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 Table of Contents  
ORIGINAL RESEARCH
Year : 2019  |  Volume : 11  |  Issue : 5  |  Page : 299-303

Referral pattern and treatment needs of patients managed at a Malaysian special care dentistry clinic


Centre of Comprehensive Care Studies, Faculty of Dentistry, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia

Date of Web Publication24-Sep-2019

Correspondence Address:
Mas S Ahmad
Faculty of Dentistry, Universiti Teknologi MARA, Sungai Buloh Campus, Sungai Buloh, Selangor.
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_84_19

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  Abstract 

Aims and Objectives: This study was undertaken to investigate the referral patterns and treatment needs of patients managed by the special care dentistry (SCD) clinic specialists at a Malaysian teaching dental hospital, in preparation for improved oral health services for this patient population. Materials and Methods: The dental records of patients who attended the SCD clinic between January and December 2017, were reviewed for information, including sociodemographic characteristics, sources and reasons for referral, dental treatment needs, and medical profile. Quantitative data were analyzed via the Statistical Package for the Social Sciences version (chi-squared test, P < 0.01). Results: A total of 182 patients were managed in 2017, consisting mostly of Malays (89.6%) and with a majority being males (63.2%) in the 0–20 years age group (69.8%). A slight prevalence of adolescent/adult patients (52.2%) was reported as compared with that of pediatric patients (47.8%), with no significant difference between the genders. Many of the patients were encountered within the mobile dental service program (53.8%) and mostly first presented for routine checkups (66.5%). Treatment needs included periodontal therapy (76.9%), restoration (47.3%), exodontia (28.0%), and dentures (12.1%). The patient study sample additionally boasted physical impairments (58.8%), complex medical conditions (32.4%), psychiatric disorders (8.8%), and intellectual disabilities (8.2%). Systemic health issues included cardiovascular (18.7%), respiratory (9.9%), and endocrine (7.7%) disorders. Significant differences in the numbers of patients with physical disabilities and complex medical conditions were observed across age groups. Conclusion: This study provides important information for the future development of SCD services at the institutional and national levels.

Keywords: Dental Services Research, Geriatrics, Special Care


How to cite this article:
Ahmad MS, Shafie NE, Redhuan TM, Mokhtar IW. Referral pattern and treatment needs of patients managed at a Malaysian special care dentistry clinic. J Int Oral Health 2019;11:299-303

How to cite this URL:
Ahmad MS, Shafie NE, Redhuan TM, Mokhtar IW. Referral pattern and treatment needs of patients managed at a Malaysian special care dentistry clinic. J Int Oral Health [serial online] 2019 [cited 2020 May 29];11:299-303. Available from: http://www.jioh.org/text.asp?2019/11/5/299/267719


  Introduction Top


People with special health-care needs (SHCN) include those with intellectual disabilities, physical impairments, complex medical conditions, and psychiatric disorders.[1] The lack of awareness among patients with SHCN and their caregivers about the importance of oral health care in this segment of the population has largely resulted in poor oral health maintenance and high dental treatment needs, which are often unmet.[2],[3],[4] Various studies have reported poor oral health status among people with SHCN, with a large percentage of them experiencing a high presence of caries, periodontal disease, and other oral mucosal lesions.[5],[6]

As the number of people living with SHCN rises at both local and international levels,[7],[8] the need for oral health services tailored for this group of patients is also growing. In Malaysia, people with SHCN aged 16 years and older are managed by special care dentistry (SCD) specialists, whereas those younger than this age range are treated by pediatric dentists.[9] Initiatives brought forward by the Malaysian Ministry of Health for promoting the oral health of people with SHCN have promoted the establishment of SCD as a recognized specialty in the country, whereas support for an enhanced oral health-care service for children with SHCN continues to thrive.[10],[11]

However, despite having expanding services that support the implementation of better oral health care for people with SHCN across the age spectrum, there has not yet been any study conducted in Malaysia, which reports on the profile of patients managed by SCD specialists in terms of referral patterns and treatment needs. Thus, this research was developed to investigate the patterns of cases referred for management by specialists at the SCD clinic of University A Dental Centre, which is the largest teaching dental hospital in Malaysia.[12] The study also aimed to identify the treatment needs of patients with SHCN, whose data are still lacking in this country. The findings of this study will serve as a useful information for financial, personnel, equipment, and infrastructure planning, which will further direct the development of oral health-care services for patients with SHCN at the organizational and national levels.[9]


  Materials and Methods Top


This was a descriptive, retrospective, and quantitative study that involved a review of dental records of patients referred to and managed by specialists assigned to the SCD clinic, University A Dental Centre, in accordance with the institution’s referral guidelines. The study only included records of patients who had indicated their agreement, via a signed consent form, for their information to be used anonymously for research purpose. Signing of the consent form is a standard procedure for all patients who obtain treatment at this facility and must be made voluntarily either by the patient themselves, or their legal guardian, where appropriate.

Ethics approval was granted by the Research Ethics Committee at the University A (ref. no. 600-IRMI [5/1/6]; REC/161/17). This research was conducted in full accordance with the World Medical Association’s Declaration of Helsinki.

Before the start of the study, a referral protocol leaflet, approved by the faculty, was given to dentists working at the University A Dental Centre primary care clinic and clinical staff involved with patient referrals, triage, and scheduling. This leaflet was designed to clearly inform on the criteria and guidelines for the referral of patients with SHCN who require specialist intervention. This set of guidelines was developed based on that produced by the Oral Health Division, Ministry of Health, Malaysia.[9]

The records of all patients with SHCN over 1 year (January to December 2017) were retrieved from the SCD clinic. The retrieved records were reviewed to obtain information on patients’ sociodemographic characteristics, medical history, dental history, complaint or reasons for seeking dental treatment, sources of referral, and dental treatment needs. Only the records of patients who had undergone a completed examination and diagnosis by specialists were reviewed. A data collection form was prepared to record each patient’s information, with reference paid to the existing standardized examination and diagnosis form being currently used at the University A Dental Centre.

Patients were categorized based on the definition of SCD established by the Royal Australasian College of Dental Surgeons.[13] These categories included those with physical disability, intellectual impairment, psychiatric disorder, and complex medical conditions. Pediatric patients were categorized as those aged younger than 16 years, whereas adolescent/adult patients were categorized as those aged 16 years and above. For the analysis of patients’ medical profiles, they were categorized into five age groups as follows: 0–20, 21–40, 41–60, 61–80, and 81–100 years of age, respectively.

Quantitative data were statistically analyzed via the chi-squared test (P < 0.01) using the Statistical Package for the Social Sciences, version 23, software program (IBM, Armonk, New York).


  Results Top


A total of 182 patients were managed between January and December 2017, by SCD clinic specialists at the University A Dental Centre.

The majority (89.6%, n = 163) of patients were Malay, whereas 6.0% (n = 11) were Chinese and 4.4% (n = 8) were Indian. There were more male patients (63.2%, n = 115) than female ones (36.8%, n = 67). More than half (52.2%, n = 95) of the referrals were adolescent/adult patients (aged 16 years and above), whereas 47.8% (n = 87) were pediatric patients (aged below 16 years). No significant difference was observed in the number of adolescent/adult and pediatric patients across the genders (χ2 = 1.536, P = 0.215). [Table 1] shows the number of patients in each age category.
Table 1: Percentage and number of patients according to age group

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Most of the patients were encountered and referred within the mobile dental service program (53.8%, n = 98). Other sources of referral included those from the primary care clinics (31.9%, n = 58), dental students (6.6%, n = 12), medical counterparts (4.9%, n = 9), other dental departments (2.2%, n = 4), and the “WeCare” e-mail (0.5%, n = 1).

Most of the patients were referred for routine dental checkup (66.5%, n = 121). Approximately 15.9% (n = 29) came in because of pain, whereas 5.5% (n = 10) were referred from other health-care professionals. Some were referred due to other reasons (11.5%, n = 21), including a request for dentures. Only a small percentage of them were referred for cleaning (0.5%, n = 1).

The majority of patients required periodontal treatment (76.9%, n = 140), followed by restorative procedure (47.3%, n = 86), exodontia (28.0%, n = 51), dentures (12.1%, n = 22), and referral for treatment under general anesthetics (8.2%, n = 15). In addition, a small percentage of patients required endodontics therapy (4.4%, n = 8), orthodontics treatment (3.8%, n = 7), oral medicine and pathology consultation (3.3%, n = 6), fixed prosthesis (2.7%, n = 5), and implant procedure (0.5%, n = 1). Some of them required other treatments (18.7%, n = 34) such as nitrous oxide sedation and topical fluoride therapy.

The most common category of patients with SHCN was individuals with physical disability (58.8%, n = 107). Other categories included those with complex medical problems (32.4%, n = 59), psychiatric disorders (8.8%, n = 16), intellectual disability (8.2%, n = 15), and other conditions (1.6%, n = 3).

Systemic illnesses reported by those with complex medical problems included conditions affecting the cardiovascular (18.7%, n = 34), respiratory (9.9%, n = 18), endocrine (7.7%, n = 14), neurological (4.9%, n = 9), musculoskeletal (4.9%, n = 9), and gastrointestinal (1.1%, n = 2) systems. A small percentage of patients also presented with cancer (3.8%, n = 7).

A significant association was observed between patient age group and the number of those having a physical disability (χ2 = 59.682, P < 0.001), specifically, more than three-quarters (77.2%, n = 98) of the patients with disability were in the 0–20 years of age category [Table 2]. In addition, a significant association was also observed between the patient age group and the number of individuals with medically compromised conditions (χ2 = 70.573, P < 0.001), with more than three-quarters of those in the age categories of more than 40 years (41–60 years = 78.6%, n = 11; 61–80 years = 94.7%, n = 18; and 81–100 years = 100%, n = 2) reporting conditions that affected their systemic health [Table 2]. In terms of gender, no significant difference was observed in the number of individuals categorized into the different types of SHCN classification [Table 3].
Table 2: Characteristic of disabilities among different age groups

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,
Table 3: Characteristic of disabilities between genders

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  Discussion Top


The SCD clinic at the University A Dental Centre was established in January 2017, to provide oral health care for patients with SHCN across the age spectrum. Two clinical specialists were assigned to manage those referred to this clinic based on referral criteria developed in accordance with the national guidelines.[10] Patients aged younger than 16 years were managed by one of the specialists, who holds a postgraduate qualification in pediatric dentistry and special care. On the other hand, patients aged 16 years and older were managed by the other specialist, who holds a postgraduate qualification in SCD. Such stratification of patients is in line with the global practice of dentistry, in which the specialist management of individuals with SHCN is determined according to a patient’s age (patients aged younger than 16 years are managed by pediatric dentists, whereas patients aged 16 years and above are treated by SCD dentists).[14]

This study found that the percentages of patients among the adolescent/adult and pediatric groups were comparable, albeit slightly higher in the former category (52.2% vs. 47.8%). The predominance of patients with Malay ethnicity may reflect the distribution of populations in the surrounding area, thus suggesting the geographical profile of patients who typically used the SCD service at this center.

This study also found that most of the included patients were encountered within the mobile dental service program. Such a finding further justifies the importance of clinicians reaching out to this population of patients in an environment external to dental surgery. Therefore, initiatives such as domiciliary dental care, community engagement programs, and extramural oral health promotion activities, where dental services are provided outside of the dental surgery vicinity, may be useful approaches to give individuals with SHCN better access to oral health-care services. The availability of oral health-care programs provided on an external basis may help to reduce barriers to the utilization of dental services previously reported as existing in this patient cohort.[15] Perhaps the mobile dental clinic program organized by the University A Dental Centre could be established as one of the main platforms for providing oral health-care services for people with SHCN in Malaysia, as the country currently faces a limited availability of such a service.[16]

This study also suggests the need to better publicize the existence of SCD clinic services, especially to the members of the dental fraternity and medical professionals who previously reported a lack of awareness of the SCD specialty.[17],[18] The low referral rate of patients from these counterparts indicates the need to create greater awareness among dental and medical colleagues of the role that SCD specialists play in the multidisciplinary care of patients with SHCN. Guidelines for patient referral should be disseminated widely to promote appropriate management of these patients. In addition, management protocols for handling emergency medical conditions should be established, as this study found a high attendance rate among patients who were medically compromised, especially those in the elderly category. The public should also be made aware of the availability of the “WeCare” e-mail facility for enquiries and direct referrals.

Patients’ referrals for checkup indicate increasing awareness among the individuals with SHCN regarding seeking professional dental care despite an absence of signs and symptoms, which used to be the most commonly cited reasoning for the utilization of dental services by this group of patients.[19] In fact, only a small percentage of patients with SHCN attended the clinic because of a complaint of pain, which was in contrast with the general population in Malaysia, whose pain was highly cited as the reason for seeking dental care.[20] As patients showed an increased demand for routine checkups, general dental practitioners, being on the front lines of providing dental services, must be adequately trained to deliver such services. Thus, SCD education has to be introduced at the undergraduate level to prepare dental practitioners for managing this population of patients. It was found that dental practitioners with educational experience in this field were more positive about and comfortable in managing individuals with SHCN, thus reducing barriers for these patients to access professional dental care.[21] The incorporation of SCD training in Malaysian dental schools at the undergraduate level suggests positive implications for increased engagement in managing patients with SHCN among general dental practitioners, whose roles also include referring patients for specialist intervention.[22]

The dental treatment needs shown by patients with SHCN in this study are similar to those found in the recent National Oral Health Survey of Adults, which reported a high percentage of Malaysians requiring periodontal therapy.[20] The need for other types of dental therapy, such as restoration, exodontia, and denture creation, provides important information for the University A Dental Centre in planning for adequate resources to cater for patients’ treatment needs. The demand for treatment under general anesthesia and nitrous oxide sedation, which could be costly, was also shown by patients with SHCN attending the SCD clinic in this study. Furthermore, the high percentage of individuals with physical disabilities attending the SCD clinic indicates the need for the center to be disability-friendly to facilitate patients’ mobility. The institution therefore must equip itself with adequate facilities to cater to patients’ needs in accessing the facility and undergoing treatment in an appropriate manner. However, the financial burden involved in preparing the required facilities, resources, materials, and manpower for catering to the various needs of patients with SHCN could be an issue for the University A Dental Centre. This is because Malaysian regulations specifically identify individuals with SHCN who hold a valid disability identification card, produced by the Department of Social Welfare, as eligible people to be exempted from fees for services provided in public health-care facilities.[23] Being a government agency, it is therefore incumbent on the University A Dental Centre to adhere to such regulations. As such, a strategic management plan should be developed to ensure the sustainability of oral health-care services provided at this facility in a manner that does not compromise patients’ access to quality oral health care nor the institution’s financial stability.

Because of time constraints, this study only investigated the profiles of patients with SHCN who attended the SCD clinic at this institution. This study did not investigate patients with SHCN who instead visited other specialty departments such as pediatric dentistry, oral and maxillofacial surgery, and oral medicine. Therefore, the findings of this study do not represent the total population of patients with SHCN who visited the dental hospital. However, the study does provide useful initial findings regarding the sociodemographic characteristics, referral patterns, categories of SHCN, and dental treatment needs of patients who attended the SCD clinic in its first operational year. This information is important to allow for future planning and further development of oral health-care services for patients with SHCN provided at the SCD clinic at the University A Dental Centre. The findings of this research would also benefit policymakers and government bodies because of their utility as evidence-based references for the planning of SCD services at the national level, as such data are currently not otherwise available.

For future studies, we would like to recommend that all patients with SHCN registered through the online registration system, regardless of the services they receive or the specialty to which they are referred, be included in similar investigations. As such, an overall profile of patients with SHCN who attend the center could be obtained while allowing for comparisons to be made in terms of patterns of patient referrals to the various specialty departments. Such a study also allows for the investigation of dentists’ and institutions’ adherence to specialist referral guidelines in accordance with those established by the Ministry of Health.[9],[10] Proper referral is important to ensure appropriate management, which in turn results in quality patient care and improvement of the oral health status of people with SHCN in Malaysia.

In conclusion, this study found that the patients referred to the SCD clinic and investigated were most commonly males, of Malay ethnicity, and aged 16 years and above. The majority of the included patients were encountered during mobile dental clinic activity and were most often referred for a checkup. A high percentage of these patients required periodontal therapy, followed by restorative treatment. The findings of this study provide important information that will guide future planning for oral health-care services targeting people with SHCN at this institution and in Malaysia in general.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Tables

  [Table 1], [Table 2], [Table 3]


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