In the present analysis, data on dental care and treatment of people with disabilities over a period of 10 years were evaluated. The data provide an overview of dental care needs and the additional evaluations made (change in DMF/T, change in indications for a treatment under GA in the following GA pre-assessments, occurrence of emergencies etc.) as well as preferences in dental therapy options in patients who require dental treatment under GA due to a disability.
Limitations
Data analysis was based on retrospectively extracted data from patient files. The authors have to assume that in line with legal requirements diagnostic and therapeutic procedures have been accurately entered into the patient files. Data are specific for conditions in Switzerland and cannot necessarily be generalised to other countries as choice of treatment is partly determined by Swiss regulations governing public funding [
36]. For example extractions are favoured over endodontics for financial reasons. The rehabilitation of chewing function has to be achieved primarily with simple, economic and expedient measures [
36] favouring removable rather than fixed prosthodontics. Fixed prosthodontics will only be funded in justified cases where there often is no alternative. The regulations are primarily geared at Swiss citizens on a low income and available benefits follow economic aspects. Medical supply of the general Swiss public on a low income is thus secured. However, the regulations make no allowance for the specific needs and requirements of people with disabilities. Not all medically possible therapeutic options are supported and funded. This aspect particularly affects people with disabilities as there is little leeway to adapt treatments plans to their individual situation and specific needs. Only for patients receiving financial support, for example from their families, is it possible for the dental team to implement treatment options that fully embrace the principles of inclusion, equality and ultimately justice.
The ethical principles of non-maleficience and beneficence can be even more difficult to implement [
28]. Limitations due to the patient’s condition including behavioural aspects can severely limit provision of regular standard oral hygiene measures even by carers. Such limitations, which may also apply to the provision of professional prophylaxis, effectively limit the implementation of the principle of beneficience and ultimately foster oral disease. The principle of justice ought to be guiding all decisions taken on the meso-level of health insurances and third-party financing institutions and on the makro level of law- and health policy makers on the financing of preventive oral health measures and care for people with disabilities. Currently all too often health care providers even in wealthy jurisdictions are severely restricted in their treatment choices by regulations and policies that seem to be designed to primarily limit costs rather than to facilitate and support health.
Access to dental care for people with disabilities who are dependent on carers who could be nurses, social worker, nursing assistants, supervisors for the people with disabilities, family members etc. generally depends on the importance the carers attach to oral health of the dependent person. Barriers for caregivers, who were mostly professional nursing staff, described in the literature are a lack of time associated with workload, and poor knowledge of dental diseases and their causes [
39]. We can only speculate, that the lack of oral-health knowledge in social workers, family members and other carers without formal training in nursing, may be significantly larger.
The present analysis is retrospective reflecting treatment concepts under GA current in Switzerland at the time of treatment. Dental treatment under GA often appears to be different from usual dental treatment. The literature indicates a tendency towards more extractions instead of tooth preservation (e.g. endodontics) to avoid possible failures and complications [
40]. However, sometimes a large number of restorative procedures are performed under GA [
9,
41]. Conservative treatment and extractions carried out under GA in Zurich were almost evenly distributed. Endodontic treatment was rare because it is particularly time consuming and may carry an increased risk of long-term complications [
18]. The literature questions the use of composite filling materials for patients with impaired oral hygiene and/or limited professional aftercare depending on material and location in the oral cavity due to increased failure rates (e.g. failure rates for composite restorations Tate et al. 30%; Molina et al. 15.5%) [
22,
42]. The present analysis has a slightly lower failure rate of conservative treatment of 9.5% over the observation period. It could be speculated, that the mean oral hygiene of the participants in the current study was better than in other studies dealing with composite fillings in patients with impaired oral hygiene due to an established recall for preventive measures applied by oral hygienists wherever possible. The present analysis has shown a similar failure rate of conservative restorations in people with disabilities treated under GA as reported by Alvanforoush et al. for a 10-year period for posterior restorations in patients treated without GA (Alvanforoush et al. failure rate: 13.3%) [
43].
People with disabilities are frequently not able to perform sufficient oral hygiene on their own and are therefore dependent on the support of their carers. Even the abilities of dental professionals can be limited by patients’ inability to tolerate procedures, lack of compliance, non-cooperation and defensive or aggressive behaviour. It is thus not surprising to find that the quality of individual routine daily oral hygiene provided at home varies greatly in people with disabilities who require GA treatment. The authors wish to highlight the importance of any improvements achievable in daily routine oral hygiene measures by relatives and caregivers for the long-term preservation of treatment success and the reduction of disease burden and future treatment needs. Caregivers accompanying people with disabilities to the clinic are routinely given instruction and motivation regarding oral hygiene and denture care during recall sessions by dentists and dental hygienists. However, there are limitations on time during these sessions not least because of the limited tolerance of patients for extended sessions. As highlighted above, many caregivers, attendants and accompanying social workers have no medical background and would thus require specially tailored and more extensive training than nursing staff. This training is currently lacking. Efforts by the dental profession, third-party funders, and health policy makers to develop and implement programs to improve oral hygiene skills of all caregivers could reduce the treatment need and associated risks for the patients as well as the financial burden for funders and secure the long-term success of complex GA treatment.
Currently there is a trend towards a more conservative approach during treatment of people with disabilities under GA to avoid high numbers of dental extractions [
29]. Equity and justice demand that treatment plans for patients with disabilities treated under GA are developed observing the same principles applied in developing treatment plans for other patients with the same aims of tooth preservations, avoidance of dental extractions and similar therapeutic outcomes [
29]. The success described in the literature of pulpotomies in permanent teeth, both, with reversible and irreversible pulpitis, invites consideration of this option for treatment under GA as well [
44]. The literature favours complete pulpotomies under GA for the vital preservation of deeply destroyed carious teeth as a timesaving method avoiding the risks and effort associated with endodontic treatment [
29]. Even root canal treatment under GA [
40,
41,
45‐
48], in spite of the time needed and the potential risks and complications, is increasingly reported in the literature.
New options in prosthetic therapy have opened up. Pre-formed stainless steel crowns have been proposed as permanent restorations placed under GA on permanent teeth [
49].
The use of CAD/CAM (Computer-Aided Design and Manufacturing) manufactured ceramic restorations is being discussed [
50]. Further research and long-term studies are required to establish the success rates of these techniques before they could be recommended as routine treatment under GA. For some patients with severe cognitive impairment who are unable to maintain oral hygiene themselves the literature presents a treatment option with a positive outlook using dental implants placed under GA [
51,
52]. It is stressed that the long-term success largely depends on patient selection taking into account possible complications and their management [
52]. The authors are very cautious in their indication for implants highlighting the importance of a regular follow-up including professional oral hygiene care.
Special needs patients often have a reduced ability to perform oral hygiene themselves and access to dental services is reduced. This in turn can result in an increased risk of caries and periodontal disease [
5‐
7]. This hypothesis is clearly reflected in the numbers of carious or unsustainable teeth in this analysis.
A comparison of the present analysis with other sources [
53‐
58] is difficult due to the heterogeneity of the investigated populations (Table
3). The DMF/T value of the examined patients is difficult to compare due to a broad age range. Based on the mean age (36.7 years) of all test persons in this analysis to classify the DMF/T value, the following statements can be made: People with disabilities have a significantly lower DMF/T value in the present analysis compared to other studies [
53‐
58] (people with disabilities in the present analysis DMF/T 7.9 (prior 1st GA) - 9.4 (prior 2nd GA)) (Fig.
5). This can be explained by the fact that although the number of DT (DT before treatment in GA: 3 (prior 1st GA) or 1.7 (prior 2nd GA)) (Fig.
5) was higher than in other studies [
53‐
55], the FT here was significantly lower due to the lower number of dental contacts (treatment only possible in GA) (FT before treatment in GA: 3.1 (prior 1st GA) or 4.6 (prior 2nd GA) (Fig.
5); FT in DMS V: 8.6) (Table
3). The cohort analysed here therefore appears to be healthier in terms of dental status (lower DMF/T values) than comparable groups of people with disabilities of the same age (DMF/T values shown in Table
3) [
53‐
58].
Table 3
Comparative consideration of studies with similar populations/age limits with regard to the DMF/T value
DT | 1.6–3.5 | 0.5 | 0.5 | 0.9 | 1.01 | 1.11 | 0.86 | 0.82 | 1.69 | 2.15 | 1.82 | 2.24 | 2.45 | 4.3 | 3.3 | 3.0 | 3.3 | 2.9 | 3.6 |
MT | 2.1–4.1 | 2.1 | 11.4 | 14.5 | 0.51 | 1.81 | 4.15 | 11.75 | 1.44 | 3.00 | 6.11 | 11.51 | 13.32 | 6.9 | 11.1 | 4.8 | 6.8 | 10.6 | 18.5 |
FT | 2.5–5.6 | 8.6 | 6.1 | 4.5 | 2.88 | 5.96 | 8.44 | 6.79 | 3.64 | 4.92 | 5.73 | 4.03 | 2.68 | 5.0 | 4.2 | 3.9 | 4.3 | 4.0 | 4.2 |
DMF/T | 8.1–9.3 | 11.2 | 17.7 | 19.9 | 4.39 | 8.88 | 13.45 | 19.36 | 6.78 | 10.09 | 13.66 | 17.77 | 18.45 | 16.2 | 18.6 | 11.7 | 14.4 | 17.5 | 21.4 |
A further study on the assessment of the oral health status of athletes with intellectual disabilities (mean: 27 years) at the Special Olympics (2008–2016) resulted in lower DMF/T values (DMF/T 7.6 (2008), 7.3 (2010), 7.1 (2012), 6.7 (2014) and 5.6 (2016)) compared to the present analysis with a DMF/T of 7.9–9.4 [
59]. A possible explanation could be that the majority of the athletes examined (95%) stated that they could carry out their oral hygiene independently [
59]. It can therefore be assumed that these athletes have a higher degree of independence and have to live with fewer restrictions due to the structured sporting activities. This will also be associated with greater use of dental services. Despite the disabilities, this group of patients often can be treated in the dental chair.
The study by Cichon and Donay (2004) [
57] with a comparable cohort (study participants were recruited from the patient clientele of a specialised clinic, including only people with physical or intellectual disabilities), recorded higher DMF/T (cf. Table
3) values than the data presented herein. The reason for this could be that some of the subjects in the present analysis were long-term patients of the clinic already at the anaesthetic clarification date. These patients may have benefitted for an extended period from participation in a in a closely monitored preventive and curative care concept, individualised according to their previous illnesses.
For people with disabilities who are not participating in a professionally organised preventive and curative oral health programme it is imperative that caregivers/legal guardian and relatives are trained to recognise dental problems among those entrusted to them and then to organise an adequate response. A reliable cooperation between caregivers, dentists and anaesthetists would be beneficial with continuously open channels of communication and fast response to any requests for support. It must also be clarified together whether a periodic chairside examination is sufficient to maintain oral health and prevent dental emergencies. Regular dental recalls after GA are essential to re-inforce instructions on oral hygiene [
60] and to detect changes. Berkowitz et al. reported that the failure to attend follow-up appointments and the disability itself are potential causes for repeat GA treatment [
25]. People with disabilities not participating in regular dental recalls were four times more likely to receive repeat GA treatment than those who attended follow-up appointments regularly. It can therefore be assumed that a regular recall reduces the degree of severity and the number of repeat GA dental procedures [
61]. Individual follow-up appointments as well as additional appointments, e.g. for dental cleaning, etc., should be discussed with the caregivers [
60]. Furthermore, intensive training on oral hygiene and nutrition [
60] at home should be provided and supported by the use of high fluoride toothpastes and sugar-free foods, for example. Dentists and oral hygienists play an important role in oral health education for all of their patients. They should be encouraged to offer specific advice on oral hygiene, nutrition and the importance of regular prophylaxis to people with disabilities and their carers to support inclusion of persons with disabilities. Long recall intervals of 12 months can only be achieved with very good communication and information transfer between the persons responsible for the (dental) medical, nursing and socio-educational care of vulnerable patients. In the literature shorter follow-up intervals of 4–6 months [
25] or even only 2 months are suggested [
62]. Such short intervals could not be implemented in the specialised clinic due to limited clinic staff and the high demand on carers of the disabled. The recall system of the clinic is well organised. A recall interval of 12 months (dentist) was augmented by 2–4 oral hygiene sessions per year for all patients for whom at least a chairside professional dental prophylaxis was possible. From the 221 patients attending the GA pre-assessment 154 patients either received treatment under GA soon after the GA pre-assessment or entered the recall system of the clinic. Patients who received treatment under GA soon after the pre-assessment entered the recall system afterwards. None of the patients (
n = 154) was lost to follow-up or missed a recall until the next treatment under GA took place. Six patients could not receive any further chairside appointment due to greatly reduced compliance. They received treatment under GA at regular intervals.
Waiting times of more than half a year (mean 32 ± 45.5 weeks) between GA pre-assessment and treatment under GA were high compared to waiting times for out-patient chairside appointments. They were partly due to limited staff and operating rooms, but also due to time taken for administrative procedures for application and approval of funding from government agencies and health insurances in parallel. Patients` appointments could only be arranged after approval of financial arrangements from third-party funders had been received. There is no data indicating a possible deterioration in oral health due to extended waiting periods.
In the absence of any symptoms and complaints, it is difficult to justify the use of GA solely for the purpose of a routine dental examination. Even if the application of GA in such cases is accepted, it is not clear how long the interval between GA treatment should be in patients who are otherwise uncooperative [
63]. There is also no literature on the safety of repeated GA applications for people with disabilities [
19]. People with congenital disabilities also reach old age and increasingly suffer from geriatric diseases. The occurrence of combinations of congenital disabilities and geriatric diseases (e.g. trisomy 21 and dementia [
63]) will be observed more frequently in the future. The additional geriatric diseases usually increase the risk of GA. The repeated application of GA must therefore be re-evaluated under this aspect. Potential post-operative cognitive dysfunction (POCD) which is assumed to influence quality of life and may increase mortality, is multi-factorial and just one aspect that needs further consideration in this context [
64,
65].
In the present analysis, no patient presented with a typical dental emergency such as a dental abscess neither during the pre-assessments nor during the control appointments. With close cooperation between the dentist and carers, early signs of possible dental problems (pain, refusal to eat, restlessness, etc.) in patients can be addressed and, if necessary, treatment under GA can be planned. However, such an approach is only feasible if treatment under GA can be organised promptly if necessary.
In the opinion of the authors, it is therefore important that prophylactic treatment under GA is not performed as a standard procedure, which only serves the purpose of a routine dental examination. A risk-benefit assessment should always be performed and peri-operative complications, which occur more often with increasing age, should be taken into account.