Atención odontológica a personas con discapacidad intelectual: una cuestión de derecho / Dental care for people with intellectual disabilities: a matter of law

En el planeta hay 100 millones de personas con alguna discapacidad yen México es el 6.2 por ciento de la población total. Estas personas son altamente vulnerables porque el entorno donde se desenvuelven no ofrece las condiciones para favorecer su integración y participación social, como el acceso a servicios médicos. De acuerdo con la Organización Mundialde la Salud, las personas con discapacidad son las menos atendidas en los Servicios Odontológicos, principalmente por inexperiencia del profesionista sobre el trato a estas personas, o bien por desconocimiento de los familiares-cuidadores de la importancia de mantener una boca sana. Las personas con discapacidad intelectual (PDI) constituyen un retopara el odontólogo, quien tiene que capacitarse para diseñar estrategiaspara su atención, ya que los tratamientos para este tipo de pacientes son específicos y poco convencionales. Adicionalmente conviene tomar precauciones en su atención dental, debido a que los PDI consumen diversos medicamentos, por lo que el odontólogo debe asegurarsecon otros especialistas para su manejo. Un punto medular sobre las características de la atención odontológica es que ésta tiene que generar confianza y enfrentar con paciencia y destreza a un PDI que cumpla con las expectativas del usuario, trato digno, calidez y confianza centrada en la prevención como principal criterio en la intervención odontológica, sobre todo en la supervisión de la higiene por parte de los familiares. Actualmente se habla de la relación médico-paciente participativa donde se define lo que corresponde a cada persona involucrada en el cuidado de la PDI, sin olvidar que esta atención conviene que sea en equipo. Así, ante este contexto, los odontólogos tendrían que formarseen el cuidado de la salud de las PDI quienes son sujetos de derecho,por tanto tienen que ser atendidos, respetados y tratados con dignidad.

On the planet, there are 100 million people with some disability andin Mexico; it is 6.2% of the total population. These people are highly vulnerable because the environment where they operate does not offer the conditions to favor their integration and social participation, such as access to medical services. According to the World Health Organization, people with disabilities are the least attended in the dental services, mainly because of the inexperience of the professional about the treatment of these people, or because the family/caregivers do notknow about the importance of maintaining a healthy mouth. People with intellectual disabilities (PIDs) are a challenge for the dentist,who has to be trained to design strategies for their care since the treatments for these types of patients are specific and unconventional.In addition, precautions should be taken in dental care, because PIDsconsume different medications, so the dentist must be sure with other specialists to handle them. A central point about the characteristicsof dental care is that it has to generate trust and face with patience and dexterity a PDIs that meets user expectations, dignified treatment, warmth, and confidence focused on prevention as the main criterion inthe intervention dental care, especially in the supervision of the hygieneby the relatives. At the moment we are talking about the participative doctor-patient relationship where it is defined that corresponds to eachperson involved in the care of the PDIs, without forgetting that this careshould be in a team. Thus in this context dentists should be trained inthe health care of the IDPs who are subjects of law, therefore have tobe attended, respected and treated with dignity.

The Mental Capacity Act 2005: Considerations for obtaining consent for dental treatment.

The Mental Capacity Act 2005 provides a legal framework within which specific decisions must be made when an individual lacks the mental capacity to make such decisions for themselves. With an increasingly aged, medically complex and in some cases socially isolated population presenting for dental care, dentists need to have a sound understanding of the appropriate management of patients who lack capacity to consent to treatment when they present in the dental setting. Patients with acute symptoms requiring urgent care and un-befriended patients present additional complexities. In these situations a lack of familiarity with how best to proceed and confusion in the interpretation of relevant guidance, combined with the working time pressures experienced in dental practice may further delay the timely dental management of vulnerable patients. We will present and discuss the treatment of three patients who were found to lack the mental capacity necessary to make decisions about their dental care and illustrate how their differing situations determined the appropriate management for each.

Americans with Disabilities Act: Its Importance in Special Care Dentistry.

This article focuses on understanding the Americans with Disabilities Act and developmental disabilities for health care providers in special care dentistry. Essential to this awareness is a comprehension of statutory and regulatory requirements and how state disability acts can be more rigorous in application. Developmental disabilities are re-examined in the context of the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). Understanding of intellectual disability, epilepsy, autism spectrum disorder, and cerebral palsy is necessary because the management of oral health considerations for special care patients has become ever more complex and indispensable.

Dentistry's intrinsic link to provision of services for persons with disabilities.

This article provides the dentist with a background on disabilities, education, practice and provision of services related to statutory and regulatory requirements, particularly the Americans with Disabilities Act anrid the California Fair Employment and Housing Act.

Informed consent, dementia and oral health care provision.

Managing patients with dementia requires a practitioner to exercise diverse skills. Communicating with the patient (as their dementia allows), relatives, caregivers and medical personnel are essential elements in the care process. Diagnosis of oral health problems may not be straightforward, clinical examination and treatment planning may be hampered by poor cooperation from the person with dementia. Practitioners must view any treatment from the patient's perspective and balance this with the requirements for sound clinical care. The consent process must be approached in a manner that fulfils the ethical responsibilities that acknowledge patient rights. This can be difficult when managing a patient with dementia. This paper will explore issues surrounding the consent process and the provision of oral health care to people suffering from dementia. It is hoped that readers will be stimulated to review their practice; especially related to informed consent, whether they routinely manage patients with dementia or not. Such practice evaluation should consider the wants and needs of patients and families on a broader than clinical basis and thus enhance the care that is brought to this group of interesting and often challenging patients.

Myths and facts about Minnesota's new safe patient handling statute and your dental practice.

With the passage of a safe patient handling statute in 2009, Minnesota became one of a growing number of states requiring health care providers to become more aware and accountable about providing appropriate assistance during the movement of patients in clinical care settings. The Minnesota Department of Labor and Industry and the Minnesota Dental Association have been working together to ensure that Minnesota's SPH regulations are as practical as possible for dental providers while still achieving the objectives of the statute. A template Safe Patient Handling Program for Clinics has been developed with substantial input from MDA's ESNA Committee and is now available on the DLI website: www.dli.mn.gov/WSC/SPHlegislation.asp. All Minnesota dental practices should use this template to develop their own safe patient handling program as soon as possible. Additional background information and resources related to Minnesota's SPH regulations are also available on the DLI website. MDA and DLI are currently also developing a hazard assessment tool for dental practices to assess their specific risks associated with patient movement. This hazard assessment will, in turn, guide decisions about what type of safe patient handling equipment and staff training will be necessary for total compliance with the new statute. MDA, in cooperation with DLI, will continue to keep dental professionals informed about when these materials will be available. Additionally, MDA is working to ensure appropriate training options will be available for compliance with SPH regulations. The University of Minnesota's School of Dentistry's Oral Health Services for Older Adults Program and Department of Continuing Dental Education have been regularly providing such training in conjunction with the school's "Miniresidency in Nursing Home and Long-term Care for the Dental Team," and efforts are now underway at the dental school to create stand-alone training options for Minnesota's dental professionals. Further information about SPH training may also be found on the DLI website (www.dli.mn.gov/WSC/SPHlegislation.asp). MDA members can also contact MDA's Elderly and Special Needs Adults Committee via the MDA central office.

Domiciliary oral healthcare.

UNLABELLED: There is increasing demand for Domiciliary Oral Healthcare (DOHC) and the skills and equipment required to provide a quality, patient-centred service with careful assessment and management in a sometimes compromised situation. Commissioning of DOHC needs to be set in the context and current agenda of equality, diversity and human rights in both health and social care. Effective marketing and community engagement are required to promote awareness of how to access services amongst people confined to home and their families and carers. Training for the whole dental team should be available in order to address the concerns and problems encountered regarding the provision of DOHC. CLINICAL RELEVANCE: Members of the dental team should be aware of the skills required for DOHC and be familiar with using effective care pathways in relation to the provision of DOHC.

BDA special care case mix model.

Routine dental care provided in special care dentistry is complicated by patient specific factors which increase the time taken and costs of treatment. The BDA have developed and conducted a field trial of a case mix tool to measure this complexity. For each episode of care the case mix tool assesses the following on a four point scale: 'ability to communicate', 'ability to cooperate', 'medical status', 'oral risk factors', 'access to oral care' and 'legal and ethical barriers to care'. The tool is reported to be easy to use and captures sufficient detail to discriminate between types of service and special care dentistry provided. It offers potential as a simple to use and clinically relevant source of performance management and commissioning data. This paper describes the model, demonstrates how it is currently being used, and considers future developments in its use.

Consent, restraint, and people with special needs: a review.

Dentists providing treatment to individuals with developmental disabilities are often faced with unique medical/legal issues. Obtaining informed consent when a patient does not have capacity can be an involved process. Issues regarding therapeutic aides used for immobilization (i.e., restraint) during treatment may further complicate the situation. This area is controversial and has even resulted in legal difficulties for some dentists. Several topics related to the use of restraint are addressed in this article. A review of the literature and applicable laws pertaining to consent issues for people with special needs is presented and appropriate use of medical immobilization is discussed. Existing guidelines are reviewed. Informed consent and the use of restraint should be incorporated into overall guidelines for the use of anesthesia, sedation, and alternative behavior management techniques in providing dental care to patients with special needs.

The Disability Discrimination Act and Access: practical suggestions.

UNLABELLED: This paper presents the results of a study exploring the implementation of the Disability Discrimination Act Access Guidelines amongst General Dental Practitioners based in Aylesbury town centre. Fourteen potential barriers to compliance are identified around the key concerns of cost, planning regulations and lack of information. Practical suggestions are then offered in line with the 'Inclusive Approach' to enable practitioners to meet the requirements and overcome practical difficulties. CLINICAL RELEVANCE: From October 2004, all general dental practices have been required to take, or begin to plan, reasonable steps to improve access to their dental surgeries in order to comply with the Disability Discrimination Act.

The Mental Capacity Act 2005 and its impact on dental practice.

In 1995, the Law Commission was given the task of investigating 'the adequacy of legal and other procedures for decision-making on behalf of mentally incapacitated adults'. It concluded that the law was fragmented and confusing and called for a single statute to govern decision-making on behalf of mentally incapable adults regarding welfare, healthcare and financial matters. There followed a 15 year period of consultation, resulting in the new Mental Capacity Act 2005 which came into full force in October 2007. Dentists who administer treatment to patients suffering from mental incapacity due to dementia, learning disabilities, depression, brain injury and other forms of mental disorder, need to be familiar with the Act and its accompanying Code of Practice. This article looks at how the new Act impacts upon the treatment of incapable patients by dentists, whether they are in general surgery, community or hospital settings. In particular, this article focuses on the provisions of the Act which relate to how and when capacity should be assessed prior to the dentist carrying out treatment and the consequences of a finding of incapacity for both the dentist and the patient in his or her care.