In March 2014 I took up the post of speciality registrar in Special Care Dentistry, Birmingham Community Healthcare Trust, one of 3 StRs in this specialty (http://www.bhamcommunity.nhs.uk/about-us/services/dental/special-care-dentistry/). The post offer the opportunity to work in primary and secondary care services, covering community clinics and some hospital based care. The service provides a more joined up/integrated dental care services for patients unable to access high street GDPs due to mental, physical or cognitive disability. This is done predominantly on a referral basis in primary and secondary care settings.

Throughout my two years as a trainee, I have been faced with many patients suffering from dementia of varying severity. These patients are referred to the service from a myriad of services from GDPs, GPs, care home managers and family self referral. Unfortunately, many of these patients have a heavily restored, neglected dentition when they reach our service, a big challenge to the clinician and patient/family/carers at this point.

Dementia is a degenerative disease, that can be categorised through the stages of early (needing assistance in choosing clothes, disorientation in time and place, decreased recall of names); middle (need for supervision in daily tasks, may be incontinent, disorientation in person); and late (severe speech loss, incontinent and motor stiffness)( https://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=133). Once a person is diagnosed with dementia, dental care should be highlighted along with other holistic services to provide health care and improve the quality of life. From my experience, this is not always the case. 

A patient with early to middle stage dementia can have an appropriate joined up/integrated preventative strategy put into place, with effective management of dental disease. However in the community dental services, there is an influx of referrals to our service when patients are in the middle to late stages of the disease. Many of these patients are immobile, unable to weight bear, exhibit challenging behaviours that are symptomatic of their disease and can be frail with other co-morbidities.  This often include previous extensive restorative work that inevitably fails when the patient is unable to adequately manage his or her oral health care, a challenge to everyone involved; The question is how do we act in this persons best interests and facilitate safe and effective dental treatment? The barriers to care at this stage can be quite difficult.

There is current research being undertaken by our Dental Public Health colleagues who are attempting to develop a dental care model that can be integrated into the holistic pathways of patients with dementia, at the diagnosis stage.  In my everyday clinical world, the evidence of these pathways is very limited at present. With the number of people being diagnosed with dementia ever increasing along with life expectancy, this increasing burden requires us all as dental professionals to act quickly when patients presented to us with dementia.  We must utilise shared care of GDPs, GPs, community and hospital services to ensure the patient receive the correct care, in the correct environment with support for the family/carers delivered by the correct professionals