Special needs dentistry (SND) aims to address the oral health needs of people with disability, medical, physical, or psychiatric conditions, that require specialised methods, techniques, and treatment plans to prevent or treat oral health issues, due to oral health being compromised directly through the condition itself, or indirectly through medication or poor access to care.1
Difficulties accessing oral healthcare services has been established as a predictor of poorer oral health measures in people with disability.2 The population with disability face a number of barriers to accessing oral healthcare services, including lack of physical accessibility to oral healthcare facilities within their local communities, and difficulty accessing oral healthcare professionals trained in Special Needs Dentistry.3, 4 The limited specialist workforce cannot address all of the current barrier issues, and therefore, there is a need for other dentists to assist in managing the population with special needs.
A wide range of conditions cause disability, with differing levels of medical, cognitive and physical impairments. Only 5.7% of Australians experience profound or severe disability5, the majority have disabilities that are minor or moderate and would benefit from accessing mainstream public dental services within the community by an experienced general dentist with increased knowledge in the management of individuals with special needs.
In July 2014, the Special Needs Dentistry Network was established in the SA Dental Service to improve access to oral healthcare for individuals with special needs. Experienced general dentists from key public community dental clinics distributed in metropolitan and rural South Australia (SA) were upskilled to provide oral healthcare for individuals with special needs. This “Hub and Spoke” model is similar to the structure to the National Health Services (NHS) in the United Kingdom6, with the “Special Needs Dentistry Network” providing an integrated care pathway between community-based general dentists and the registered SND specialists, post-graduate SND trainees, and SND experienced general dentists in Special Needs Unit, Adelaide Dental Hospital. This enabled SND Network dentists to be a point of referral:
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from less experienced community based general dentists to enable assessment and provision of oral healthcare for individuals with special needs, who may be too complex for them to manage, but whom may not require the input of a specialist in special needs dentistry
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to specialists in SND for provision of dentistry for individuals with special needs beyond their expertise, or who require access to behavioural or physical supports including wheelchair platforms, oral sedation, general anaesthesia, and
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from specialists in SND for provision of maintenance or preventative care for patients with special needs whose immediate oral healthcare needs have been stabilised.
The use of a validated tool which could be used by community based general dentists to stratify patient-complexity in an objective and reproducible method, equivalent to that performed by an experienced SND specialist, had the potential to ensure that patient complexity was matched with the SND skill set of the dentist, thereby reducing the number of individuals with mild SND complexity being referred to the Special Needs Unit, reducing specialist waiting list times, as well as travelling time and associated financial costs for patients.7
The British Dental Association case mix tool (BDA CMT) and simplified case mix tool (sCMT) are assessment tools designed to measure patients’ complexity. Both were selected for investigation in this study due to their high applicability for implementation within the SA Dental Service, given the oral healthcare delivery model resembling the NHS, where the BDA CMT and sCMT have been widely implemented.
The BDA CMT consists of a structured matrix with six parameters relating to patient-related complexities that measure its effect on oral healthcare provision.8
The six parameters are as follows:
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Ability to communicate
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Ability to cooperate
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Medical status
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Oral risk factors
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Access to oral care
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Legal and ethical barriers
Each parameter contains a detailed narrative to assist in assigning a complexity score. Table 1 demonstrates the narrative for the ability to cooperate parameter. The scoring is measured on a four-point scale with zero representing no barrier or complexity for that parameter and A, B, and C representing increasing levels of complexity.8
Table 1
BDA CMT narrative and complexity score scale for ability to cooperate6
Complexity score | Narrative |
0 | 0 | Patient will accept all restorative care and simple extractions with local anaesthesia +/- standard behavioural management techniques |
A | 3 | Full examination and/or simple treatment possible, but requiring additional support or behaviour management techniques |
B | 6 | Limited examination only possible Clinical holding required Patient will accept limited restorative care of anterior teeth only with difficulty |
C | 12 | Patient requires general anaesthesia, sedation or other advanced management techniques to accept treatment |
The data from the BDA CMT can be analysed based on the sum of all the weighted scores across all six criteria which is then assigned to a band shown in Table 2.
Table 2
BDA CMT data analysis: banded total score method13
Total score | Complexity band |
0 | Standard patient |
1–9 | Some complexity |
10–19 | Moderate complexity |
20–29 | Severe complexity |
30 + | Extreme complexity |
The simplified case mix tool was developed following psychometric investigation conducted by Duane et al9 where the oral factors parameter was omitted as it did not add to reliability, score weighting was removed and complexity was collapsed into a three-point scale to allow more efficient use.
This study to explores the potential applicability of both the BDA CMT and the sCMT for individuals with Special Needs, who are eligible to access oral healthcare through public dental clinics in South Australia.