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SPECIAL NEEDS DENTISTRY
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SPECIAL NEEDS DENTISTRY
• What is special needs dentistry- The improvement of oral health of individuals and
groups in society who have a physical, sensory, intellectual,
mental, medical, emotional or social impairment or disability or,
more often, a combination of a number of these factors. (JointAdvisory Committee for Special Care Dentistry)
-Special Needs Dentistry (SND) is defined as an area in
dentistry which concerns in the oral health management of
patients adversely affected orally by intellectual or physical
disability and medical or psychiatric issues or, more often, a
combination of a number of these factors, where such conditions
necessitate a modified delivery of oral health care for patients’
total health well-being. ( The Malaysian Dental Journal)
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SPECIAL NEEDS DENTISTRY
• It is defined by a diverse group of people with:
– a range of disabilities
– complex additional needs
– long stay residential care – people in secure units
– people who are homeless.
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SPECIAL NEEDS DENTISTRY
• It is important to remember that not everyone with disability
requires SCD, as not all disability limits oral health.
• Also, those people who are ABLE to express need and ABLE to
easily access mainstream dental services, despite disability,
are not in need of SCD.
• Whereas, those people unable to express need or unable to
access care because of disability (for example, due to reduced
communication, fear, inability to co-operate) require SCD.
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Group of People Needing Special Care
• The Joint Advisory Committee for Special CareDentistry has identified the population who requirethe services of special care dentistry as:
-'Individuals and groups in society who have a physical, sensory, intellectual, mental, medical,emotional or social impairment or disability or moreoften a combination of a number of these factors.‘
• However, there is no ready made database toprovide figures for the proportion of the populationthat fall within this definition.
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Group of People Needing Special Care
Faulks and Hennequin described three groups of people
who require SCD :(Defining the population requiring special care dentistry using the international
classification of functioning, disability and health – a personal view. J Disabil Oral
Health 2006; 3: 143 –152.)
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1. People who experience disability due to impairment of oral
function and/or structure and who are limited in their activity
and/or participation directly by their oral status
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2. People who have a condition that has direct or indirect
repercussions on their oral health
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3. People who are disabled by their social, environmental or cultural
context, which reflects on their oral health.
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Scope for This Speciality
• This involves:
1. Diagnosis of orofacial conditions and the provision of
appropriate information to patients of diagnosis, treatment
or management options and their consequences.
2. Removing tooth tissue and/or placing materials for the
purpose of either the temporary or permanent restoration
or replacement of tooth structure or the rehabilitation of the
dentition.
3. Performing procedures on the orofacial complex, teeth,
and the hard and soft tissues surrounding or supporting the
teeth.
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Scope for This Speciality
4. Extracting teeth.
5. Administration of local analgesia and, or sedative drugs
in connection with procedures on the teeth, jaws and the
soft tissues surrounding or supporting the teeth.
6. Prescribing medicines appropriate to the scope of
practice, the sale or supply of which is restricted by lawto prescription by designated health practitioners.
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Scope for This Speciality
7. Prescribing special tests in the course of dental
treatment.
8. Using ionizing radiation, for diagnostic purposes, in the
course of the practice of dentistry.
10. Performing procedures on any person preparatory to, or
for the purpose of, the construction, fitting, adjustment,repair, or renewal of artificial dentures or restorative or
corrective dental appliances.
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Barriers to Accessing Care
1. Current workforce:
– Most dentists working in the field of SCD are based in the
salaried Community Dental Service.
– General dental practitioners contribute to the overall
picture of SCD, but only a small number of practitioners
have a special interest in this field.
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Barriers to Accessing Care
2. Current training:
– On the whole, individuals who have undertaken trainingin SCD have been responsible for their own training,formal and informal.
– It should not be left to the individual dentist to fund theirtraining in SCD.
3. Current delivery of SCD:
–As SCD is not yet an established specialty, the hospital-based services which do exist (often provided by theCommunity Dental Service) depend upon the goodwill ofspecialist and consultant colleagues.
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Barriers to Accessing Care
4. Access to the building:
- Despite legislation and the clear expectations of the
Equality and Human Rights Commission (EHRQ), physical
access to dental surgeries continues to be a barrier todental patients.
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Barriers to Accessing Care
– Dental clinics which set up which is not ‘elderly
friendly’.
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Barriers to Accessing Care
5. Access to the dental surgery:
-Examine the entrance including door width, door
opening, position and design of door handles. Include the
reception and waiting room, looking at the height of the
reception desk, clear signage, non-slip flooring,
communication aids, appropriate seating including chairs
with arm rests, and space for wheelchairs.
- Transportation.
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Barriers to Accessing Care
5. Access to the dental chair:
-It is important to consider whether people with physical
disabilities can easily access the preferred dental chair or
whether the same model is available with a 'break-leg'facility to ease transfer.
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- When transfer is not straightforward, because the
patient cannot stand or weight bear, 'transfer' or 'banana
boards' can be used. This method requires that thedental chair has a break-leg design and is lifted or
lowered to the same level as the wheelchair. After the
side arm is raised or removed, the smooth curved board
(hence the name 'banana board') is placed between theseats to allow the person to slide from the wheelchair to
the dental chair or vice versa.
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-A portable turntable can also be a useful device. It has
the advantage of being able to be used with most wheelchair
and dental chair designs, and can be used in place of a hoist for
some patients with good upper body strength.
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-A hoist is the best option for safe and efficient transfer
of patients unable to do so independently, to the dental
chair.
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-Recent innovations for patients who should not be
moved from their wheelchairs have included fixed and
portable wheelchair reclining platforms with integrated
head rests.
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– The Mun-H-Center in Gothenburg, Sweden, is a National
Resource Centre for oro-facial aids and has developed a set
of four cushions to provide 'non-steady anatomicalsupport' in the dental chair . They can be used individually
or in combination, depending on the needs of the patient.
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Philosophy of care• A philosophy of care is a framework of care goals and values
to help you make the best choices for your child and family.
• Special Care Dentistry has a broad based philosophy which
takes a holistic view of oral health and requires specialists to
liaise and work with all those members of an individual's careteam. This is particularly important in the case of people at
the more severe end of the spectrum of disability, where a
greater range of issues needs to be considered.
HUH???
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• Reason :so that you are prepared to make
thoughtful decisions when crisis moments
arise; it may be difficult to make decisions in
the moment without a philosophy to guide
you.
WHY???
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• -Get your child stable and comfortable as you cannotfind a framework of care if you are focusing onimmediate issues.
-Clear your mind.
-Talk about it!Benefit from the experience of othersby talking with your partner,pediatrician, hospicecounselor, other families, clergy, family and closefriend.
HOW???
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• The ethos of Special Care Dentistry (SCD) has always echoed this
philosophy. It is concerned with the improvement of oral health of
individuals and groups in society who have a physical, sensory, intellectual,
mental, medical, emotional or social impairment or disability (or, more
often, a combination of a number of these factors) through this broad-
based, cross-agency, partnership approach. The development of a
Specialty in SCD would provide a better balance between need and
provision, and between prevention and treatment, which is exactly what
the Government is working towards in tackling health inequalities.
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Reducing Inequalities
• 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. (D. Faulks et al; European Journal of
Dental Education ISSN 1396-5883 ; 5 January 2012)
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Reducing Inequalities
1. Lack of Education:
• Lack of education has been cited as one of the barriers for thepoor awareness of the importance of oral health for people
with disabilities and, subsequently, one of the factors that
impacts in the provision of oral health care for a significant
number of individuals within society.• Education as a possible solution to improve access to oral
health care for the people who needs special health care.
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Reducing Inequalities
• Undergraduate education:
– Include Special Care Dentistry in undergraduate teaching.
– Centered on demonstrating positive attitudes towards
diversity and included disability awareness, public healthaspects of Special Care Dentistry and relevant ethics and
legislation.
– In 2006, the American Dental Education Association
(ADEA) adopted a resolution to ensure that education
programs include both didactic instruction and clinical
experiences involving treatment of people with special
needs’.
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Reducing Inequalities
• Postgraduate and specialist education:
- Currently, Special Care Dentistry is recognized as a
registered specialty in four countries: Brazil, Australia,New Zealand and the UK.
• Training of professionals complementary to dentistry:
-Special Care Dentistry is embedded in prequalification
courses for dental nurses, hygienists and therapists in theIreland, the UK and Argentina.
-The Academy of Dentistry for People with Disabilities inthe USA allows hygienists to take the fellowshipexamination and, if successful, to become fellows of the
Academy.
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Reducing Inequalities
2. Awareness among the public:
– Many people with disability is not registered as a Person
with Disabilities (PWD) with the Social Welfare
Department. Consequently, he does not receive anybenefit or assistance from the JKM (Social Welfare
Department) for disabled people.
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• June 02, 2011 14:15 PM
• Most Handicapped People Not Yet Registered With JKM
• By Zulkiple Ibrahim
•
KUALA LUMPUR, June 2 (Bernama) — Fifty-year-old AbdulRahim (not his full name) had both his legs amputatedbecause of diabetes about a decade ago. Last year, thewheelchair-bound government retiree had his left handamputated due to gangrene.
• However, Abdul Rahim is not registered as a Person withDisabilities (PWD) with the Social Welfare Department.Consequently, he does not receive any benefit or assistancefrom the JKM (Jabatan Kebajikan Masyarakat) for disabledpeople.
• Why did he fail to register with the JKM?
• “Nobody told me to do so. And I really don’t know about anyform of assistance that is available from the government,” hesaid.
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Impact of
Health and Social Policy
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Services &protection
The Department ofSocial Welfare
Ministry of Women, Family,and Community Development
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State Home for Disabled
• Now known as the Taman Sinar Harapan
(Centre of Bright Future or TSH)
• Various types of disabilities such as cerebral
palsy, Down's Syndrome, hydrocephalus,
mental retardation, speech defects and
deafness
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Sheltered Workshop (Bengkel Daya)
• Give people with disabilities opportunities
leading to dignity, self worth and socialization
amongst their peers
• Objective: To create employment
opportunities for the disabled and at least to
help the group to be economically
independent.
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Bangi Industrial Training and
Rehabilitation Centre
• Provide services for physically disabled peoplewith vocational training and medicalrehabilitation:
IT – ComputerFashion Design & Tailoring
Electronics Prosthetic and Orthotics Multimedia
Wheelchair ManufacturingElectronic Computer Painting
Rehabilitation Ward Physiotherapy
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Community-based Rehabilitation Center
• 313 CBR centers established throughout the
country
• Educational programs provided: reading,
writing, social skills, language development,
career guidance, vocational training, religious
and recreational activities
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Pusat Pemulihan Dalam Komuniti
Bukit Baru
P P lih D l K i i
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Pusat Pemulihan Dalam KomunitiBukit Baru
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• Rumah Orang Tua Melarat (Old Folks Home)
• Rumah Bina Diri(Self awareness Home)
counseling, education, vocation, religious
educational and recreational activities.
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What is disability?
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What is disability?
• A disability is a condition or function judged to
be significantly impaired relative to the usual
standard of an individual or group. The term is
used to refer to individual functioning,including physical impairment, sensory
impairment, cognitive impairment, intellectual
impairment, mental illness, and various typesof chronic disease.
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Mobility and physical impairment
Cerebral palsy
• Abnormal oral habits: tongue thrusting,
mouth breathing, drooling
• Difficulty in sucking and eating
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Vision disability
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Hearing disability
Mouthbreathing
Sign Languages
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g g g
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Learning disability
•
Attention deficit/Hyperactivity disorder(Atomoxetine)
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Psychological disorders
• Schizophrenia
(high DMFT)
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Brain injuries/disability
• Autism
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Austism spectrum disorder
Autistic disorderAsperger’s
syndrome
Pervasivedevelopmental
disorderRett syndrome
Childhooddisintegrative
disorder
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Interlectual disability
• Down syndrome
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Down Syndrome in Malaysia
•In an earlier report published in 1989,incidence of Down syndrome in Malaysia is 1
in 950
•
Incidence classified into 3 major ethnics inMalaysia
Malay - 1 in 981
Chinese - 1 in 940
Indians 1 - in 860
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Wh i diff b h h f
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What is different about the teeth of
people with DS?
Delayed eruption
Microdontia
Macroglossia
Malocclusion
Gingivitis
Dental caries
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Metabolic Diseases
Genetic conditions that result in metabolism
problems
defective gene that results in an enzymedeficiency
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• Disabilities can affect people in different ways
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Overview of demography of disability
Number of registered People With
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Number of registered People With
Disabilities in Malaysia
Disabilities 2012Visual 27636
Hearing 39303
Speech 180
Physical 106252Learning 117699
Mental 2130
Multiple disabled people 12713
Total 305,640
However, these data are incomplete as registration of persons with
disabilities in Malaysia is not compulsory
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Who are eligible?
• Not all patients who fall under the category of
special needs require management by the
specialist in SND.
• Referral to specialist in SND should be limitedto those patients with complex problems
which may, for example, require treatment in
the hospital setting or those with issues ofmultiple problems
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• Can be referred to Hospital Kuala Lumpur and
Hospital Serdang for further management co-
morbidities and polypharmacy.
• Strategies such as effective communication,relaxation method, desensitization, and
general anaesthesia are often used in
managing people with special needs receivingoral health care in the surgery.
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Current workforce
• Most dentists working in the field of SCD are based in the salaried CommunityDental Service.
• There is a smaller constituent of SCD based in general and teaching hospitals who
are either salaried NHS or university staff.
• General dental practitioners contribute to the overall picture of SCD, but only a
small number of practitioners have a specialist interest in this field.
QP
Service for Children With Special Needs in
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Service for Children With Special Needs in
Malaysia
• The Oral Health Division has recognized children with special needs as oneof the priority groups. A programme for CHILDREN WITH SPECIAL NEEDS
was launched in 1993 with emphasis given to the disadvantaged group at
outpatient clinics besides some form of treatment given to children at the
institutions.
• Objective: To improve oral health of children with special needs that willcontribute to enhanced quality of life.
• Activities: Inculcating good oral health practices, increasing awareness of
carers of children with special needs and improving skills of dental
personnel.
• This is to ensure that good oral health is achieved through oral healthpromotion, clinical preventive measures and other necessary treatments
in line with Vision 2020 and the Vision for Health towards the
development of a caring society.
QP
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Voluntary Organisations
•Collectively and individually, they are a primary source of knowledge and expertise on all aspects oflearning disability.
• Based on British society of disability and oral health guideline of 2012, the range of organisationsinvolved includes:
-Self-advocacy groups, in which people with learning disabilities come together to find strength inunity, explore common problems and share solutions.
-Citizen advocacy groups working in partnership with people with learning disabilities to inform themof their rights, help them assert those rights.
-Parent and carer groups in which members learn from each other’s experiences, and work togetherfor greater success and a diminished sense of isolation.
-Policy-shifting organisations, which advise, campaign, inform and co-operate with others to changenational and local policies and practices.
-Service providing organisations, which provide services, usually under contract from the statutoryagencies, and sometimes with added value from voluntary input.
QP
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• In Malaysia , there are 49 Kiwanis clubs across the country, with more than 1300
members. The first club, the Kiwanis Club of Kuala Lumpur was chartered in 1976by the then returning Ambassador to the US, "Bapak Kiwanis" Tan Sri Khir Johari.
QP
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QP
The National Autism Society of Malaysia (NASOM) is a non-profit, non-governmental welfare organisation which was formed in
1986 by a group of parents and professionals. It was registered on 3rd March 1987, as a national voluntary charitable organisation
and aims at providing education, help, care and protection for people with autism and their family members. Currently, NASOM
has established 14 Early Intervention Programmes and 3 Vocational Programmes for people inflicted with autism in Malaysia.
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PSDNJ started as a small support group of parents who sent their children to Kiwanis’s
Early Intervention Centre. With guidance and support from the Kiwanis members and
teachers, we started to form our society, Down Syndrome Society of Johor. We are
the first association created specifically to support the cause of individuals with Down
syndrome established at the state level. Following from the success of this
organization, there are now currently 8 such State-level associations in Malaysia.
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Speech TherapySpeech –language pathologists assess and treat individuals from children to
adults with communication difficulties. These include understanding, expressing,
pronunciation difficulties, voice difficulties, fluency and nasalized speech.
They may also work with people who have feeding and swallowing difficulties.
Speech –language pathologists work collaboratively with patients, families
and related professionals to ensure patient’s needs are been addressed holistically.
Current delivery of SCD
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Current delivery of SCD• As SCD is not yet an established specialty, the hospital-based services which do
exist (often provided by the Community Dental Service) depend upon the goodwill
of specialist and consultant colleagues to gain access to facilities such as generalanaesthesia operating lists. This increases the complexity of the services and the
difficulty of coordinating the various agencies involved in an individual's care.
• Specialists work need not, and indeed should not, be restricted to working in
hospitals. Local studies demonstrate that general and community dental services
provide the majority of the currently supplied care for people living in community
settings who are on disability registers.
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Skills mix and facilities
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• Whereas consultants and a large proportion of specialists have until recently had a strong
hospital focus, there is recognition that not all of them need to be based in hospitals or, if
they are, they may only provide certain aspects of care in a hospital setting. SCD should be
predominantly community based. This would have the effect of reducing inequality in two
ways:
• Directly — by improving physical access to a specialist service that is not solely hospital based
• Indirectly — by improving access through support for interested generalists in primary dental
care.
• Hospital services should be closely aligned with specialists in a community setting so that
people who require hospital-based treatment because of medical complications,
multidisciplinary care, and/or care under general anaesthesia, may do so seamlessly.
• Ideally, the dental team will include dental care professionals (DCPs) such as dental therapists
and dental hygienists, and may involve liaison with health promotion services to ensure that
a preventive approach is taken locally to support health care for people with disability. Such
an approach allows a proactive move to reduce and prevent dental disease rather than the
currently common reactive approach of treatment of disease.
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Malaysia
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MalaysiaSpecial Needs Dentistry (Snd) In Malaysia: A Way Forward
Siti Zaleha Hamzah - Special Needs Dentistry, Hospital Serdang
INTRODUCTION
• Ministry of Health Malaysia (MOH) recently recognised SND as a dental specialty to provide better oral
health needs of the population with disabilities who, due to advances in medicine and improved general
healthcare are surviving much longer into old age.
• In Malaysia, it is predicted that, with an increased number of elderly in the community due to an
improvement in health care delivery and health awareness, the population with disability/ies may also
expand as older people are more likely to develop coincident or consequent disability with ageing. Apartfrom that, it has been reported that the number of Malaysian population suffering from various types of
disability had significantly increased from 132, 655 in 2003 to 197, 519 in 2006. Therefore, the demand in
oral health care for these special needs groups is expected to outstrip the service currently provided. The
same situation is also reported in United Kingdom, Australia and New Zealand.
• Many studies have confirmed that people with disabilities are more likely to have a poorer oral health
condition than those in general population, mainly due to barriers such as limited access to dental service,
financial problems and the complexity of medical conditions from which they suffer.
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DEFINITION
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DEFINITION
• In Malaysia, Special Needs Dentistry (SND) is defined as an area in dentistry which
concerns in the oral health management of patients adversely affected orally byintellectual or physical disability and medical or psychiatric issues or, more often, a
combination of a number of these factors, where such conditions necessitate a
modified delivery of oral health care for patients’ total health well-being.
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SERVICE DELIVERY AND PATIENT MANAGEMENT
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• SND includes the delivery of oral health care, focusing on individuals with special
needs above 16 years, and it is a hospital-based dental specialty due to the
complexity of the problems that the patients are often presented with.
• Therefore, referral to specialist in SND should be limited to those patients with
complex problems which may, for example, require treatment in the hospital
setting or those with issues of multiple co-morbidities and polypharmacy.
• For the time being, patients with special needs can be referred to Hospital KualaLumpur and Hospital Serdang for further management whereby care provided
includes various types of treatment in general dentistry.
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l d l l
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Special Needs Dental Surgeons in Malaysia
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SND IN THE COMMUNITY DENTAL SETTING
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SND IN THE COMMUNITY DENTAL SETTING
• With the aim to reduce the gap and burden for patients to access oral health
care facilities, the community component in SND would enhance and
encourage knowledge and competence of the community based dental
officers in managing and providing care for patients with special needs
through various strategies and planning.
• The set-up of the SND service in the community is to facilitate the delivery and
provision of oral health management and care for those patients who are
considered having mild to moderate disabilities/medical problems.
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CONCLUSION
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• More dental practitioners are expected to develop their interest in SND field as thetraining pathway becomes clearer, as well as the initiative of the Ministry of Healthto support the career development of the specialist in SND in line with otherexisting dental specialties in the near future. To ensure a continuing developmentin this rewarding field of dentistry, research in SND should be encouraged andincorporated in planning, development, and monitoring of the specialty.
• Thus, future studies should investigate the oral health status of adults withdisabilities in Malaysia in various aspects, such as caries experience andperiodontal status which is currently lacking.
• There are many ethical issues related to this area of health care and few questionsor problems can be addressed in a yes/no, black or white manner.
• Thus, details investigation and attention are required to explore these areas ofconcern in the future development of SND service in Malaysia.
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THANK
YOU!
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References
• http://www.hraljournal.com/Page/7%20Kamarulzaman.pdf • http://www.cbrglobal.org/Downloads/PS2a.pdf
• http://www.ijssh.org/papers/447-H10019.pdf
• http://www.pdknet.com.my/web/index.php?module=view_pdk&pdk_id=
6
• http://www.ncbi.nlm.nih.gov/pubmed/24417495
• http://www.ndss.org/Resources/Health-Care/Associated-
Conditions/Dental-Issues-Down-Syndrome/
• http://www.mdj.org.my/index.php?option=com_content&view=article&id
=141&catid=53&Itemid=133• http://www.disabilitymalaysia.com/about.html
• http://ohd.moh.gov.my/v3/index.php/en/contact-us
• https://www.mah.se/.../Malaysia/.../oral healthcare in malaysia 05.pdf