versão On-line ISSN 1698-6946
Med. oral patol. oral cir.bucal (Internet) v.12 n.7 Madrid nov. 2007
Alfonso Escribano Hernández1, Tomás Hernández Corral2, Eduardo Ruiz Martín3, Jose Andrés Porteros Sánchez4
(1) Técnico de Salud de la Gerencia de Atención Primaria
(2) Director Médico de la Gerencia de Atención Primaria
(3) Médico odontólogo de la Gerencia de Atención Primaria de Salamanca. Coordinador del Programa de Salud Bucodental de Discapacitados Psíquicos
(4) Gerente de la Gerencia de Atención Primaria. Salamanca
Objective: Disabled people have the same right as other people to receive the health care they need, but they sometimes have difficulties to achieve it. In Castilla y Leon it has come into effect a law to guarantee Primary and Secondary Care coordination to provide dental treatment under sedation or anaesthesia to mentally disabled people who need it. Our aim is to evaluate the results of the implementation of such a law through a specific protocol in our health setting.
Study design: Descriptive, made in a Health Area over a year, on mentally disabled people who were sent to hospital for treatment under anaesthesia after Primary Dental Care Units assessment. It has been studied the age, gender, mental disease, dental diagnosis and treatment undergone.
Results: 108 patients attended the program (51% male), with a mean age of 31 years. 67% presented profound learning disability, 19% mental illness with disability, 11% presented cerebral palsy and another 3% had autism. Most frequent dental pathologies were caries (86%) and dental plaque (71%). Most common dental procedures were tooth extraction (78%), professional tooth cleaning (75%) and fillings (67%).
Conclusions: We achieved to provide necessary dental treatment to a large number of disabled people, who would not have received it otherwise. It was a challenge to plan and implement the protocol coordinating Health Care Levels and workers. It still has to be done an economic and efficiency analysis of procedures and a patient satisfaction study.
Key words: Dental care for disabled, patient care planning, program evaluation.
Objetivos: Las personas con discapacidad tienen el mismo derecho que el resto de la población a recibir las prestaciones sanitarias que requieran, pero en ocasiones tienen dificultades para ello.
En Castilla y León se ha publicado un Decreto que garantiza la coordinación entre Atención Primaria y Especializada, para que las personas con discapacidad psíquica que precisen tratamientos odontológicos bajo sedación o anestesia, lo reciban correctamente.
Nuestro objetivo es evaluar en nuestra Área los resultados de la aplicación de dicho Decreto a través de un protocolo específico.
Diseño del estudio: Descriptivo, realizado durante un año en un Área de Salud, sobre los pacientes discapacitados psíquicos que, tras ser atendidos en las unidades de salud bucodental de Atención Primaria, son derivados al hospital de referencia por precisar anestesia general para su tratamiento. Se estudió su edad, sexo, discapacidad psíquica padecida, diagnósticos odontológicos e intervenciones a las que se sometieron.
Resultados: Accedieron al programa 108 pacientes (51% varones), con 31 años de edad media.
El 67% presentaban retraso mental profundo, el 19% enfermedad mental con discapacidad, el 11% parálisis cerebral y el 3% autismo.
Las patologías bucodentales más frecuentes eran la caries(86%) y la placa dental (71%).
Las intervenciones más habituales fueron exodoncias (78%), tartrectomías (75%) y obturaciones (67%).
Conclusiones: Se consiguió que un número importante de discapacitados accedieran a intervenciones necesarias que, de otro modo, no hubieran recibido.
La organización e implantación del protocolo supuso un reto de coordinación de gerencias y profesionales.
Queda por hacer un análisis de los costes y efectividad de las intervenciones y de la satisfacción de los usuarios.
Palabras clave: Cuidados dentales en discapacitados, planificación de cuidados, evaluación de programas.
The Law 8/2003, of 8th of April, about rights and duties of people related to health(1) emphasizes the right of some groups of people to special health programs, especially for disabled people.
Disabled people should have access to dental care preventive procedures under the same conditions than the rest of the population. However, they sometimes have difficulties to receive the same health service provision as other citizens, what justifies planning and coordination efforts to take care of them on the grounds where those services should be properly provided. Their vulnerability implies others responsibility (not only relatives but also health workers, managers and politicians).
In this sense, the decree 142/2003, of the 18th of December, of the Health Ministry of Castilla y Leon(2) sets out some measures to define, guarantee, coordinate and extend the dental care provision of Castilla y Leon Health System, especially to those who can not keep self-control because of their disability, and thus, cannot get a proper dental care. They will be sent to those health grounds where dental care provision can be guaranteed.
This special care is justified because most disabled people have dental impairments(3,4). It can be stated that disabled people, especially those mentally handicapped, have a lot of oral diseases and treatment needs, most of them not satisfied. Their prevalence of missing teeth is greater than in general population(5). It is common to find poor dental hygiene with high levels of dental plaque and gingivitis, calculus in early ages, intense halitosis and food remnants in teeth and mucosal, and cariogenic and soft diet. It is more frequent than in general population to have gingival overgrowth because of hydantoins, chronic infections and inflammation, systematic tooth extraction instead of conservative treatments, young partially or totally edentulate patients, restrictions or impossibility in the use of prosthesis because potential risks, bad occlusion, traumatic occlusion and bruxism, with dental abrasion and hypersensivity(6).
Due to a lesser stress tolerance of these patients, some problems are almost invariably present when taking dental management(7,8). In any case, treatments could and should be carried out adopting some special measures for controlling behavioural problems, such as general anaesthesia, deep intravenous sedation, or ambulatory treatment with anxiolytic premedication(9).
The mentioned decree establishes that organizational and structural adjustments will be carried out in every Health Area to achieve these goals.
It also provides for drawing up a specific protocol to point out how these people will receive the dental care procedures that they need.
This care must be provided by dental care units staff, whatever the health ground they are working in, with the support of whoever they need.
An adapted protocol has been done in Salamanca, taking into account some experiences in other areas of Castilla y Leon and of other communities, and the workers and handicapped associations opinion. It guarantees dental treatment under anaesthesia to mentally disabled patients when prescribed by a dental practitioner.
Obviously, and it is established in the decree, it is necessary a follow up and an evaluation of the results of such a protocol in practice, what is the aim of this article.
Material and methods
Study design: descriptive.
Population: mentally disabled patients referred to an Area Hospital to receive general anaesthesia after being attended in Primary Dental Care Units.
Period of study: from the 1st of June 2005 to the 31st of May 2006.
Variables: age, gender, mental disability, dental diagnosis and treatment undergone.
As our patients were studied in depth in an operating room, the caries diagnosis was made using a probe together with visual criteria. Afterwards, caries was classified following Black classification. We just filled type 1 but not the rest because its possible complications (pulp inflammation and neuralgia) would lead to another surgery procedure under general anaesthesia, unwanted in these patients.
Tooth mobility was diagnosed by Millers Mobility Index, making tooth extraction only in levels II and III and in those of level I when there was periodontal disease which suggested a quick evolution to upper levels.
Finally, periodontal status was evaluated through the Community Periodontal Index of Treatment Needs (CPITN), as World Health Organization recommends for dental research(10).
Mental disabilities were grouped in 4 categories, as stated in the protocol:
- Autistic disorders
- Cerebral palsy
- Profound learning disability
- Mental illness with disability
Statistic analysis: description of patients distribution by age, gender, mental diseases, dental diagnoses and treatment undergone.
During the period of study, our Primary Dental Care Units treated 42720 patients, 492 mentally handicapped.
Among these, 108 were sent to Hospital because they needed general anaesthesia for their treatment (51% male), with a mean age of 31 (standard deviation: 14.1). Age distribution histogram can be seen in figure 1.
The 67% of the patients presented profound learning disability, 19% mental illness with disability, 11% cerebral palsy and 3% autism.
It was impossible for us to achieve a dental diagnosis in a single patient due to his lack of cooperation and his refusal to go to Hospital.
The dental pathologies of the other 107 patients are presented on table 1.
On one hand, caries was the most frequent pathology (present in 86% of patients). The mean number of caries person was 8,6 (SD: 4,7), with a median of 8, and ranged from 1 caries in a patient to 21 in 4 of them. This pathology was distributed by tooth as follows: 16% in incisors, 8% in canines, 31% in premolars and 45% in molars.
On the other hand, among all the patients referred to Hospital for treatment, only 87 persons really underwent treatment under anaesthesia. Their dental procedures are shown in table 2.
The remaining 21 patients who didnt undergo surgery was either because they didnt go to the hospital or because they had anaesthesia contraindications.
There was only a patient who needed an endodontic treatment because of posterior prosthetic requirements.
Among 68 patients with any tooth extraction, the mean number of them was 5,6 (SD: 5,1), the median was 3 and they ranged from 1 in 7 patients to 21 in other 3. This procedure was distributed by tooth as follows: 21% in incisors, 9% in canines, 33% in premolars and 37% in molars.
Among 58 patients with any filling, the mean number of them was 5,7 (SD: 3,8), the median was 5 and they ranged from 1 in 4 patients to 19 in 1. Its distribution by tooth was: 12% in incisors, 7% in canines, 28% in premolars and 53% in molars.
There are some published studies on mentally disabled patients, in which osteointegrated implants achieved a satisfactory oral rehabilitation, without any complications or differences with healthy people, being the failure rate about 5-6%(9,11,12).
However, other studies state that severely handicapped patients constitute the group with more relevant dental needs due to their medical, social and economical limitations, being difficult for them to have access to conventional dental care(13-16).
This people have also problems with preventive procedures such as tooth brushing, dental floss use and even mouth rinses, which have been proved to be effective(17).
According to the disabilities, deficiencies and health status survey of 1999, the rate of mentally handicapped people among 6 to 64 years of age is 8,07 per 1000 population in Castilla y Leon and 9,38 in Spain(18).
In our Health Area, over the period of time analysed, Dental Care Units saw 492 mentally handicapped patients, what accounts for the 11,5 per 1000 of their activity.
Among them, 108 had a dental treatment under anaesthesia, which means a 22% of the mentally disabled patients.
Therefore we think this protocol has been successful, as it has been recently introduced and it is common to have difficulties with any other program and when trying to integrate this kind of population in daily health activities.
The distribution of our disabled patients, their dental pathologies and their procedures is similar to the single study on this subject we have found after a bibliographic search(19). We must point out the number of caries and dental plaque among pathologies, and the number of tooth extraction, fillings and professional tooth cleaning. The lack of this kind of bibliographic references means the shortage of programs similar to ours or that they are not spread in scientific literature. We must say it is pioneer in our circles.
In other studies on disabled people(20), the amount of pathology was lesser than in ours, but they had studied all patients and not only those referred to general anaesthesia.
In any case, the large number of pathologies seen and surgery procedures done reaffirm our opinion of the success of the protocol.
It remains to be studied the success or failure of treatments.
It has still to be done as well a patient satisfaction and a cost analysis.
It was difficult to organize and implement these protocol activities because they involved two health levels (Primary Care and Hospital), many workers and a big coordination effort. In any case, we achieved to provide necessary dental treatment to a large number of disabled people, who would not have received it otherwise, which allows us to be reasonably satisfied.
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Dr. Alfonso Escribano Hernández
Gerencia de Atención Primaria
37007 Salamanca. Spain