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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 12  |  Issue : 1  |  Page : 1-7

Curriculum for Special Care Dentistry: Are we there yet?


1 University Malaya Dental Education Enhancement and Development (UMDEED), Kuala Lumpur, Malaysia
2 Department of Restorative Dentistry, University of Malaya, Kuala Lumpur, Malaysia
3 Department of Paediatric Dentistry and Orthodontics, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia

Date of Submission03-Jun-2019
Date of Decision26-Aug-2019
Date of Acceptance09-Sep-2019
Date of Web Publication25-Feb-2020

Correspondence Address:
Dr. Zahra Naimie
University Malaya Dental Education Enhancement and Development (UMDEED), Faculty of Dentistry, University of Malaya, Kuala Lumpur.
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_146_19

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  Abstract 

A presented paper is reviewed for the Special Care Dentistry (SCD) teaching of dental undergraduates from different continents and compared it to the current SCD education scene in Malaysia. Related literature were reviewed together with the current updates of SCD in Malaysia as an overview to bridge the gap for SCD teaching, planning the learning outcomes, and the curriculum guidelines. It highlights the barriers, similarities, and the different approaches applied in Malaysia. Constructing the SCD curriculum and adhering to it is a challenge. Most countries will be bound to the local expectations and needs to be able to construct their national guidelines. The literature shows the difference in approach of teaching SCD globally. Different factors such as lack of SCD expertise, lack of disabled-friendly facilities, overloaded curriculum, and lack of educational resources were highlighted in the literature as factors that can halt the SCD education. Educators need to incorporate the learning outcomes, the local needs, and/or curriculum guidelines within their institutions to design the content of their own programs. The Malaysian experience can be an example of a southeast Asian approach in SCD education.

Keywords: Curriculum, Dentistry, Education, Special Care, Teaching


How to cite this article:
Naimie Z, Ahmad NA, Shoaib LA, Safii SH, Mohamed Rohani M. Curriculum for Special Care Dentistry: Are we there yet?. J Int Oral Health 2020;12:1-7

How to cite this URL:
Naimie Z, Ahmad NA, Shoaib LA, Safii SH, Mohamed Rohani M. Curriculum for Special Care Dentistry: Are we there yet?. J Int Oral Health [serial online] 2020 [cited 2022 Jan 18];12:1-7. Available from: https://www.jioh.org/text.asp?2020/12/1/1/279212




  Introduction Top


Special Care Dentistry (SCD) or Special Needs Dentistry (SND) is a branch of dentistry that manages a wide range of patients who requires some modifications in dental management due to their medical conditions, social backgrounds, psychological issues, disability (intellectual or physical), and oral health needs.[1] The term “special care” was introduced in 1981 when American Dental Association, Journal of the American Association of Hospital Dentists, and Academy of Dentistry for Persons with Disabilities (formerly Academy of Dentistry for the Handicapped) established Journal of Special Care in Dentistry.[1] Since then, there have been several attempts in defining the term, some varies based on the continents where the study arises and also the extent of the disability described. In the United Kingdom, the Royal College of Surgeons of Edinburgh defined SCD as “the specialty of dentistry concerned with the oral health care of patients with special needs for whatever reason, including those who are physically or mentally challenged.”[2] In Australia and New Zealand, this branch of dentistry is known as SND and is defined as “that part of dentistry concerned with oral health of people adversely affected by intellectual disability, medical, physical, or psychiatric issues.”[3]

In Malaysia, the term SCD had been unanimously chosen by the Malaysia Pro-Tem Dental Specialty Board (DSB), committee of SCD during the Pro-Tem DSB meeting on the October 11, 2016.[4] It was agreed that, the term SCD was to be applied nationwide. Following this meeting, the DSB for SCD has defined the term SCD as “the field of dentistry which is concerned with the oral health management of people with physical, intellectual, medical, psychiatric conditions, or a combination of these factors; whose delivery of oral health care necessitate specialised techniques or methods in meeting their complex requirements.”[4] The term SCD will also be used for the purpose of this document.

The characteristic that sets apart this specialty from other branches of dentistry includes a wide range of patients with special needs who may have problems accessing routine dental care at a general clinic.[1] These patients may include the elderly and the individuals with physical disability, intellectual disability, complex medical problems, psychiatric illnesses, and behavioral conditions [Table 1]. It is important for all health professionals to understand the scope of this specialty in order to facilitate referral to SCD specialists. This will ensure that the patients are able to obtain access to dental treatment of equal quality to medically fit individuals.[5] In addition, there are multiple underlying factors involved in managing patients with special needs that include their level of dependency, cooperation, and expectations from the family or caregiver. The family and clinicians both can be baffled by the wide range of conditions referred to as special needs thus a classification system is essential, especially to ease communication. [Table 1] describes types of special needs with some examples for each category.
Table 1: Types of special needs and the examples[5]

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  Prevalence of Disability in Malaysia Top


A wide range of disability prevalence reported in the literature is due to variance in the assessment of a disability, type of disability, definition of disability, and the methodology used for example the questionnaire design, objectives and form of data collection.[6] The World Health Organization (WHO) reported 15% of the world’s population were affected by various types of disability.[7] However, the prevalence ranged as low as 0.7% in Kenya to as high as 20.0% in Australia.[8] Considering the population profiles and Malaysian Health Statistic, a high level of prevalence was expected.[9] This in part due to growing aging population (65 years and older) among Malaysians at 5% in 2010 to estimated 14.5% in 2040. By year 2020, 7.2% of the Malaysian population will be of people aged 65 years and older.[10]

The prevalence of disability in Malaysia as reported by the Government of Malaysia was 1.3%, which was lower than the Economic and Social Commission for Asia and the Pacific of United Nations (ESCAP) average at 4.6% and even lower than the estimate by WHO at 15%.[11],[12] Meanwhile, the National Health and Morbidity Survey reported a prevalence of 26.9% (95% confidence interval [CI]: 25.7, 28.1) for overall impairment and disability in Malaysia.[11] Furthermore, ESCAP reported the increasing prevalence of disability with age in southeast Asian countries from 5.2% in the age group of 0–14 years to 16.3% in the group of 15–59 years, respectively.

Therefore, the increasing number of SCD patients with disability and those that require special dental care warrant a revision on the scope of teaching in the undergraduate curriculum. Graduate dentists should be prepared and able to manage this group of patients, either by promoting prevention of common oral diseases or by providing necessary treatment, which includes referral to SCD specialists when it is beyond their capability in managing some patients.[13]

SCD patients have shown greater unmet dental needs compared to the general population.[14],[15] Their oral health problems are related to their disability and health problems that sometimes preclude them from receiving appropriate dental treatment.[14],[15],[16],[17] The difficulty in receiving dental health care may be caused by the lack of cooperation, communication, and cognitive capacity among patients with special needs.[18] Other problems may also relate to a practitioner’s attitude and perception of special needs, their level of clinical skills, knowledge, and experience in providing care for people with special needs.[19],[20],[21],[22] The complexity in managing these patients necessitates acquisition of sound medical knowledge, clinical competency, and positive attitude among dentists to treat this patient population.[2]

Optimal oral health is an integral component of health and well-being; therefore, performing routine oral hygiene, accessing professional dental care, and giving informed consent concerning health-care treatment are significant issues among the population with special needs.


  Barriers for Special Care Dentistry Patients Top


In general, patients with special needs are at high risk for developing oral diseases. Furthermore, access to dental care has been highlighted as a major challenge, which most of the time has been ignored where care for SCD is concerned. However, the need for this access may vary according to the types of disabilities. Some patients require more extensive and complex dental care but unfortunately, these individuals have to live with gross oral infections that can lead to or complicate illnesses such as aspiration pneumonia, uncontrolled diabetes, wound healing, stroke, prosthetic joint failure, and heart disease, resulting in additional expenses of medical care. Furthermore, for those with chronic illnesses, lack of dental treatment can lead to oral infection, which may exacerbate their systemic conditions.

Considering the fact that disabled population in the world is estimated to be 650 million people with 80% of them being in developing countries, dental professionals are expected to be able to treat these special individuals and to provide primary care to such individuals, adults or children, but the lack of adequate knowledge, training, and understanding of the needs of this population may hinder such services.[11]

A study[5] indicated that in the United States, no trained dentists or “credentialed dental providers” were available to provide treatment for adults with special needs; however, for children with special needs, trained dentists and staff were available.[2] In the UK, patients with profound disabilities are treated at the Community Dental Service by professionals who are trained to treat such patients and who are considered as a specialist in SCD.

In Australia,[3] services for the patients with special needs are well established with their respective regional approach in majority of the hospitals that cater to the treatment needs of such patients. In Malaysia, the authorities are working toward setting up centers to attend to people with disabilities. Majority of literature reported on the services and barriers of SCD, just a handful reflected on SCD in dental curriculum with regard to SCD education among dental programs as the undergraduate programs were providing the most training in the area of SCD. Implementation of SCD curriculum requires multidisciplinary input within a dental school that may also be influenced by the local teaching resources, financial and economic support, availability of physical facilities, background of patients with special needs in Malaysia, and other factors. Therefore this paper is aimed to visit the current development of undergraduates’ dental curriculum in Malaysia parallel to other countries like the UK, US, Japan, Korea, Hong Kong and Australia which have also implemented SCD education in their undergraduate curriculum.


  Current Scenario for Special Care Dentistry Teaching in Malaysia Top


Health education is a combination of learning experiences designed to help individuals and communities improve their health, by increasing their knowledge or influencing their attitudes. This includes the training for health providers to be able to cater for the community needs. It is essential for both medical and dental practitioners to be competent in treating patients from all scopes of health, be it with or without disabilities.

In dental education, dental graduates were equipped with theoretical and practical knowledge to ensure that they will be competent dentist. However, on the basis of the finding of a study, it is mentioned that most (between 50% and 80%) dental students were reluctant to treat SCD patients, particularly those with sensory, intellectual, psychiatric disabilities, and infectious diseases.[13] The reason for not providing care to these patients was due to lack of training and clinical experience managing them.[13],[23] This matter was looked at by Dougall et al.,[24] and they had come out with a guide to construct undergraduate (UG) curriculum in SCD at undergraduate level. As for Malaysia, most dental schools do not offer a specific module in SCD yet. The teachings about SCD were observed to be very limited, sporadic, and inadvertently taught in some dental disciplines outside SCD.[24]

There is an absence of structured learning objectives, teaching methodologies, and assessments.[9] Often, the dental schools may have incorporated SCD in other dental teachings, especially pediatric dentistry, oral surgery, human disease, prosthodontics, and community dentistry.[13]

However, SCD teaching in Malaysia is delivered through different methods such as didactic teaching, disability equality training (DET) workshop, and experience in dental clinics, geriatric and medical rehabilitation wards, nursing homes, and special needs and other rehabilitation centers for individuals with intellectual disabilities and underprivileged individuals.

Limited numbers of experts in this area were reported by the dental school deans and head of schools, which were the main reasons for not offering SCD education for UG. Other reasons were the lack of disabled friendly facilities, clinical sites, patients, overloaded curriculum, and educational resources.[13]

SCD has been covered as an integrated module in the undergraduate curriculum for the last two academic years at the University of Malaya. Students are exposed to examining, diagnosing, and preparing treatment plan for the SCD. Since the last academic year, we run a dedicated SCD clinic under two specialists, which the fifth-year students attend on a rotation basis. In addition, fourth-year students conduct a field visit to any one center for special needs such as home for the aged or disabled, rehabilitation centers for physically and intellectually disabled or socially deprived. Since this academic year, third-year students undergo a DET workshop conducted by officials from the Ministry of Women, Family, and Community Development.[23]

The Malaysian Qualification Agency (a statutory body to accredit academic programs from educational institution) should look into a new accreditation standard for SCD program at UG level.[23]

Collaborative exercise between dental school, medical schools, and external organization such as “Special Olympics” and government agencies may allow knowledge transfers, sharing of expertise and resources for SCD teaching, clinical experience for dental students, and research development.[9],[13]

Constructing the SCD curriculum and adhering to it is a challenge. Most countries will be bound to the local expectations and needs to be able to construct its national guideline. From the literature, the difference in the approach of teaching SCD globally was encountered. It is notable that factors such as the learning outcomes, assessments, teaching methods, facilities, and trainers’ qualifications are essential to form the core of the curriculum [Table 2]. These factors will be revisited in our second paper related to SCD curriculum from the Malaysian perspectives.
Table 2: Special Care Dentistry training around the globe

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  Discussion Top


Dental graduates in Malaysia like other parts of the world are increasingly being challenged by treating patients with special care. In Malaysia, due to lack of emphasis, and even sometimes absence of SCD curriculum in the BDS education, overcoming challenges in managing patients with SCD may be an issue for dental professionals. Inadequate educational plan of SCD curriculum for undergraduate is not the only challenge. Other factors such as lack of training (educational material), lack of trainers (experts/teachers), and lack of infrastructure in terms of dental equipment and facilities are also important factors contributing to the obstacles. Lack of SCD expertise was identified by the top management of the majority of the dental schools in Australia and Malaysia as the major obstacle in delivering the SCD teaching and learning at undergraduate level.[15] In addition, Malaysian respondents also highlighted the lack of “disabled-friendly facilities” as an obstacle that exists where SCD education is referred.[15]

Apart from the obstacles highlighted, it is obvious that dental schools need to search for the SCD curriculum, which wills suits their target population. This step will enable them to teach using that curriculum and ensure the students as well as the society will benefit from it. The American Dental Education Association policy statements (2006) emphasised that by integrating basic skills as a solid portion of the curriculum, not only SCD population but all other patient groups will be benefited.[28],[29]

Dental institutions are the feeders for the future clinicians that will be managing this population. The continuity of the training from the feeder till the end facilities such as the clinics and hospitals are essential. Dental education has the capacity to bridge the gap between capable clinicians in handling the SCD oral health scenario and the treatment of SCD patients.

Educators which are in most cases are clinicians and specialists in the dental institutions must understand the importance of clear learning outcomes in designing their dental undergraduates’ programme as most curriculum are influenced by the curriculum guidelines of individual institutions and the local needs of the community. It is apparent that dental education is the key to improve the field of special needs dentistry through comprehensive development of a standardized SCD curriculum. The policy makers, the stake holders and the educators must work hand in hand where education for SCD is concerned.

Dental graduates in Malaysia like other parts of the world are increasingly being challenged by treating patients with special care. In Malaysia, due to lack of emphasis, and even sometimes absence of SCD curriculum in the bachelor of dental surgery education, overcoming challenges in managing patients with SCD may be an issue for dental professionals. Inadequate educational plan of SCD curriculum for undergraduate is not the only challenge. Other factors such as lack of training (educational material), lack of trainers (experts/teachers), and lack of infrastructure in terms of dental equipment and facilities are also important factors contributing to this too.

Patients with special needs are prone to experience oral health diseases due to poor oral hygiene, restricted access to dental treatment, and inexperienced dental professionals treating them.[17],[25] The number of SCD specialists who were trained to cater for this population is also limited.[13] As a result, both the government and the patients will be burdened by the cost factor of treating dental problems for this population.[25] In addition, history information in the literature describing the special need care providers’ training and the curriculum needed for this specialty are limited. Dental curriculum and clinical training for SCD are considered as the backbone and important areas to be emphasized. Therefore, it is important to bridge the gap in SCD by highlighting the areas that need to be addressed to improve oral health care for this population. Many research addressed the SCD from different angles across the globe but there are limited studies in Malaysia addressing the SCD training and further discussing it.

Therefore, dental schools need to search for the SCD curriculum, which suits their target population, thus they can teach using that curriculum and ensure the students as well as the society will benefit from it.[26],[27] The American Dental Education Association policy statements (2006) highlighted that by integrating basic skills as a solid portion of the curriculum, not only SCD population but all other patient groups will be benefited.[26],[27] Finding of the study indicated that the top management of the majority of the dental schools in Australia and Malaysia believed that lack of SCD expertise is the major obstacle to deliver the SCD teaching and learning in undergraduate level.[13] However, Malaysian respondents also highlighted the lack of “disabled-friendly facilities” as an obstacle that exists where SND education is referred.[13]

Therefore, dental education appeared to bridge the gap between capable workforce to enhance SCD oral health situation and SCD patient. In fact, dental education centers/units are involved in training the staff to improve the SCD oral health as well as proving the service to this population in their clinics. Educators which are in most cases are clinicians and specialists in the dental institutions must understand the importance of clear learning outcomes in designing their dental undergraduates’ programme as most curriculum are influenced by the curriculum guidelines of individual institutions and the local needs of the community.[26],[27],[28],[29]

Acknowledgement

We would like to thank the staff at the Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2]


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