This article was first published in the ADA’s News Bulletin magazine in April 2022.
“Currently, we have 24 practising special needs dentistry specialists across Australia. But the statistics show us that there’s 4.4 million Australians who are living with a disability,” begins Dr Trudy Lin, recently awarded SA State Young Australian of the Year, and special needs dentistry consultant at Adelaide Dental Hospital.
The numbers, when she puts it that way, are fairly stark.
“So what that shows us is there’s no way we’ll be able to meet the need by training up more specialists who will come to every single person that has a disability – and that’s where we need general dentists to upskill and be willing to look after these patients too.”
Special needs dentistry (SND) is a broad topic, certainly, and equally addresses a broad tranche of Australian society. Patients whose needs and health status require special support may include those living with disability, who are facing socioeconomic barriers such as homelessness or domestic violence, or who may be fighting physical or mental health challenges such as cancer or psychiatric disorders. As Dr Lin describes it, “it is dentistry that involves providing oral healthcare for people with various types of disability and complex medical conditions. The oral healthcare for this population is important because the conditions themselves put them at higher risk of getting dental disease, for example, through medication side effects, and through the barriers they face to accessing oral healthcare. The populations who require special needs dentistry sit under the broader umbrella of disability, as there are all sorts of ways that disability can arise. It can be physical disability, sensory disabilities, psychosocial, as well as medical.”
Dr Avanti Karve, also a dedicated advocate in this space, and principal special needs dentist at her practice Mind Body Teeth, points out there are many definitions of special needs or special care dentistry. “The RACDS definition which was used at the inception of SND as a specialist field in Australia outlines: ‘Specialist practice in SND supports the oral healthcare needs of people with an intellectual disability, medical, physical or psychiatric conditions that require special methods or techniques to prevent and treat oral health problems, or where such conditions necessitate special dental treatment plans’,” she says.
“Special needs dentistry is challenging, broad ranging and inclusive. Which other specialist practice equips you to liaise with the Head and Neck team to ensure cancer patients maintain their mouth; work with psychologists to develop home care protocols for a patient with autism, and learn life lessons from geriatric patients? Special needs dentists have to not only be clinically sound, they also routinely have to be excellent at complex oral diagnosis, think outside the box of traditional management techniques, and they must be strong advocates for the oral health of the most vulnerable of our society. After more than 15 years in this field, I still learn something new every day and love my job.”
Meeting special needs with general care
However, Dr Karve agrees with Dr Lin that this segment of oral care does not fall within the parameters of specialisation only, with care by general dentists an essential part of the special needs landscape.
“Basic training in SND should be mandatory in all undergraduate dental programs in keeping with the international charter [the UN Convention on the Rights of Persons with Disabilities (CRPD)] and local legislation. The importance of oral health in persons with intellectual disability has also been highlighted in the recently published National Roadmap for Intellectual Disability.
“Not all patients with special health needs need specialist care. Many can access care in the community if ‘reasonable adjustments’ are made to ensure equity of access to care. We need more interest from general dental practitioners to manage high-functioning and medically stable patients, so specialist practice is reserved for the most complex and medically unwell. We need a good ‘hub and spoke’ model of primary, secondary and tertiary care – and better funding to train more specialists in SND and attract them to Australia.”
“There’s always going to be a subset of the population that has complex medical conditions or disability that do require a specialist level of care,” says Dr Lin. “But we know that people with disability don’t fit into one category. It’s very diverse – so there’s also a really big proportion of the population that can be managed by general dentists.”
For dentists and dental staff who have not had much exposure to patients with special needs, the idea can be somewhat daunting. However, they are reminded by these specialists that, in this area perhaps more than any other, the care of a special needs patient involves communication and a holistic approach – you are not alone.
“The area of SND is incredibly collaborative,” says Dr Karve. “At the SAN hospital [the Sydney Adventist Hospital in Sydney] and at Westmead hospital, where I work, I am constantly consulting with other healthcare providers from a range of different specialisations. But even general dentists can consult with the patient’s caregivers, residential facilities, doctors, even psychologists or therapists, to understand how they can provide the best experience for the patient within your usual rooms or practice. You can also reach out to a specialist, consider a residency in SND or commit to specialist training in this space.”
“Any and every dentist could just have a little bit of extra knowledge, skill and on-the-job training, simply from getting exposure to looking after more types of patients with those conditions, who are often perfectly suitable to be seen by general dentists,” says Dr Lin. “I really encourage general dentists to be open and willing to look after any person who makes it to their dental chair. But then also, you can always refer and consult with specialists when it’s a very complex level of need. Contacting us in the Special Needs Unit is a good way to help you gauge whether the person is someone that needs that specialist level of care, or is suitable to be seen in the general setting. This brings us back to how we look at meeting the needs of the special needs population – understanding how important it is that a large number of these patients be treated within a general setting.”
Indeed, one popular presentation on the subject of SND arising from Congress 2017 and now found on the ADA’s CPD Portal, presented by Dr Warren Shnider (his story features in part 2 of this story; published 17 April 2022), puts general care for special needs patients very plainly: “For staff, carers and patients it is often complicated and awkward. Sometimes it is humiliating, and embarrassing. If unplanned, it will always be a waste of time. But it doesn’t need to be like that at all. Patients who have special needs are a normal and integral part of our communities, our clinics and our everyday lives. Their travel from front desk to surgery can be as seamless as everyone else’s. Planning is the key.”
“There is this stigma related to disability in our society,” says Dr Lin, “and I think that that could be part of the reason why people are sometimes hesitant to look after people with disability, because there’s that fear of the unknown or not knowing what to say or how to communicate. But I say it’s as simple as smiling, saying hello and getting to know more people with disability in your community. There are studies that show, the more exposure that a person has had to people with disability, it makes you more likely to then be willing to look after those people in your respective healthcare field. The way you can learn is simply by going in there, trying it out and learning from the patient and the caregivers, then liaising with the medical team and other allied health professionals to get to know that person. It can be that simple.”
Quality of life, or life itself
Of course, SND specialists such as Drs Karve and Lin take cases far beyond general scope as well, and this is where holistic and collaborative care can create an impressive level of treatment that is much more than the sum of its parts.
“In the example of our head and neck cancer patients, multidisciplinary team collaboration is essential for us to be able to provide them the best gold-standard oral healthcare possible,” says Dr Lin. “We have a very close relationship with many specialists that work at the Royal Adelaide Hospital and are in constant communication with them about the medical complexities that arise with these patients, but then also equally as important are social factors for the patients too. So, we talk a lot with other allied health professionals and social workers to ensure the patients are supported psychosocially, but also physiotherapists and speech pathologists. Especially for our patients that have dysphasia, which is an issue with their swallowing, they’re at higher risk of aspiration pneumonia, which is directly relevant and can be caused by things like dental plaque.
“In fact, there’s a study that came out of New South Wales in 2019 that showed that Australians with an intellectual disability are dying 20 years younger than the general population, and the leading cause of their premature death is lung disease. Half of those 50% are aspiration pneumonia. Those of us in the profession know that one of the causes of aspiration pneumonia is inhalation of dental plaque – and this is where you clearly and specifically see how dentistry is important. Not only does good oral health help you with getting a job and integrating with your social, emotional and general health, it can also literally be about life or death. And so that’s why advocacy and pushing for more preventive services for dental care in programs like the NDIS is so important.”
Meanwhile, even when not life or death, it is quality of life that is affected by oral healthcare in this segment of society.
“The cases I remember are always about how improving the person’s oral health has such a positive impact on their general health and wellbeing,” says Dr Karve, “whether it is coordinating a multi-disciplinary GA for a patient with severe intellectual disability, or facilitating implant replacement for a young man with autism who has had a fall and lost his two front teeth. It is the relief of the family when their grandma with dementia is no longer suffering with oral pain, but rather enjoying her mealtimes, or the pride on a phobic patient’s face when they are able to come in for a check-up without the need for medical sedation.”
“I’ve got two mottos,” says Dr Lin. “The first is: never treat a stranger. And my second motto is: I’m not here to look after teeth. I’m here to look after the person the teeth belong to; that’s what really drives the way that I look after people who come to me because I believe that the teeth are connected to the rest of the body. You know, the mouth is the gateway to your body and your general health, and your smile is your gateway to being included in society. It affects your psychological well-being and your emotional well-being. I’ve had patients who, because I’ve been able to get them out of dental pain and get them a set of teeth, now have the confidence to turn their life around – to go and get a job, get a girlfriend and feel they’ve got this confidence to go out there and live the best life that they can.”
A new tool for the job
Dr Lin has now completed a thesis that was many years in the making. This translational research project looked at implementing a referral tool to help dentists identify those patients who are in a higher-risk category requiring specialist level care, versus the patients who have lower to moderate levels of complexity, who would then be suitable to be seen by a general dentist with perhaps just a little extra support and training.
“The tool is based on the ‘case mix’ tool developed by the British Dental Association, contextualised for the Australian population and especially for our patients with disability,” says Dr Lin. “The British Dental Association case mix tool is based around six criteria, which look at different patient-related factors that might increase the complexity for providing dental care. For example, there’s a criterion that assesses their ability to cooperate, a criterion that assesses their medical status, and then also legal-ethical barriers such as consent.
“Once these six criteria have been worked through, the case mix tool then comes up with a score that places the patient at a level of complexity, to then help inform the dentist as to which person is most suitable to treat this patient. Should they be seen by a specialist, or can the issue in question be managed in a general practice?
“At the moment, my research has shown that this tool, that has been validated and used in the UK, is actually very relevant to be used within the context of the Australian healthcare system. During the course of the project, we matched up that tool’s results with referral assessments and the complexity assessment processes of very experienced specialists working in the Special Needs Unit [in a hospital], and we found that it has very strong correlation and reliability.
“Over the past year, we’ve been getting ready to implement this tool within the South Australian public dental service. Just a couple of months ago, I completed training of the dentists that are about to start implementing this tool in our statewide dental system. So it’s very exciting – because that’s been four years in the making!
“I began on the principle with that there are three pillars we can address. The first would be trying to advocate on a governmental level to change policy and funding. The second pillar would be raising awareness in the general population about special needs dentistry: what it entails, what types of people are more likely to require that additional level of care and why it’s particularly important for them to see a dentist. Then the third pillar is about education and upskilling our general dentists. This tool and this kind of work quite effectively addresses that third pillar.”
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