient feels comfortable.
• Show your empathy towards patient instead of sympathy.
• It is important to make an observation of patient’s mood for the day and listen to what he/she likes or dislikes.
• Make an attempt to build a rapport with patient by connecting and relating to his/ her needs.
• Bare in mind that this whole process requires a team effort including your dental surgery assistants and carer/family members.

Here, I shall share several tips and tricks when handling special needs patients which you can practise in your dental practice:

Clinical scenario 1: What if my patient does not want to come into the surgery room?

• You can do the oral examination at a non-conventional setting such as in a non-crowded waiting area, in an enclosed room or in the toilet in front of a mirror (Fig.1).

Clinical scenario 2: What if my patient cannot sit at the dental chair?

• Sit your patient on a normal firm chair and place it to the wall to prevent movement (Fig.2). This method can be used for oral examination and simple dental procedure. After several visits with enhance rapport, patient may sits on the dental chair.
• You can use the knee to knee method (patient sits down on his/her wheelchair and clinician sits facing in front of the patient).
• Perform standing position dentistry for patient on a wheelchair.
• May utilise portable dental equipment for dental procedures.

Clinical scenario 3: What if my patient does not allow regular examination?

• You may want to introduce yourself as a teacher instead of as a dentist. Most patients have high respect for teachers. You may develop a good rapport with this trick.
• Some patients (those who are easily confused or feeling threaten with covered face) may want to see the dentist’s face during communication therefore you can wear a face shield for infection control and provide facial vision for the patient (Fig. 3).
• Use toothbrush instead of mouth mirror during examination. You may want to get the carer/family members to help you to hold the toothbrush and pretend as if they want to brush the patient’s teeth and at the same time you are able to do the examination.

Clinical scenario 4: What if my patient does not like me or have a specific favourite dentist/ popstar?

• During examination, if patient does not seem to have a good rapport with you, you may want to consider getting your associate or collegues to perform the second oral examination with gentle reassurance. This is called rescuing technique.
• Show a picture of his/her favourite dentist/person or a picture/video of the popstar while doing the oral examination. I have a patient who likes to watch hair commercial during dental treatment.

General dentists should be able to manage special care patients within the scope of practice, to be able to identify, assess and treat oral health issues presented by individuals with special needs. However, in some complex cases or significant challenging behaviour, referral to a specialist might be necessary depending on the severity of the patient’s condition.

 

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About the Author

Dr. Norjehan Yahaya is a Specialist in Special Care Dentistry at Kuala Lumpur Hospital. She graduated with a Doctor of Dental Surgery from Dalhousie University in 2002 and earned her Doctor of Clinical Dentistry from the University of Melbourne. A pioneer in Special Care Dentistry in Malaysia, she has contributed to developing policies and guidelines, including for the management of haemophilia. Her clinical focus is on dental care for medically complex cases, especially patients with bleeding disorders.

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