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.1 Although, oral health care of special needs children is well taken care of by paediatric dentist, there seems to be a lack of continuity of care once they go into adulthood. Inadequate manpower with advanced skills in handling this special needs group, lack of dental awareness and poor coverage are probably the major contributing factors to unmet treatment needs for this group of people.

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.1 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.2

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.3 While in the past few decades, countries like Australia, New Zealand, Canada and United Kingdom have developed a dental specialty programme that addresses the dental management of special needs patients who require oral health care, Malaysia is still exploring this option 4, and for this reason, Malaysia has to send oral health personnel overseas to obtain specific training in this specialty.

With two specialists in Special Needs Dentistry currently practising in Malaysia, the oral health issues of people with special needs can be addressed and managed in a more appropriate manner which benefit the patients, mostly in the area of domestic oral health with the aim to enhance their quality of life. As the service took place in the Ministry of Health in the early 2011, the two pioneer specialists together with the Oral Health Division, MOH have developed the core competencies and focus in this field.

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.

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. Nevertheless, not all patients who fall under the category of special needs require management by the specialist in SND. The patients who are seen by the specialist in SND are either in ASA III or ASA IV group/category. Therefore, not all people with disabilities (PWD) card holders authorized by the Social Welfare Department are eligible to receive special oral health care. Dental care can be provided by the dentists at the mainstream dental setting in cases where the patients can access the dental services and are able to communicate details of their problems (without compromised verbal communication, cognitive impairment or behavioural problems and in absence of complex medical conditions). 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. However, specific concern may be given in behavioural management of the individuals depending on the patient’s need to encourage better and comfortable support for treatment delivery emotionally and environmentally. This will enhance patient’s cooperativeness which leads to proper oral hygiene care, thus preventing complex complications due to poor oral hygiene. Strategies such as effective communication, relaxation method, desensitization, oral sedation, relative analgesia and general anaesthesia are often used in managing people with special needs receiving oral health care in the surgery.

  

Left: Use of nitrous oxide for relative analgesia (inhalation sedation).
Right:  Dental management of special needs dentistry patient.

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 patient’s 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 patient must also be informed that the initial consultation must not be necessarily followed by treatment at the specialist centre. The initial appointment with the specialist is for oral health assessment only and to identify the dental needs. 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. They may be placed in the waiting list according to the urgency of the problems. The decision for patient to undergo treatment under oral/IV sedation or general anaesthesia must be determined by the specialist and not by the referring clinician. The commitment of the patient/parents/guardians/carer is essential to inspire good oral hygiene and appointment attendance is important because those who fail to attend three consecutive appointments with the specialist without valid reasons will be removed from the list of the referral centre.

It is the responsibility of the referring clinician to complete a referral letter or form which contains details information about the patient which include patient’s 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 patient’s 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.

An austistic patient who presented with history of neglected oral hygiene care receiving treatment under GA


Dental management for the “frail and dependent” elderly or also known as Geriatric Dentistry is a part of Special Needs Dentistry. Khas

 

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. The specialist in SND is responsible to provide consultation by collaborating with the public health specialist who is managing patients with special needs at the allocated community dental clinic. Even if the patient is managed at the community level, in a case when the disabilities become more complex and require specialist management at any stage, he/she can be referred to the hospital. For example, patient with early stage of dementia progressing into late stage of dementia at which the behaviour becomes more challenging and GA is required to carry out comprehensive dental treatment.

 

Community workshop to educate carer about techniques of oral hygiene care at home for people with disabilities

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. Information on barriers and local access to dental care for this group of population should be investigated in greater detail so that the oral health care disparities can be reduced. Another area requiring further research is the quality of dental services for persons with disabilities by exploring areas related to clinical determinants of quality dental treatment and the timeliness, efficiency, and effectiveness of available dental services.

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. The autonomy of an individual is of paramount concern in planning their care but the lawyers and ethicists are as yet unable to establish a robust but flexible framework to ensure that decision making will ensure a positive outcome for each individual. Communication, responsibility, guardianship and social beliefs all impact in our work. It is acknowledged that the law in the area of Disability Awareness is recent, evolving and already subject to revision. This is to be applauded, but also requires an acknowledgement that the changes over the last decade have been huge and have required a paradigm shift in thinking or even begin to implement the changes. Not all affected parties are able to move at the same rate; but all are aware that many well meaning, informed positive acceptable and common sense solutions used in the past will no longer stand up to scrutinize if challenged. Thus, details investigation and attention are required to explore these areas of concern in the future development of SND service in Malaysia.

REFERENCES

  1. Ramli R; Wan Othman WMN; Abu Talib N; Mohd Rashid N; Junid NZ; Looi LL; Bok L; Abu Kassim R; Mohd Zaki H; Mah L; Mohamed N; Ismail N, Guidelines on Oral Health Care for the Elderly in Malaysia. In Oral Health Division; Ministry Of Health Malaysia, Eds. 2002; pp 1-52.
  2. Gallagher, J.; Fiske, J., Special Care Dentistry: a professional challenge. British Dental Journal 2007, 202, (10), 619-629.
  3. Tiller S; Wilson KL; Gallagher JE, Oral status and dental service use of adults with learning disabilities living in residential institutions and in the community. Community Dental Health 2001, 18, (3), 167-171.
  4. Ettinger, R.; Chalmers, J.; Frenkel, H., Dentistry for persons with special needs: How should it be recognized? Journal of Dental Education 2004, 68, (8), 803-806.

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