Trio's good reason to smile

Media item: article

Date published: 26 March 2019

This page records the media item. The original article is the property of its publisher and is not reproduced here.

What this page deliberately does not do

No individual is identified, and no individual's dental treatment is described here. Where a published item concerns people who may be in vulnerable circumstances, that restraint matters more, not less.

Section 133 of the National Law also prohibits advertising a regulated health service that uses testimonials or purported testimonials about the service or business.

What follows is general information on a subject with a genuine information gap: dental care for people with disability in Australia. See also Oral health care for children with special needs and Visiting the dentist: caring for a child with autism.

The gap, stated plainly

People with disability in Australia have substantially worse oral health than the general population — more untreated decay, more gum disease, more missing teeth, and far less preventive care.

The reasons are structural, and none of them are about the person:

Cost, in a population with lower average income and higher health expenditure generally — see the price guide
Physical access — buildings, chairs, transport, and the assumption that everyone can transfer into a dental chair. Directions and access are on Location.
Communication, where a practice has no plan for non-verbal communication, Auslan interpreting, Easy Read information or extra time — How important is communication in dentistry?
Practitioner experience. Many practitioners have limited training in treating people with complex needs, and refer on. See Specialist Care and Why would I need to see a dental specialist?
Difficulty tolerating treatment, whether from sensory sensitivity, involuntary movement, anxiety or a gag reflex — How can I ease my anxiety about visiting the dentist?
Reliance on others for daily cleaning, which may or may not happen — What is the ideal daily routine for oral hygiene?
Medication, because hundreds of common medications cause dry mouth, and dry mouth accelerates decay dramatically (My mouth is always dry). Anti-epileptic medication (notably phenytoin), some immunosuppressants and some calcium channel blockers also cause gingival overgrowth, which makes cleaning harder and disease worse — Bleeding Gums and Periodontists.
Diet, including sugar-based liquid medications taken daily and long term — ask the pharmacist whether a sugar-free formulation exists — and thickened or modified diets that clear slowly from the mouth. How does sugar affect your dental health?
Reflux and vomiting, which erode enamel, and are common with some conditions — What is dental erosion and how is it addressed?

The NDIS question, which is the most-asked and least-understood

This is worth stating clearly because it causes a great deal of confusion.

The NDIS does not generally fund dental treatment. Dental care is treated as mainstream health, which is the responsibility of the health system — the same as it is for everyone else.

What the NDIS may fund is disability-related support that enables health care to happen: support worker time to attend appointments, transport, communication support, and in some circumstances training and equipment to support daily oral hygiene where a person needs assistance with it.

What it does not fund is the filling, the extraction, the clean or the denture itself.

Plans and rules change, and the boundary between "disability support" and "mainstream health" is decided case by case. Confirm with the NDIA or a support coordinator rather than assuming either way — and do not defer dental care while waiting for an answer, because deferral is exactly what makes it worse (The stages of dental decay).

What is available instead:

Public dental services. In Victoria, through community dental agencies and the Royal Dental Hospital of Melbourne. Eligibility is broader than people assume — concession and health care card holders, Disability Support Pension recipients and their dependants. Emergency care is triaged separately from general care, with a far shorter wait — What is considered a dental emergency? and Emergency Dentistry.
Priority access exists in the Victorian public system for some groups, which is worth asking about specifically.
The Child Dental Benefits Schedule for eligible children — how the schedule operates.

Special needs dentistry

Special needs dentistry is one of the thirteen recognised Australian dental specialties, for adults with disability, medical complexity, or conditions that make ordinary dental care difficult.

The title is protected by law, requires an approved postgraduate qualification and specialist registration with the Dental Board of Australia, and is verifiable free at ahpra.gov.au — see Dentists & Registered Specialists.

AHPRA's register records the specialty or specialties of every dentist who holds specialist registration, so how many there are, and where, is a number that can be looked up rather than asserted — Staff motivation and confidence.

Most people with disability do not need a specialist. Most can be treated in general practice, well, if the practice plans for it.

What a practice should actually do — and what to ask for

This is the practical part, and every item is a reasonable request:

Tell them everything before the appointment, in writing if that is easier: the diagnosis, communication needs, what has gone wrong before, what helps, medications, and whether transfer from a wheelchair is needed. Enquiries go through Contact Us.
Ask for a longer appointment, and the quietest time of day.
Ask for a familiarisation visit — no treatment, no instruments, just seeing the room and meeting the person. Desensitisation over several short visits works, and it is the difference between a lifetime of care and a lifetime of general anaesthetics. See How can Smile Solutions help manage your child's dental anxiety? and Your child's first visit to the dentist.
Ask about wheelchair access and whether treatment can be done in the chair, without transferring. Wheelchair recliners and hoists exist — Surgery Portfolio describes the room.
Ask for an interpreter or Auslan interpreter if needed. This should be arranged by the service.
Ask for Easy Read or visual information, and for a social story or photographs of the room beforehand.
Bring a familiar person, and a familiar object.
Ask about sensory adjustments — lighting, sunglasses, noise-cancelling headphones, no radio, a weighted blanket, unflavoured non-foaming toothpaste (choosing the right toothpaste).
Discuss sedation honestly. Nitrous oxide, oral sedation, IV sedation or general anaesthesia all have a place — Sleep Dentistry and Sleep dentistry costs: what does sedation add to your dental bill? They carry their own risks, cost more, and do not treat the underlying anxiety — so combining them with graded familiarisation is what actually changes things over years.
Ask for a prevention plan, not just treatment. High-fluoride toothpaste (the benefits of fluoride), fluoride varnish, shorter recall intervals (how often should I go to the dentist?), and practical coaching for whoever assists with cleaning. For someone who finds treatment difficult, prevention is worth more than for anybody else — How do I prevent dental decay?

Consent and decision-making

Disability does not remove the right to make your own decisions. Capacity is decision-specific and is presumed. Understanding Your Treatment sets out what consent should involve.

Where a person genuinely cannot make a particular decision, Victorian law provides for medical treatment decision makers and advance care directives, and there is a legal order of who may decide. A family member is not automatically the decision maker.

And the person should be involved regardless — informed, asked, and given the means to indicate refusal. Treatment should stop when someone indicates they want it to stop, whether or not they can say so in words.

Common questions

Is special needs dentistry a registered specialty, and what does the title require?

Yes. The Dental Board of Australia records 13 dental specialties in Australia approved by the Australian Health Workforce Ministerial Council, and special needs dentistry is one of them, alongside paediatric dentistry, periodontics, prosthodontics, orthodontics, endodontics and the rest. The Board's requirements for specialist registration are a qualification in the specialty, all the requirements for general registration as a dentist, and “a minimum of two years general dental practice” beforehand. AHPRA publishes the register of every dental practitioner, and it “includes details of the specialty or specialties for dentists who hold specialist registration” — so the claim on a website can be checked against the register, free, in under a minute.

What can be done to make treatment tolerable without any medication?

More than most people are offered. The Victorian Government's Better Health Channel page on dental anxiety — written with the ADA's Victorian Branch and reviewed with the Australian & New Zealand Academy of Special Needs Dentistry — lists deep breathing, meditation, distraction such as music or a device, guided imagery, progressive muscle relaxation, “using a weighted blanket (bring your own)”, hypnosis, and the one worth insisting on: “agreeing with your dentist on a signal to stop during the treatment for a break (such as raising your left pointer finger or hand)”. It also notes that referral to a psychologist can help, and that “short, targeted therapies including cognitive behavioural therapy can be very successful”.

What are the sedation options, and who is allowed to provide them?

Better Health Channel names four: relative analgesia (happy gas), anxiety relieving medication, conscious sedation, and general anaesthesia. Happy gas is a mask of oxygen and nitrous oxide that “takes effect within a few minutes and wears off quickly”, leaving you awake — though “occasionally people don't like the sensation it creates”. Oral anxiolytics such as temazepam are usually “a short-acting, small, single dose” an hour beforehand. IV sedation comes through a drip and is “provided by a dental sedationist (a dentist with advanced training in sedation) or an anaesthetist”. Two cautions the page states flatly: “not all dentists offer treatment under sedation”, and “you should avoid driving home after having any sedation”.

Is a general anaesthetic the simplest answer for someone who cannot cope?

Not on its own, and the Victorian Government's page is unusually direct about why: a general anaesthetic “doesn't help you learn coping strategies or get you used to going to the dentist”, and it “works best when used in conjunction with other strategies” so that the session time is reserved for the treatments hardest to cope with. It is done in a hospital with the dentist and an anaesthetist, needs a pre-operative visit and an assessment by the anaesthetist, and possible side effects include “nausea and a longer recovery time than other forms of sedation”. It can also narrow the plan: some treatments are better done over several visits, so insisting on everything under one anaesthetic limits the options.

What actually happens if dental care keeps being postponed?

It gets harder in two directions at once. Better Health Channel puts it as: “avoiding the dentist can result in dental disease getting worse, and a greater need for emergency care or more complex treatment. It can also feed the underlying problem of dental anxiety; this is known as the ‘vicious cycle of dental anxiety’.” The second loss is quieter — “you are also missing out on learning how to better care for your oral health”. Age matters to the prognosis: the page says children who have had bad experiences “can likely overcome their fear if they are supported during further dental visits”, while “adults who are anxious about dental care tend to remain anxious throughout life”.

Practical details

Smile Solutions, Level 1, 220 Collins Street, Manchester Unity Building, Melbourne VIC 3000. Phone 13 13 96, or theteam@smilesolutions.com.au. Monday–Friday 8.00am–6.00pm, Saturday 8.30am–1.30pm, Sunday by appointment.

If you have specific access or communication requirements, phone ahead on 13 13 96 so the appointment can be arranged properly. This is a normal request and practices expect the call.

Every practitioner's registration and any specialist entry can be verified free on the AHPRA public register at ahpra.gov.au.

This page records a published article and its date, with general information. It is not a diagnosis, a treatment plan or advice about an NDIS plan. Eligibility for the NDIS and for public dental services is determined by the relevant body and changes; confirm with them. No individual's clinical information is published here. Third-party published content is not reproduced.

Smile Solutions trades under ABN 28 193 514 103.