The impact of COVID-19 on access to dental care for people with disabilities: a global survey during the COVID-19 first wave lockdown.

BACKGROUND: It is unclear what immediate impact the COVID-19 pandemic has had on delivery of oral healthcare to people with disabilities worldwide. AIM: To report the international impact of COVID-19 lockdown on oral healthcare provision for people with disabilities before, during and after the first lockdown (March to July 2020). MATERIAL AND METHODS: Cross-sectional online self-administered survey of dentists who treat people with disabilities completed 10th to 31st of July 2020. Responses allowed comparison from before, during and immediately after the first wave lockdowns of the COVID-19 pandemic. Data were analysed using McNemar's test to compare reported practice before to during lockdown, and before to after lockdown. RESULTS: Four-hundred-thirty-six respondents from across global regions reported a significant reduction from before to during and from before to after lockdown regarding: the proportion of dentists treating people with all types of disability (p <0.001) and the number of patients with disabilities seen per week (p<0.0001). The proportion reporting no availability of any pharmacological supports rose from 22% pre-lockdown to 61% during lockdown (p < 0.001) and a persistent 44% after lockdown (p < 0.001). An increase in teledentistry was observed. CONCLUSIONS: During the first COVID-19 lockdown, there was a significant negative impact on the delivery of dental care to people with disabilities. Oral healthcare access was significantly restricted for people with disabilities with access to sedation and general anaesthesia particularly affected. There is now an increased need to ensure that no-one is left behind in new and existing services as they emerge post-pandemic.

Development of a battery of tests to measure attitudes and intended behaviours of dental students towards people with disability or those in marginalised groups.

INTRODUCTION: Recommended curricula in Special Care Dentistry (SCD) outline learning objectives that include the domain of attitudes and behaviours, but these are notoriously difficult to measure. The aims of this study were (i) to develop a test battery comprising adapted and new scales to evaluate values, attitudes and intentions of dental students towards people with disability and people in marginalised groups and (ii) to determine reliability (interitem consistency) and validity of the scales within the test battery. MATERIALS AND METHODS: A literature search identified pre-existing measures and models for the assessment of attitudes in healthcare students. Adaptation of three pre-existing scales was undertaken, and a new scale was developed based upon the Theory of Planned Behaviour (TPB) using an elicitation survey. These scales underwent a process of content validation. The three adapted scales and the TPB scale were piloted by 130 students at 5 different professional stages, from 4 different countries. RESULTS: The scales were adjusted to ensure good internal reliability, variance, distribution, and face and content validity. In addition, the different scales showed good divergent validity. DISCUSSION: These results are positive, and the scales now need to be validated in the field. CONCLUSIONS: It is hoped that these tools will be useful to educators in SCD to evaluate the impact of teaching and clinical exposure on their students.

The healthcare system and the provision of oral healthcare in EU Member States: France.

The French oral health system is based on the provision of dental treatment and is organised around a fee-per-item model. The system is funded by a complex mix of public and complementary health insurance schemes. The system is successful in that it provides access to affordable dental treatment to the majority of the French population. However, France had the highest health expenditure as a share of gross domestic product (GDP) of all European Union countries in 2008 and rising oral health inequalities may be exacerbated by the manner in which oral health care is provided and funded. In addition, there is no organised national strategy for the prevention of oral diseases or for oral health promotion.

Guidance for the core content of a Curriculum in Special Care Dentistry at the undergraduate level.

Given the rapidly changing demography of populations worldwide, dental professionals of the future need to be able to meet the challenge posed by the evolving landscape in health care needs. Leading institutions are now embedding teaching and learning in special care dentistry (SCD) within their curricula, to provide students with the knowledge, skills and attitudes to meet the oral health needs of vulnerable groups within their communities. The International Association for Disability and Oral Health (iADH) has initiated the development of undergraduate curriculum guidance in SCD through a consensus process. The curriculum in SCD is defined in statements of learning outcomes with many of the skills being transferable across the undergraduate course. This curriculum includes examples of teaching and assessment, designed to enhance critical thinking in relation to SCD and to promote positive attitudes towards disability and diversity. The learning outcomes are designed to be readily adapted to conform to the generic profiles and competencies, already identified in undergraduate frameworks by global educational associations, as well as meeting the requirements of professional regulatory bodies worldwide. Suggestions for teaching and learning are not intended to be prescriptive; rather, they act as a signpost to possible routes to student learning. Ideally, this will require that students have a sufficiently diverse patient case mix during their undergraduate studies, to achieve the required levels of confidence and competence by the time they graduate. Clinical care competencies in SCD emphasise the need for learners to broaden their theoretical knowledge and understanding through practical experience in providing care for people with special health care needs. It is crucial to the development of equitable dental services for all members of a community, that these learning outcomes are embedded into evolving curricula but most importantly, that they are evaluated and refined in a dynamic way with shared learning for all teachers.

Using e-learning to train dentists in the development of standardised oral health promotion interventions for persons with disability.

BACKGROUND: This study aims to evaluate whether an e-learning curriculum was sufficient to impart the necessary knowledge to dentists to allow them to implement an oral health promotion intervention in an institution for persons with disability. MATERIALS AND METHODS: Participants were asked to complete a 10-module online training course and to implement a standardised intervention in an institution. The outcome measures were as follows: online tracking of progress; multiple choice questionnaires completed at the end of most modules; self-efficacy questionnaire completed before and after online training; completion of training and calibration in the use of a standardised risk assessment form; initiation and full completion of an oral health promotion intervention in an institution; satisfaction of participants with the online training experience; and evaluation of the impact of the intervention by the institution staff. RESULTS: The study sample included 26 dentists. The 10 modules were passed by 24 dentists, and the mean value of the highest overall score recorded in the multiple questionnaires was 88.4% (± 4.0). Twenty participants completed the self-efficacy questionnaire before and after training; the mean values of scores after training were statistically different and higher than those at baseline. Questionnaire regarding satisfaction with the online training experience was completed by 22 participants; all of them stated that they were satisfied with the online training experience. CONCLUSIONS: The results indicate that the online training course helped participants to increase self-efficacy and to provide interventions in institutions. This study could have implications for both undergraduate and postgraduate dental education in France.

The value of education in special care dentistry as a means of reducing inequalities in oral health.

People with disability are subject to inequality in oral health both in terms of prevalence of disease and unmet healthcare needs. Over 18% of the global population is living with moderate to severe functional problems related to disability, and a large proportion of these persons will require Special Care Dentistry at some point in their lifetime. It is estimated that 90% of people requiring Special Care Dentistry should be able to access treatment in a local, primary care setting. Provision of such primary care is only possible through the education and training of dentists. The literature suggests that it is vital for the dental team to develop the necessary skills and gain experience treating people with special needs in order to ensure access to the provision of oral health care. Education in Special Care Dentistry worldwide might be improved by the development of a recognised academic and clinical discipline and by providing international curricula guidelines based on the International Classification of Functioning, Disability and Health (ICF, WHO). This article aims to discuss the role and value of promoting and harmonising education in Special Care Dentistry as a means of reducing inequalities in oral health.

Masticatory dysfunction in persons with Down's syndrome. Part 2: management.

The functional and anatomical characteristics of Down's syndrome have direct repercussions on oral health; orofacial dysfunction results and feeding and swallowing are impaired. These problems have been described in an earlier article. Different techniques are proposed for the prevention of the development of orofacial dysfunction in Down's syndrome. In particular, early myofunctional therapy coupled with appliance wear has been shown to be successful over the long term when multidisciplinary management is possible. Functional or conventional orthodontic treatment may be successful for older children when performed concurrently with the use of appropriate behaviour management techniques. More recently, techniques for the compensation of masticatory dysfunction in adults have been proposed, although further research is necessary to confirm their efficacy. The aim of this second article was to review techniques for the prevention, treatment and compensation of orofacial dysfunction in persons with Down's syndrome from birth to adulthood.

Masticatory dysfunction in persons with Down's syndrome. Part 1: aetiology and incidence.

The functional and anatomical characteristics of Down's syndrome have direct repercussions on oral health. Orofacial dysfunction is on account of poor neuromotor control, muscle weakness, dental anomalies, dysmorphology and intercurrent illness. In particular, feeding and swallowing are impaired. The aim of this first article was to summarize the orofacial difficulties encountered by persons with Down's syndrome at all stages of life and to explain their aetiology. Indicators are proposed for the identification of masticatory problems within this population and reduced masticatory efficiency is discussed in relation to repercussions on oral and general health and on the social integration of persons with Down's syndrome. A second article will describe techniques for preventing, treating and compensating for masticatory dysfunction in this population.

Chewing indicators between adults with Down syndrome and controls.

Down syndrome induces a neuromotor deficiency that affects the orofacial musculature, and thus could be implicated in the feeding difficulties affecting people with this disease. This study aimed to investigate the differences in chewing indicators between a group of 11 adults with Down syndrome and a group of 12 healthy subjects without Down syndrome. Chewing ability was evaluated by means of video recordings taken during a standardized meal that included 10 natural foods. The variables collected were masticatory time, number of masticatory cycles, chewing frequency, number of open masticatory cycles, and number of food refusals. There were several differences in both directions for masticatory time and number of masticatory cycles between the two groups. In addition, with the exception of purée, the group with Down syndrome had significantly lower mean chewing frequency than the reference group, and was unable to eat all the foods presented.

Impact of teaching requirements for students on the activity of a university dental hospital.

OBJECTIVES: This study aimed at investigating the influence of teaching requirements on the clinical activity of a dental hospital. METHOD: The annual clinical activity of seven classes of fifth-year students (n = 294) was monitored between 1994 and 2001 within the conservative dentistry and endodontic departments of a French dental hospital. The variables chosen were: (i) the mean number of procedures performed per student, and (ii) the proportion of different types of treatment within the global activity (i.e. endodontic treatment, anterior, and posterior restorations). These data were analysed in relation to changes in student assessment criteria over time. RESULTS: Quantitative clinical teaching requirements were removed for the academic year 1998-99 and student clinical activity subsequently decreased by 32.7%, going from 51.9 +/- 12.2 dental procedures on average per student in 1997-98, to 29.1 +/- 7.2 in 2000-01. The mean number of patients treated per student also declined significantly during this period. The size of the minimum clinical requirement altered over the years prior to being removed altogether and a positive correlation existed between the volume of activity and the minimum requirement over this time. The types of treatment provided changed independently from the assessment criteria over the study period. There was a decrease in the percentage of amalgams placed and an increase in the number of posterior composites. A negative correlation existed between the evolution of these two types of treatment. CONCLUSION: This study demonstrates that the clinical activity of a department in a dental teaching hospital is directly related to the assessment criteria fixed by the university. This may have repercussions for hospital services.

Consequences of oral rehabilitation on dyskinesia in adults with Down's syndrome: a clinical report.

The aim of this article is to demonstrate that the presence of orofacial dyskinesia is often owing to underlying facial dysmorphology in persons with Down's syndrome. A series of cases is presented where orofacial dyskinesia was successfully treated by therapy establishing occlusal stability. The diagnosis of dyskinesia owing to dysmorphology should be precluded before any link with the degree of intellectual disability or neurological deficit is presumed. A multidisciplinary approach may be necessary to diagnose and treat these patients.

Accuracy of estimation of dental treatment need in special care patients.

OBJECTIVES: To assess the ability of carers and dental professionals to estimate treatment need in a group of children and adults with special needs. METHOD: A retrospective study of a series of 103 special needs patients who had received restorative dental treatment under general anaesthetic was undertaken. The initial reason for attendance and the time lapse between first symptoms and decision to consult were established. The parent or carer was asked to estimate treatment need and to assess the degree of discomfort suffered by the patient. The dentist evaluated treatment need by means of a pre-operative treatment plan. These results were compared to actual treatment performed. RESULTS: Treatment need was severely underestimated by both carer and dentist. The degree of advanced pathology found in the population would suggest that pain suffered was also underestimated. CONCLUSIONS: Access of patients with special needs to dental care may be limited by the ability of their carers to evaluate their oral condition and/or by the persons inability to express their pain or discomfort.

Dental care access among individuals with Down syndrome in France.

The aim of this study was to compare levels of dental care utilization, receipt of dental services, and oral hygiene habits between a sample of individuals with Down syndrome (DS) and their siblings. Data were collected by means of a recently validated, French-language, questionnaire measured of oral health and its related problems for individuals with DS. A cross-sectional survey was undertaken of parents of children with DS attending a national meeting for families and carers of individuals with DS in France. Older individuals with DS were significantly more likely to visit a dentist regularly than their older non-DS siblings, but the group with DS was significantly less likely to have received any dental treatment. The group with DS was significantly more likely to have difficulty finding both medical and dental services. Parents were nearly twice as likely to report problems finding dental services for their child with DS as they were medical services. In a multiple logistic regression analysis within the DS group, it was found that older age, regular speech therapy and ophthalmology consultations, and reports of no difficulty finding a dentist were independently associated with increased odds for regular dental consultations. Analysis of the findings suggests that the parents of children with DS in France frequently encounter problems of access to oral health care and that individuals with DS are less likely to receive dental services than are their non-DS siblings.

Evaluation of a long-term oral health program by carers of children and adults with intellectual disabilities.

The oral health program presented here was undertaken in three French centers for persons with special needs. The program aimed to educate the carers about dental disease, to motivate them with regard to prevention, and to improve the oral hygiene and oral health of the residents. This study evaluated the impact of the program in terms of change in attitudes and behavior expressed by the carers by means of a questionnaire. Following demonstration of oral hygiene techniques on an individual basis, the number of residents who had their teeth cleaned more than once a day rose from 24% to 52% (p < 0.05). The percentage of carers able to clean both posterior and anterior teeth of their key residents increased from 24% to 60% (p < 0.05), and the percentage finding tooth cleaning easy increased from 36% to 60% (non-significant). The intervention was thus deemed moderately successful, although the carers continued to take better care of their own oral health than that of the residents. The need for ongoing training is emphasized, both for the carers of those with special needs and for the dental profession. The lack of a validated means of measuring the impact of such interventions on care providers for this population is discussed.

Development of a synthetic bolus using silicone elastomer for the study of masticatory efficiency.

STATEMENT OF PROBLEM: Masticatory efficiency has been proposed as an outcome measure for prosthetic rehabilitation. However, no standardized method is available for this type of assessment. PURPOSE: This study developed a normalized synthetic test food with reproducible physical and rheologic properties. MATERIAL AND METHODS: Two silicone putties of different hardness were studied. The texture of each putty varied by the addition of silicone oil. Rheologic characteristics of 7 samples were compared with the same properties of 5 natural food substances. RESULTS: Seven varieties of synthetic bolus were produced, each of which were of a different hardness, modulus of elasticity, and tensile strength. The natural food substances demonstrated great rheologic variability. The synthetic bolus samples exhibited a texture profile approaching that of natural foods. The principal difference between the 2 groups tested was that of the homogeneity of the silicone samples. CONCLUSION: None of the samples reproduced all the rheologic properties of the natural food substances; however, the results showed that their characteristics were sufficiently similar for the silicone samples to be suggested as a reproducible alternative for the testing of masticatory efficiency.