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ELECTIVE REPORT Powered By Docstoc
					Varyani, Pooja (2010) An observational study of special care dentistry at
the Special Olympics, Lincoln Nebraska. [Elective Report]

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An observational study of Special Care Dentistry at
     the Special Olympics, Lincoln Nebraska


              Word Count- 4029 words

Contents                             Page Number

Summary                                  3

Introduction and Literature Review       5

Aims                                     10

Materials & Methods                      12

Results                                  20

Discussion                               21

Conclusion                               23

Acknowledgements                         25

References                               26


The objective of this project was to gain insight into Special Care Dentistry

and to investigate the main issues concerning Special Care Dentistry in

America and in Scotland. This was achieved by spending time shadowing

Special Care Dentists in Glasgow, and becoming a dental volunteer at the

Special Olympics national games in Lincoln, Nebraska 2010 which ran from

the 19th to the 23rd of July.

       In Glasgow, two days were spent at Dykebar Hospital in Paisley

observing Dr Georgina O’Mailley and Dr Abigail Hefferman who are both

Special Care Dentists. This experience highlighted the broad variety in

Special Care Dentistry that exists: there were patients with physical and

intellectual disabilities, alcohol dependence, psychiatric patients and patients

being treated for oral cancer. Furthermore, Dr Petrina Sweeney, Clinical

Senior Lecturer in Adult Special Care Dentistry and the supervisor of this

project, had got in touch with Dr Steve Perlman, who is currently Professor in

Paediatric Dentistry at Boston University as well as the Senior Global Clinical

Advisor of Special Olympics’ Healthy Athletes Special Smiles program. Dr

Perlman very kindly arranged for my colleague and me to volunteer in the

Special Smiles part of the Special Olympics. Healthy Athletes involved several

components: fit feet (podiatry), fun fitness (physical therapy), opening eyes

(optometry), health hearing (audiology) and special smiles

      Healthy Athletes took place at the Pershing centre, Lincoln Nebraska.

At Special Smiles, as part of the screening process, the athletes would be

given a full dental examination by dentists, fluoride prophylaxis and a caries

risk assessment was done for each athlete. If an athlete was participating in a

contact sport such as basketball, mouth guards were constructed so that the

athletes could use it for their events. Further to this, the importance of

maintaining good dental health was emphasised through giving oral hygiene

instruction and dietary advice. Special Smiles also gave the opportunity for

dental professionals from around the United States to become more familiar

with managing patients with special needs, and work as a team in the best

interests of the athletes. After receiving a full dental examination, any new

diagnoses made such as teeth needing restorations, extraction/extractions

being needed or new crowns would be discussed with the athletes, and

subsequently the athletes would have the option of receiving dental treatment

upstairs where there was a dental clinic and a team of qualified dentists and

dental students from Lincoln, Nebraska.

                   Introduction and Literature review

This literature review explores the main issues surrounding Special Care

Dentistry as well as giving a bit of history about the Special Olympics. The

Special Olympics was founded by Eunice Kennedy Shriver whose concept

was to offer people with intellectual disabilities everywhere "the chance to

play, the chance to compete and the chance to grow." The term intellectual

disability refers to impairments in both cognitive functioning and adaptive skills

whose onset is during the developmental period.1Eunice Kennedy Shriver day

is held on the fourth Saturday of September every year as a reminder of the

impact she has on many lives.

   The Special Olympics originally started as a background summer camp for

people with intellectual disabilities in June 1962 and evolved into a global

event. There are national as well as world-wide events. The first national USA

games were held in Iowa State University in 2006. In 1997, Healthy Athletes

became an official Special Olympics initiative, offering health information and

screenings to Special Olympics athletes worldwide2. 2010 marked the year of

the second ever national USA games held in Lincoln, Nebraska. This year

was the first year to offer dental treatment for athletes at the Special

Olympics, which was part of the Mission of Mercy. The Mission of Mercy

consists of dental volunteers and professionals and is generally a two day

event at locations across the USA. This is where any patient can receive a

wide array of dental treatment for free if needed as it is all funded for by dental

organizations of the host state, which raise private donations to cover the


   . In the UK, Special Care Dentistry has been recognised as a speciality by

the General Dental Council on the 3rd of September 2008. It is concerned

with the improvement of the 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 factors3.

Patients presenting with either of these disabilities or impairments have other

needs which healthcare professionals should consistently meet so that a

patient has equitable oral health outcomes in terms of self-esteem,

appearance, social interaction, function and comfort.4

   Current UK criteria suggest that there are approximately 10 million people

classified as being disabled5. Given this number, it is interesting to find that

surveys of new dental graduates have demonstrated low confidence scores in

the management of patients with special needs and inadequacies in

professional training for dentists and hygienists have been reported.6 Here are

some of the reasons given by dentists for not providing services for people

with impairments:

   •    Too time-consuming/expensive

   •    Difficulties of access to the surgery

   •    Challenging behaviour

   •    Waiting room disturbances

   •   Need for special facilities

   •   Lack of training and experience 7

    When observing patients with intellectual and physical disabilities in

Dykebar, it was interesting to see how important communication is in the

handling of patients, and the amount of time that went into communicating

with patients. There are three main elements of communication: words, tone

of voice and body language. However, words on their own they account for

only a small part of communication.8 This holds true for all patients, however

for patients with special needs, good communication is crucial to the overall

management, even for matters such as consent.

   The teaching of Special Care Dentistry in the undergraduate curriculum is

relatively low in priority compared to other specialities. Although there has

been day visits to Easterhouse in Glasgow, this has only been a taster of

Special Care Dentistry, which is the reason for choosing this topic as an

elective project.

       In contrast to the UK, Special Care Dentistry in the United States is not

regarded as a speciality. According to an article from the Journal of Dental

Education, it would be all but impossible to anticipate a few score or even

hundreds of special care specialists to assume all the needed care for tens of

millions of individuals, including (as defined by the Commission on Dental

Accreditation) “those patients with medical, physical, psychological, or social

situations that make it necessary to modify normal dental routines in order to

provide dental treatment for that individual. This article concludes with a final

thought stating instead of a “Let someone else do it” attitude “Let us all do it!”9

This shows that already there is a striking difference between dental care for

patients with special needs in America and Scotland, with Scotland having

dentists specially trained to treat patients with special needs. However, the

Disability of Discrimination Act (1995), is designed to ensure that services are

equally accessible to disabled and non-disabled people.5

       One of the key issues that had been emphasised from this elective is

the barriers to dental care for patients of Dykebar and athletes in the United

States. As detailed in a book entitled special care dentistry, there are several

of these barriers. There are barriers with reference to the individual such as

lack of perceived need, financial considerations was perhaps one that was

highlighted at the Special games because dental care is privatised there.

Other barriers included those relating to dental professions, to society and to

the government10. According to an article about access to dental care in

Florida, it is estimated that 75% of people with developmental disabilities rely

on government funding for dental and medical services11. In America, the

problem of access to dental care can be largely attributed to two major

obstacles: an    inability   to   afford   preventive    and    treatment-related

dental services and the limited number of dental professionals providing such

care to this population. For example, more than 1.5 million mentally

developmentally delayed adults rely on Medicaid (reimbursement scheme),

which does not cover dental care.12

       It is well documented that people with learning disability or mental

health problems have similar oral diseases but poorer oral health, particularly

periodontal health, and health outcomes from care than the general

population. Additionally, people with learning disabilities living in community

settings are less likely to have received dental treatment. Even when

treatment occurs, it is more likely to result in extractions than fillings, crowns

and bridges13. It was observed in the clinical records of patients at Dykebar

that a lot of them had received general anaesthetic so that dental work could

in actual fact be carried out on them. Inhalation and intravenous sedation are

indicated as the next line of treatment when an individual is unable to co-

operate for care with local analgesia because of anxiety, learning disability or

physical disability such as a movement disorder.14It has been suggested that

approximately 20% of people with a disability need a general anaesthetic.15


The aims of this project are as follows:

       To gain an insight into the world of special care dentistry

       Appreciate the differences between dentistry in the USA and in


       Assess the barriers to dental care

       Enhance management skills of patients with intellectual disabilities

       Witness different approaches to treating patients with intellectual


       Work as a team and promote dental health to all the athletes

                                  Figure 1

                                  Figure 2

Figure 1 and 2- Special smiles dental clinic where athletes went to get dental


                       Materials and Methods

At the Special Olympics, there were several stations located downstairs in the

screening clinic for Special Smiles and these stations followed a sequence. In

order, the first was dental examinations, followed by oral hygiene instruction,

followed by caries risk assessment, if an athlete needed a mouth guard then it

was made, fluoride application and finally dental goodie bag. If the athletes

needed dental treatment then they were escorted by volunteers upstairs to the

Mission of Mercy clinic. Each volunteer was allocated to any station which

required their assistance on that day.

       Initially, the first three days were spent at the caries risk assessment

station. The format of the caries risk assessment was very different to that

carried out in the UK. According to Paediatric Dentistry by Welburry, the

purpose of caries risk assessment is to predict whether the disease is likely to

develop in as yet caries-free individual, or to determine the rate of progression

in a patient who already has some caries experience. Research has shown

that experienced the clinician can achieve a high level of prediction simply on

the basis of socio-demographic history. Thus the need for microbiological

investigation may not confer significant additional benefit. This book also

states that the most useful clinical predictor for caries is past caries

experience.16 Therefore the views on caries risk assessment are very different

in the UK and the USA. In the USA, a system called CAMBRA (CAries

Management By Risk Assessment) was used to gauge an athlete’s caries


        According to the Californial Dental Association Journal there was an

article about CAMBRA which states that there are four strong disease


1) frank cavitations or lesions that radiographically show penetration into


2) approximal radiographic lesions confined to the enamel only

3) visual white spots on smooth surfaces

4) any restorations placed in the last three years.

These four categories are strong indicators for future caries activity and

unless there is nonsurgical therapeutic intervention the likelihood of future

cavities or the progression of existing lesions is very high17. These were all

part of the CAMBRA sheet. There were several other components to this risk

assessment which firstly involved asking the athletes a series of questions

regarding their dental health. This examined disease indicators and risk

factors such as current decay condition, current bacterial challenge, decay

history, dietary habits, current prescription medications, saliva flow, medical

conditions, and oral hygiene habits.

              Figure 3: example of the caries risk assessment sheet

      Secondly the pH of the athlete’s saliva under the tongue was measured

a value was determined by comparison to a pH scale. According to an article

entitled Management and treatment of the biofilm aspect of caries

disease, pH strategies play an important role in reversing the selection

pressure on the diseased biofilm. While cariogenic bacteria are both

acidogenic and aciduric, many healthy oral bacteria have the ability to elevate

the oral pH after acid development in the classic Stephan curve from dietary

events. 18

       The last aspect of CAMBRA involved taking a cotton swab of the

plaque on the labial coronal two thirds of the athlete’s lower anteriors, without

the swab touching any soft tissue, after which the swab was placed in a meter

which could quantify the oral bacteria level an athlete had. Low risk was 0-

1500, moderate risk was 1501-3000, high risk was 3001-6000 and lastly

6001-9999 was classified as extreme risk. According to the system, any risk

above 1500 meant that the athlete should see their dentists to help lower that

risk. The majority of athletes were deemed as either high risk or extreme risk,

with the exception of a few being moderate or low. Advice which followed for

those who were high or extreme risk was to concentrate on using the right

tooth brushing technique and visit their dentist to discuss ways of reducing

their risk of developing new carious lesions.

              Figure 4                                   Figure 5

Figure 4 - Equipment needed for completing the caries risk assessment using

CAMBRA: gloves, antiseptic hand gel, disposable mirrors, pH paper, cotton

swabs and carimeter. Figure 5- the caries risk assessment team

Here is a list of the dietary advice that was given to the athletes:

   •   Drink carbonated or fruit juice using a straw

   •   Preferably drink water or milk

   •   Reduce the consumption of sweets or cakes to meal times

   •   Eat cheese as a healthy alternative snack

   •   Avoid snacking between mealtimes

   •   Choose fruits over sweets

   •   Chew sugar free gum containing xylitol

The reason for promoting xyliotol sugar free chewing gum is that it has

specific effects on oral flora and especially on certain strains of mutans

streptococci, which adds to its caries-preventive profile and gives it a vital role

in the preventive strategy for dental heath.19

       At the oral hygiene station, a list of general questions was asked to

athletes such as:

   •   How often do you brush your teeth?

   •   How long do you brush your teeth for?

   •   Do you brush your gums?

   •   What toothpaste do you use?

   •   Do you rinse after brushing?

   •   Do you floss or use any form on inter dental cleaning and how often?

   •   How often do you visit your dentist?

After discussing the important aspects of oral hygiene, the athletes were then

shown the modified bass technique, using a manual brush as well as the

electric toothbrush. This was demonstrated at the oral hygiene station using

an over-sized toothbrush on a toy dinosaur. Once the athletes were shown

how to brush their teeth they were asked to show the volunteers their method

of brushing their teeth by brushing the dinosaur’s teeth, any ways that athlete

could improve their brushing was then suggested. A Cochrane review

concluded that powered toothbrushes with a rotation-oscillation action are

more effective than manual brushes in reducing plaque and gingivitis in the

short-term, and gingivitis in the long-term20.

                        Figure 6 - the oral hygiene station

       Dental students from the University of Nebraska Medical Centre

usually covered the mouth guard station. However, it was interesting to watch:

the mouth guards were softened using hot water and moulded to the athlete’s

dentition and then cooled. The athletes could then use their mouth guards for

contact sports.

                         Figure 7- the mouth guard station

      After completing the dental screenings in the Special Smiles program,

all athletes were given a goodie bag full of oral hygiene aids which included

electric toothbrushes, toothpaste, flossing sticks and sugar free chewing gum.

If the patients needed dental treatment, they were escorted upstairs to the

Mission of Mercy dental clinic which was part of the Special Smiles program. I

had also assisted the dentists as they treated patients here. A variety of

procedures were observed such as simple restorations, extractions and

periodontal treatment.

              Figure 8- dental goodie bag that athletes received


This year a total of 4768 athletes received free health screenings. Of this

number, a total of 977 athletes were screened in the Special Smiles program.

From this number, 288 were given mouth guards and 450 dental procedures

were carried out. The number of athletes from each state who came to

participate in the games varied a lot, being 204 athletes from the state of

Nebraska and the being 3 from the state of Alaska. The home state of

Nebraska had 94.1% of their athletes screened too. Overall the percentage of

athletes from all of the states who were screened was between 70-100%,

resulting in a high turn out in general and showing that healthcare is a strong



By observing special care dentistry in two different forms, and in two

completely different clinical environments so much has been learnt in terms of

how to manage and treat patients with special needs and the constant

challenge of reinforcing dental care to not only the patients but to their family

and carers. Good communication and patience is essentially the key to

successful management of patients with special needs. Also, the experience

highlights that interventions on a one-on-one basis are successful at getting

the importance of dental health out to patients, more so than broader

advertisement of the matter. Dental professionals should continuously

emphasise prevention in the overall best interests of the patient as it was

astonishing to find many of the athletes were only brushing once daily or once

every two days.

       The American approach to caries risk assessment was interesting to

be a part of, and very different to the UK version of the caries risk assessment

which neither quantifies neither bacterial level nor measures the pH of saliva

for a patient. When carrying out the caries risk assessment, the presence of

white spot lesions and decaying teeth were screened for, and if present the

athlete was made aware of it. Many athletes had multiple carious teeth and

clearly needed dental attention. There could be many reasons for them not

seeking dental treatment such as fear or anxiety, lack of education of the

importance of healthy teeth and gums, cost and access.

       Moreover, a lot of the athletes showed signs of gingivitis and

periodontitis indicating that their tooth brushing technique needed to be

looked at. Many athletes also showed signs of non-carious tooth surface loss

(mostly erosion) and when noticed this was brought to their attention and

ways of reducing it. It is said that those with severe neuromuscular,

neurological or learning difficulties often suffer with incontinence of saliva and

bruxism, thus increasing tooth wear.5 Patients with special needs are so much

more prone to getting dental caries and periodontal problems for many

reasons. The medications that they are on cause them to have substantially

decreased salivary flow. Sometimes their manual dexterity is not optimal

which is why eliciting the aid of an electric toothbrush is helpful. Furthermore,

so many patients rely on their carers to brush their teeth, and if their carers

are unaware of the correct method of brushing, it is the patient who will suffer.


Overall the whole elective project has been enjoyable and the best way to end

a stressful year of the dental course. From observing patients at Dykebar, I

gained an appreciation for how diverse special care dentistry is due to the

array of patients seen. The dentists I observed were inspirational in their

patient-centred care, being able to establish such a good rapport with their

patients and making dental treatment easier for them. Sometimes even with

the most challenging patients, good communication skills can lead to vast

progress in dental work because the patient trusts the dentist. There were a

number of interesting observations made in general. The majority of patients

really do rely on their carers so it is important to communicate all relevant

dental information to their carers and make sure they are well informed with

regard to keeping dental appointments and maintaining oral hygiene for

patients. Many patients at Dykebar who had intellectual disabilities also went

to disability centres such as the Anchor centre too. Although it has been

emphasised many times throughout the undergraduate dental course in

Glasgow, healthcare really is a team effort, and holistic care is vital for the

well-being of patients.

       The Special Olympics in particular was an experience of a life-time and

I have loved every moment being a dental volunteer for Special Smiles. My

colleague and I got tickets to the opening ceremony, which was grand to

encourage all the athletes from across the United States. The atmosphere

was phenomenal, and the athletes showed a lot of enthusiasm for learning

about how to brush their teeth and eat healthy. For certain athletes it did take

longer to get across the importance of brushing their teeth, but having their

family and coaches around them helped. Being a volunteer at the Special

Olympics felt amazing to be part of such an energetic and passionate dental

team in caring for the athletes all across the states. I met so many dental

professionals from all across America and it was interesting to hear about

their daily routine, how they carry out dental examinations and how many

patients a day they see. Moreover, I met dental students from the dental

school in Lincoln who were also volunteering, so it was interesting to find that

dentistry is a four year course in America, and dental students first enter

dental school at the age of twenty-three after completing four years of college.

This is very different to the UK where the majority of people start after school

being around eighteen years of age.

       In terms of similarities between Special Care Dentistry in America and

Scotland, there were a number of points which were discovered. Many of the

athletes and the patients at Dykebar were not as thorough with their oral

hygiene, a lot of them had not heard of ‘spit don’t rinse’ rule, which I

continuously emphasised to all the athletes I met. Above all, the most critical

issue that was noted here was that access to dental care in the states for

some of the athletes- they simply could not afford the dental care there as it is

all private, which forces a lot of patients to follow these mobile dental clinics

set up by the Mission of Mercy to get treatment. At the Special Olympics,

despite having an enthusiastic attitude towards dental care, it did

fundamentally highlight that this particular group of patients have a lot of

decay, with many unfamiliar with how to brush their teeth. However, the

athletes did know a lot about dietary advice, yet this was still emphasised

remind them. The program was good to emphasise the importance of dental

care and the need to address patients that needed treatment.

       The experience has been so much fun, and it is something I would

definitely consider taking part in the future again. Given the number of people

with disabilities in the UK, it is vital to gain an appreciation for how to care for

them. I felt like as a dental undergraduate, not much exposure is given to us

with regard to how to manage patients with special needs, so I am really

thankful I got this opportunity to volunteer at the Special Olympics.


I would like to thank Dr Steve Perlman and Shantae Polk for arranging the

opportunity to volunteer in the Special Smiles program at the Special


I am also extremely grateful to Kenneth Macrae from the Churchill University

Scholarship Trust who awarded a grant in the sum of £250 towards this


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