The complexity of special needs dentistry combined with a practitioner shortage and funding issues means uncertainty for the exponentially growing number of patients that need it most. Tracey Porter writes.
When Dr Helen Marchant opened a new clinic in Werribee earlier this year, the press came calling.
As exciting as it must have been for Dr Marchant on a personal level, the journos weren’t there because yet another health professional had spied an opportunity to open a business and make a name for themselves.
They sat up and took notice because one of the country’s foremost experts in her field had witnessed firsthand the increase in demand and decided she could do more to help put patients—as well as those who love them—at ease.
It was an uncharacteristic moment in the sun for this new area of dentistry that had been operating in the shadows.
What is special needs dentistry?
The Royal Australasian College of Dental Surgeons defines special needs dentistry (SND) as the branch concerned with the oral healthcare of people that require special methods or techniques to prevent or treat oral health problems, or where their conditions necessitate special dental treatment plans.
These conditions can be intellectual disabilities and/or medical, physical or psychiatric conditions, or a combination. But to the band of professionals charged with looking after this unique group of patients, it is so much more.
Who it benefits
SND’s individual population means there’s no such thing as a typical caseload. The specialists’ waiting rooms are filled with an assortment of complex cases. They can range anywhere from those with a disability diagnosis such as autism through to mental health or extreme phobia issues, all of which may come
with additional challenging behaviours and conditions.
They also treat medically complex cases, such as patients with cystic fibrosis who are heading for a lung transplant but who first need to be checked for signs of oral infections. Cancer is also responsible for a number of referrals to SND clinics, with patients having radiotherapy finding it dries the mouth out and affects the saliva glands. Chemotherapy makes patients prone to oral infections that can have serious consequences if left untreated.
Dr Avanti Karve, the first graduate of the Doctor of Clinical Dentistry Program (Special Care Dentistry) with the University of Sydney, says she was drawn to the SND sector largely because of the crossover between medical and dental work. She currently works as a staff specialist for the Sydney West Local Health District based at Westmead Centre for Oral Health.
Dr Karve says owing to the complex nature of their work, SND specialists are often intertwined into the life of their patients much more than would be the case for a dentist in private practice.
A lot of SND work is aimed at offering holistic patient treatment programs where teams liaise closely with the patient’s other caregivers to ensure the best possible care. Managing SND patients is a typically more complex task as they are booked for longer appointments, and more time is spent preparing for new clients and data gathering both pre and post-consultation.
It’s not uncommon for a patient to live in residential care, have carers who look after them on a daily basis, have a family member who consents for them and an administrator to handle their finances. They will often have a general medical practitioner and other specialists and allied health providers who need to be involved.
More than a treatment
Dr Karve says this puts special needs dentists in a position of trust and can lead to them becoming their patient’s advocate.
“We are able to sometimes facilitate care that might not be available through other services, for example where a patient is having [dental] work done, doctors are also able to take advantage of the fact the patient is under general anesthetic to get routine blood tests done. Similarly, if the patient is having other surgery we can take that opportunity to go and have a quick peek at their teeth which might not be possible otherwise in some patients.
“A lot of times this is about patient advocacy but the flipside of that is sometimes you might be one of the first clinicians to encounter abuse or neglect, and you have reporting responsibilities around that. Often, particularly around early diagnosis in a neuro-degenerative case where the ability to self-consent is potentially not being exercised, we may be one of the first clinicians to address that issue. That is the invasive nature of our work. It is interesting and very rewarding.”
Where they can be found
To offer SND services, clinics must have excellent disabled access as a minimum.
Because some patients have sensory issues there is a need for quiet private spaces, while specialist drugs such as nitrous oxide, and equipment such as hoists, pillows for support and tools to distract patients are often required. It is for this reason most specialist SND clinics are attached to hospitals.
According to the Australian Society of Special Care in Dentistry (ASSCD), there are 15 SND specialists working in Australia currently: seven in Victoria, two each in New South Wales and South Australia (who also cover Tasmania), and four in Queensland (one of whom makes monthly visits to the Northern Territory).
In addition there are many more dentists working in the SND field who work as general dentists, while some oral health therapists, hygienists, dental therapists and dental prosthetists also see SND patients.
A growing patient population
Dr Karve says this patient population is growing predominantly because patients with special needs are living longer.
“Australians are living longer, but we also have those with developmental disabilities and complex systemic diseases where 30 years ago they might not have survived past childhood but are now living into adulthood and older. But as Australians grow older, the number of those with neuro-degenerative diseases, particularly dementia, Alzheimer’s and so on, are growing.”
“What funding we have had comes and goes, which makes providing ongoing care difficult… the government is overdue in releasing the next 10-year oral health plan.” – Dr Kerrie Punshon
But both Dr Karve and ASSCD president Dr Kerrie Punshon say there are real concerns about the numbers of specialist SND practitioners available in Australia,
as not all health professionals had a good grounding in SND during their training
Growing waiting lists are the inevitable result. Dr Karve says it’s important for general practitioners to acknowledge and try to accommodate the higher functioning patients within these populations, particularly those for whom funds is not an issue and could quite easily be treated.
“There are obviously those who do require specialist care but I think it’s important to try and promote the inclusion of those with special needs within the general dental community.”
The mistaken beliefs that all SND patients need to be treated under general anaesthetic and that it’s all too hard puts some practitioners off entering the field.
Access all areas
Many SND specialists believe the sector needs better access to oral health services for SND patients, Dr Punshon particularly.
“This varies throughout the country, but in many areas access to appropriate dental services is limited or does not exist. At
a more complex level, access to specialist services is patchy and general anaesthesia difficult, with few hospitals willing to accredit dentists to provide these services.”
Dr Punshon says there is a large oral health and overall health disparity between SND patients and the general population. To correct this imbalance, the sector needs better trained oral health professionals involved in teaching, continuing educational development and mentoring, and also increased resources at a postgraduate specialist training level.
While specialist SND training is available as a postgraduate course via The Universities of Sydney, Melbourne and Adelaide, presently there are no scholarship programmes to encourage more Australian registered dentists to undertake study in this area.
“We are an ageing group, and two specialists have retired in the past year
or so,” says Dr Punshon.
“Currently we have three local students in Australian university training programs. Most of the students we have trained in our university programs have come from overseas on full scholarships, and return to their country of origin to set up SND services in their home countries. We support this, as we are a regional and international educational provider and are very proud of our overseas graduates on their return home—but, at the same time, would like to see more local dentists undertaking training also.”
Dr Punshon says a lack of funding available to SND patients—a situation expected to get worse if the Medicare Child Dental Benefits Scheme is withdrawn in May 2’s federal budget as expected—also means that those who could benefit most from specialist treatment are not always able to access it.
SND patients with chronic diseases were previously entitled to Medicare funding— however, while this was well targeted, it was also poorly conceived leading to its withdrawal a few years ago.
Government funding available for SND patients is largely provided by states with commonwealth funding limited to Department of Veterans Affairs and the Cleft Lip and Palate Scheme.
Commonwealth funding has become politicised, Dr Punshon says.
“What funding we have had comes and goes, which makes providing ongoing care difficult. SND was a priority area in the last 10-year plan. The government is overdue in releasing the next 10-year oral health plan, and it is yet to be put to parliament.
“In the new plan, SND has been broken up into different areas—aged care, mental health, disability and chronic disease—but these areas are still supposed to be priority areas. The last 10-year plan was not fully implemented, and we still lack baseline data for the SND population in Australia, so we have no way of measuring how we are going as a nation.”