any patient, best interests must be protected. Difficulty arises in adolescents with an
intellectual impairment who are over the age of consent. In this situation parents or
carers are unable to give a valid consent on their charge's behalf. That is, an adult
cannot consent for treatment on behalf of another adult. Dentists would be well
advised to obtain a second opinion on their treatment plan before embarking on
dental care for an impaired young person who is judged to be incapable of giving
their own valid, that is, informed, consent. This is particularly the case where dental
care under general anaesthesia is being contemplated. It is prudent, also, to discuss the
proposed treatment plan and to obtain the agreement for the care that is being
suggested from those who have an interest in the patient.
There will be occasions when it will not be possible to easily undertake an
examination for a child or adolescent with a profound learning disability. In those
circumstances, a decision has to be made as to whether some form of physical
intervention, previously termed restraint, may need to be used. The clinician must
decide, on the basis of a number of factors, what is the best way forward. At all times,
as part of the dentist's duty of care, she or he must act in the patient's best interest in
reaching a decision as to whether to use some form of physical intervention. This
decision must be taken in the light of a number of factors, modified after Schuman
and Bebau and incorporated into the British Society of Disability and Oral Health's
Policy Document on Physical Interventions (1123Hhttp://www.bsdh.org) as follows:
Key Points
Physical interventions
- Minimum to be effective.
- Clearly documented ⎯ type/reason.
- Only employed by trained staff.
- Beneficial for individual to complete treatment.
- Not seen as punishment/for convenience.
- Not likely to cause physical trauma.
- Not likely to cause more than minimal psychological trauma.
- A means of avoiding more severe restraint (e.g. GA).
- To control involuntary movements.
- To avoid injury to self, others.
- Agreed with others close to patient.
17.2.2 Oral health
Dental caries
In the absence of targeted preventive and treatment programmes, children with
impairments fare less well than their normal peers. While overall disease experience
as measured using the dmf/DMF index (decayed, missing, filled primary/permanent
teeth) is similar, for the child with impairments there is often more untreated decay,
more missing, and fewer filled teeth. Early studies point to a reduced prevalence of
dental caries in children with Down syndrome, but this feature may be attributable
more to the later eruption of teeth relative to a control group of unaffected children so
that the teeth are 'at risk' in the mouth for a shorter period. The relative
microdontia/spacing seen in young people with Down syndrome may also be a