Midway through my foundation training year I, like my peers, had to make the decision where to go next. There were a number of options; from becoming an associate in general practice, to working in a dental hospital, oral and maxillofacial department or the community dental services. During my foundation training, I really enjoyed treating children and patients with dental anxiety and I wanted to gain further experience in managing these patients. Therefore, I decided to start applying for jobs within the community dental services (CDS) and a few months later, I was offered a dental officer job within the Somerset CDS.
Role
The CDS provides continuing dental care to people that cannot reasonably access general dental services. These include people with a physical, mental or medical disability and those with learning difficulties.
The CDS will also provide a course of treatment to a child or adult if they have dental anxiety, behavioural issues or high decay rate. These patients are referred to the CDS by a GDP and after a course of treatment has been completed will be discharged. The CDS will also provide emergency dental care for people without a GDP or for those working away from home or on holiday.
Induction
Starting any job can be daunting however, with hindsight, there was no need for me to worry as the Somerset CDS had prepared a twoweek induction programme. During these two weeks I observed a number of dentists doing examinations, domiciliary visits, treatment under inhalation or intravenous sedation and general anaesthesia sessions. This was really helpful as it gave me the opportunity to see the variety of treatment available in CDS as well as picking up tips and ideas on how to manage these patients. Furthermore, I attended training days on the management of vulnerable adults and children, assessment of mental capacity, use of mobility aids and communication techniques. This included ‘Total Communication’ - a form of nonverbal communication. By the end of the fortnight, I felt prepared and excited to start my new journey.
Special needs
During my time within the CDS, I saw patients with a variety of different physical, mental and medical disabilities. The most common conditions encountered were Down syndrome, autism, epilepsy, brain injury, Parkinson’s and dementia. However, there were some patients with conditions that I had never heard of which required me to read over the characteristics and the management beforehand.
To begin with I found the initial examination of patients with special needs a little overwhelming because there were so many factors that needed consideration such as patient access, mental capacity, consent, communication, patient cooperation, medical complications, medication interactions and carer/next of kin involvement. Over time, I
developed a structured examination process to allow me to consider all these factors and to come up with an individual dental care plan for each patient.
Performing dental treatment on patients with special needs normally just required extra time and patience. However, sometimes obstacles did arise, for example, restricted access or poor moisture control. In my experience, the main restriction to performing dental treatment in this group of patients was co-operation. Many patients could not tolerate any form of dental treatment and therefore intravenous sedation or general anaesthesia was indicated.
Domiciliary care was provided to patients that were unable to attend the dental clinic because of a physical, medical or behavioural issue. The majority of these patients were elderly and lived in residential or nursing homes. Poor oral hygiene in this group of patients was extremely common. Therefore, most domiciliary visits had a strong
emphasis on providing oral hygiene instruction to both the patients and their carers. When treating patients in a domiciliary setting I found the use of the atraumatic restorative technique invaluable. This technique involves the use of hand instruments to remove carious dental tissue and restoration with an adhesive material, such as glass ionomer cement.
Dental anxiety
Dental anxiety is extremely common in both children and adults and can be managed with behavioural approaches or adjunct treatment modalities, such as conscious sedation.
I found that combining the behavioural approaches ‘tell, show, do’ and ‘graded exposure’ were extremely useful in the treatment of anxious children. Behavioural approaches also worked well in adults, however I found that the
majority would come to the first assessment expecting a form of sedation and sometimes it was difficult to persuade them to try a behavioural approach instead.
I completed an inhalation sedation (IS) course a few months after joining the service. Inhalation sedation is the use of nitrous oxide and oxygen and can be used to reduce anxiety during dental treatment. I found it worked well in both children and adults, however, it required the patient to have a good breathing technique. I found that doing a trial assessment prior to performing any treatment was useful as it allowed the patient the opportunity to experience IS and gave me the opportunity to teach them the correct breathing technique. Sometimes IS was not sufficient to reduce a patient’s dental anxiety and, in this case, intravenous sedation or general anaesthesia was indicated.
In very young children or children that required multiple extractions, general anaesthesia was the treatment option of choice from the outset. The aim of this was to prevent any future dental anxiety.
Conclusion
Working within the community dental service was an extremely rewarding experience. I learnt a great deal about my practice, the wider patient community and myself as a dental professional. I would recommend anyone interested in special care dentistry, paediatric dentistry or anyone looking to improve their patient management skills to work for a period of time within the CDS. As with all things, you do not know what it is really like until you try it.