Introduction

After a busy term at dental school, when talking to my family and friends at home, the words 'special care' would often feature in our conversations. But nine times out of ten, the instant reaction would be a completely blank face, followed by: 'I have no idea what that is!'

Special care dentistry (SCD) always seemed to crop up as a mysterious topic to those not in the know, with lectures usually being squeezed into an already packed timetable, and with other areas such as restorative and facial aesthetics becoming more popular thanks to social media, I think SCD deserves some more promotion.

SCD, the newest dental speciality,1 is a speciality that, as defined by the General Dental Council (GDC), works with patients 'to [improve] the oral health of individuals and groups with physical, sensory, intellectual, mental, medical, emotional or social impairment or disability, or a combination of all'.2 This therefore requires more specialist techniques, equipment and often management in a hospital or community setting. One might say: 'what's the point in learning about a speciality that most won't encounter?' Yet, two of the GDC's standards are 'to communicate effectively' and 'to put patients' interests first'.3 So, as clinicians with a duty of care for all our patients, how can we ensure this if the patient is non-verbal or has a phobia? What should we consider if they have a schizophrenia diagnosis or perhaps have finished a course of chemotherapy? That's where SCD comes in (see Table 1 for examples of impairment).

Table 1 Examples of impairment
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What exposure is there to SCD for undergraduates?

Although my exposures as an undergraduate have been few and far between, I've found the scope of SCD to be vast - encompassing many different disciplines, from medicine to psychology and even law. It has always stood out to me for in highlighting the importance of the person behind the dental problem, a feature which definitely makes SCD clinics among my favourites. As an undergraduate, it can be easy to tunnel vision into remembering all the theoretical information needed to treat teeth, while forgetting the person behind them. But with 16% of adults under 65 and 45% of adults over 65 in the UK having a disability,4 these clinics are key to understanding how practices can adapt to suit these patients' needs. I've seen the many different ways clinicians communicate - from sign language to communication boards, to learning about wheelchair hoists and even how the room layout can be customised. As a student it could also be an opportunity to see rare presentations that only seem to appear in textbooks; the first time I'd ever seen medication-related osteonecrosis of the jaw clinically, in my five years as an undergraduate, was in the SCD department. Yet, in a recent talk with a group of undergraduates across the UK, 42.0% had no experience of this speciality and only 9.4% had treated patients with additional needs (see Figure 1). Students are likely to see a significant number of patients with additional healthcare needs in the course of their careers and will therefore need to be equipped with the knowledge and skills to manage these patients once they graduate.

Fig. 1
figure 1

Survey of undergraduate students' experience of special care dentistry across the UK (n = 53)

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From my own experience, the earlier SCD is introduced to aspiring students and covered within the undergraduate curriculum, the better. Prior to starting dental school, I shadowed a fantastic dentist - I'll call her Dr G - who had a special interest in a community practice. I saw how adaptable Dr G and her colleagues were with each patient, to meet their unique needs. In the two weeks I spent there, I saw a variety of patients who had additional needs: from patients with severe phobias who go from being visibly anxious to completely at ease, to a patient who would only let the dentist examine them if they were given cookies. The work they undertook was demanding, but witnessing their amazing determination and expertise was what inspired me to ultimately pursue dentistry as a career.

SCD for general practitioners

Following graduation and foundation training, all NHS dental practitioners should be able to deliver level 1 complexity of care for SCD.5 Competencies and requirements for this are summarised in Table 2. To ensure this care can be delivered by primary care dentists, it is important that dental schools incorporate SCD within their curricula as a specific speciality subject - although some of the skills required to treat patients who have additional needs are not unique to SCD. There are overlaps with other specialities; for example, managing medically complex patients and the use of sedation and general anaesthesia in oral surgery.

Table 2 Level 1 complexity of care - requirements for special care dentistry5
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The GDC undergraduate curriculum Preparing for practice6 places the assessment and care of people with special needs as a core learning outcome for the dental team, and there are curricula available for dental schools to address this essential learning need of their undergraduates.7

Widening oral health inequalities

Widening inequalities in oral health exist between social classes, regions of the country and among certain minority ethnic populations.8 The inequality for people with additional needs has been described as a 'cliff-edge' burden compared to the general adult population.9 Figure 2 shows that untreated dental decay rates for prisoners, people who are homeless and people living with long-term disability are at much higher levels, even compared to the lowest occupation and poorest groups in the general population.

Fig. 2
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Mean number of decayed teeth among male adults aged ≤65 years in England, Wales and Northern Ireland, reproduced from Richard Watt et al., 'Understanding and tackling oral health inequalities in vulnerable adult populations: from the margins to the mainstream', British Dental Journal, 2019, Springer Nature9

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The impact of COVID-19 on oral health is likely to be more severely felt by those who were already more likely to have poorer health outcomes, including people with disabilities and those living in more deprived areas.10 Many SCD services have postponed their services, not been able to access general anaesthetic lists and cancelled domiciliary care as a result of the pandemic.11 The backlog from longer waiting lists may shift the responsibility of some of these patients onto general practice, so the future generation of dentists should feel equipped to safely manage patients with additional needs who can be seen in primary care.

Conclusion

Now, as a final-year student, the world beyond dental school often seems to be about UDAs and clinical 'before and after' photos, perhaps at the expense of less time with patients. Yet, SCD is another reminder that dentistry is truly about taking the time to get to know the patient. Given the recent events of the pandemic, SCD services will be more needed than ever. For patients who have been in intensive care, their medical needs could be more complex, including potential mobility problems following strokes caused by the infection and the management of chronic conditions or long COVID. SCD departments will be essential in supporting the most vulnerable and may be a rare moment of contact for patients who have been isolated for months, but it is not just their role to look after these vulnerable patients. All dental professionals have a part to play in caring for vulnerable groups and so it is vital that students have exposure to SCD, to encourage the next generation of dentists to be fully adaptable to all patients' needs.

Throughout my (albeit short) dental career so far, SCD departments have always left me with a lasting impression - I may never have pursued dentistry without it! I have been truly privileged to learn skills which are so transferable and can be used with patients in any setting, which all should have the opportunity to learn. I hope that, in our increasingly diverse society, SCD in the undergraduate curriculum is here to stay. It's these experiences which help to ensure the highest standards of care expected by our patients, so that we all feel happy to treat any patient who comes through the door into our care.