Career: Taking special care

SPECIAL care dentistry is a specialty unlike most others where every day – and every patient – presents their own unique challenges. The care offered is very much patient-led and takes a holistic approach that considers all aspects of a person’s life and medical care. Delivering even the most basic oral care may require careful planning, a variety of sedation techniques and even unusual communication methods.

As a specialty, it is relatively new and quite small, having been approved by the General Dental Council in 2008. Dentists working in the field from 2008 to 2010 could apply for inclusion on the specialist list upon completion of a satisfactory portfolio of evidence.

The first specialty training registrars were appointed in October 2009 by the London and Oxford deaneries and were quickly joined by others across England, Scotland and Wales. There are currently 18 trainees nationally with plans to further expand the number of training pathways.

According to the British Society for Disability and Oral Health, the specialty takes a holistic approach to providing oral care for “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”.

Training

To enter specialty training you should have a BDS or equivalent, completed dental foundation training and it would be advisable to have one of the Royal College examinations, i.e. MJDF or MFDS. Training lasts three years, leading to a Certificate of Completion of Specialty Training (CCST).

The curriculum covers:

• Biological sciences

• Concepts of impairment disability functioning and health

• Behavioural sciences

• Oral health promotion

• Oral healthcare planning for individuals and groups

• Clinical special care dentistry

• Legal aspects, ethics and clinical governance

• Knowledge of research, statistics and scientific writing.

Currently, the curriculum is delivered in different ways depending on the training programme. Some trainees carry out a masters degree as an integral component, but others undertake distance learning either through the Diploma in Special Care Dentistry (DSCD), Royal College of Surgeons of England or the Bristol University Open Learning for Dentists (BUOLD). All trainees need to successfully pass the Tricollegiate Exit Exam (RCS Glasgow) in order to gain CCST.

Trainees are continually assessed through work based assessments and case based discussions with an emphasis on reflective learning. At the end of each year, the trainee must pass an Annual Review of Competence Progression (ARCP).

Some training programmes are hospitalbased with elements of primary care experience, but we are based in community dental services under the supervision of primary care consultants in special care dentistry. We also both work within hospital settings, giving a wide exposure and breadth of experience.

Necessary skills

Working in special care dentistry requires a variety of skills, including behavioural techniques, sedation, hypnosis and acupuncture. Each day is different and each patient unique, including the way that we need to communicate with them such as using Makaton or word boards.

Special care dentists need to have a comprehensive knowledge of either the Mental Capacity Act 2005 or the Adults with Incapacity Act (Scotland) 2000 and the notion of informed consent as many patients lack the capacity to make decisions about their own dental treatment. This can be a complex area and laws vary between Scotland and the rest of the UK.

Sometimes, examination of a patient is not possible without general anaesthesia or sedation, so the specialist must be prepared to treat whatever they find. For a patient who has had little or no past dental treatment, their needs may be significant. It may also be necessary to perform a biopsy if suspicious lesions are found. This kind of treatment places demands on the dentist both clinically and physically.

Other areas of special care are concerned with treating those with medical complications such as haematological disorders or those about to start cancer therapy. These cases require close liaison with other medical professionals to provide effective and safe dental care.

For oncology patients, dentistry may not be a priority but a failure to address these issues may have serious long term complications and affect the success of their treatment. The challenge here is to help these patients swiftly with kindness and understanding.

In practice

Special care dentistry is a rewarding career that encourages us to adapt and strengthen our skills, while sometimes ‘thinking outside of the box’. While working with special care patients we spend a large amount of time with them and their carers and come to know them as people, not just as patients. No matter how professionally detached a dentist may try to stay we inevitably become emotionally attached to some.

To enter into this specialty is to accept this and ensure that we use these experiences positively to help us to treat patients within the context of their own lives.

Sources:

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

• GDC curriculum

• British Society of Gerodontology - www.gerodontology.com

Jane Temple and Jessica Rowley are specialty training registrars with the Yorkshire and the Humber Postgraduate Deanery

A Day in the life

Below are examples of ‘typical’ days for Jane who works at Sheffield Salaried Dental Care Services and Jess who works at City Health Care Partnership Dental Services Hull

Jess

8:30am Resuscitation training and practice using the hoist with sedation team

9:30am Urgent new patient referral – needs to start radiotherapy in 2/52. Treatment planning in liaison with oncology/ radiology

10.30am Intravenous sedation to facilitate examination and all necessary treatment for patient with advanced Huntington’s disease

11.30am Local anaesthetic extractions for quadriplegic patient who requires hoisting

1.30pm Observe learning disability team on home visit

2.30pm Lead a best interests meeting for a patient with Down’s syndrome and severe congenital cardiac disease

4:00pm Case based discussions with consultant and other registrar

5:30pm Finish

Jane

7:30am Preparation of domiciliary equipment and travel to homeless project

8:30am Treat homeless patients with a range of social issues including drugs, alcohol and mental health problems

11:30am Home visit for new patient who is repeatedly biting his lip. Patient has cerebral palsy, uses a wheelchair and communicates with a word pad. Liaison planned with speech and language therapists to determine the best treatment

1:30pm Observed by educational supervisor whilst providing hypnosis for an extraction, followed by a case based discussion

3:00pm Inhalational sedation for fillings on a phobic patient.

4:00pm Assessment of a patient with Huntington’s disease for treatment under intravenous sedation

5:30pm Finish

Q&A Carole A Boyle, Consultant in Special Care Dentistry

What attracted you to a career in special care dentistry?

I realised that I enjoyed treating people rather than drilling teeth. Unlike now, at that time there was no training path in special care dentistry so I had to make up one as I went along. I enjoy oral surgery and conservative dental treatment and in my current job I can do both but for a very interesting group of patients. Special care dentistry is ordinary dentistry for extraordinary patients.

What do you enjoy most about the job?

I enjoy the range of patients that I see. One moment I’m talking to somebody who is extremely anxious and phobic of dental treatment but also highly intelligent and knowledgeable. The next I am gaining consent for sedation for someone with a mild learning disability. I also see patients with complex medical histories and trying to work out the best and safest way of providing care for them is incredibly challenging but also very rewarding.

What do you find most difficult?

The most difficult part of the job is engaging patients and their carers to motivate them to provide simple oral hygiene. It is upsetting to begin every treatment with plaque removal for patients with learning disabilities because their carers do not see the necessity to assist their client in brushing their teeth between appointments. It is also frustrating sometimes not being able to provide more complex dental treatment for people who are unable to cooperate due to dental phobia or disability.

What unique challenges do special care dental patients pose?

We have to be quite ingenious sometimes in working out the best treatment plan for patients and also how to provide care. I treat patients under general anaesthesia and sometimes the challenge is getting the patient into the anaesthetic room and asleep before we can even examine them. I am quite inventive with administration of premedication. You have to be flexible and adaptable – things don’t always go to plan.

Have you been surprised by any aspect of the job?

I think the biggest surprise is that I have got to know my patients very well and have a large group that I see on a regular basis. Unlike many hospital consultants we see our patients for recall and over the years I have got to know my patients and their parents/carers. It is very rewarding when I get a hug from someone who is pleased to see me.

What advice would you give to a trainee considering special care dentistry?

I think my advice to anyone thinking about becoming a special care dentist would be to get some experience of special care. It is only when you meet a patient who refuses to let you examine them due to anxiety or a learning disability that you really understand the challenges faced by this specialty.

What is your most memorable experience so far in the specialty?

I think some of the individual people and patients that I have met. I am amazed by the patience of parents of adults with learning disabilities, where every single day is a challenge. This has made me appreciate some of the difficulties people have in accessing dental care, how lucky I am and it enriches my life knowing these patients.