The solution to the treatment of disabled and obese patients and dental equipment
The treatment of disability patients, including the obese, has risen in importance in the last decade. The introduction of legislation and the growing number of obese patients has raised the profile of issues surrounding the treatment of this group of patients. The scale of the problem can be seen by the incredible statistic given by Nitschke and Kaschke. The concept of a ‘Flexible Clinic Space’ has been developed by Design Specific Ltd. that addresses all the major issues surrounding special care surgery design.
‘In 2009, 7.1 million people (8% of the population) were officially recognised as having severe disabilities in the Federal Republic of Germany. At the same time, about 2.34 million Germans were in need of special care with some overlap between these groups’ and in the abstract to the paper the following observation was made ‘Dental care should compensate any deficits to ultimately attain the same standard of oral health. To achieve these goals, ease of access to dental care as well as dental services appropriate to the impairments have to be established’.
Professional bodies such as the International Association of Disability and Oral Health and the individual country organisations have continually highlighted the problems.
Dental provision for patients with disability
It must be the objective to provide a full and adequate dental provision for patients with disability resulting from physical and mental impairment as well as resulting from age, disease or trauma. Age related disabilities range from Alzheimer’s where fear and stress are common features to trauma resulting from accidents or fire arms events. Disease affects the whole human condition and can render bones to be brittle and circulation to be restricted and in such cases the method of handling the patient becomes important.
The treatment of normal ‘healthy’ patients raises but a small proportion of the problems for the whole population and must be regarded as the easy end of the market. The emergence of specialist equipment to deal with the handling problems has significantly contributed to the overall solution to the problem and Design Specific Ltd., in particular, have created a range of dedicated products to meet the expressed needs of clinical staff that include ease of use, seated treatment, convenient storage and good patient support.
Bariatric dental chairs for obese patients
To deal with the increase in patient weight dental chair providers have also introduced products with increased load carrying capacity and size. Typically chairs have a safe working load in the order of 150kg but patient weights can approach 300kg. The major issue for such patients is the size as fatty tissue is relatively light and bulky to achieve the mass. Even if dental chair can carry the weight it may be unsuitably too narrow and not give sufficient support to the soft tissue.
The issues surrounding the treatment of disability patients
The issues surrounding the treatment of disability patients can be seen as those relating to the patient, the clinical staff and the economics of treatment. There is no such person as a ‘standard’ disabled person each will have a set of conditions unique to them, this is over and above the condition of their teeth or the required treatment. Generalisations therefore do not apply. It is highly likely that an individual patient may have more than one condition, a dementia patient may also have a heart condition and serious mobility problems. A diabetic patient may have serious foot and leg problems compounded with a heart condition.
The patient condition will vary significantly. It is quite possible that a long term disabled patient has not been receiving regular dental supervision over a long period. The lack of facilities and specialist staff and the mechanism for referral means that they can go unnoticed until their condition becomes acute requiring dramatic intervention. If the patient has any neuro-disability conditions it is probable that they will find the visit to a dentist as a stressful event, we all do to some extent.
This stress is seriously increased by incorrect handling. Hoisting onto a conventional chair may be wholly inappropriate because of their physical condition. The fear of being handled into a sling and then lifted free adds significant stress. Sliding them across a board from wheelchair to dental chair removes them from their safe zone into an unsupported movement. An alternative is to treat them with their head tilted backwards which is wholly unacceptable for both patient and dental staff.
The stress renders some patients unable to cooperate with the clinician leading to incomplete or unsuccessful treatment. The use of general anaesthesia becomes a necessary but undesirable outcome. This procedure has its own set of risks that need to be evaluated. The whole experience can be so stressful that any visit in the future may be delayed or cancelled leading to further complications.
Special care dentistry and transfer of disabled patients
Unless the correct environment is provided the health of the clinical staff is at risk. Where the proper facilities have not been provided for wheelchair working the posture of the dentist is far from ideal. As the head is unlikely to be in a proper position for treatment the dentist will have to bend and twist around the patient to get access. This has inevitable consequences. A large proportion of dentists occupied in disability work develop serious back pain and could potentially lead to claims for compensation.
The transfer of patients adds significant stress to the clinical staff. Slings and use of additional lifting equipment add complexity to the process and the concerns of clinical staff for their patients’ wellbeing add unnecessary concerns. In many cases the concerns over transfer to conventional chairs outweigh those over the dental procedures and a focus for the staff is taken away from the primary purpose of the visit. As patients present themselves with a whole variety of conditions and complications the senior dental nurse, or dentist, has a significant role in deciding the most appropriate handling and treatment options. This is seriously compromised if the best handling options are not available. A patient with serious kyphosis may be required to be transferred to a dental chair or a patient in a moulded wheelchair is treated in a head back position. The consequences of a bad decision are the responsibility of the staff and this can have career implications.
Whilst economic factors should not affect clinical decisions they will inevitably have an influence. The higher the cost of each individual treatment the less efficient and effective the service. Whilst capital cost is a consideration at the outset it is not a consideration during service where convenience and effectiveness, leading to reduced treatment times, take priority. Any innovation that can contribute to the overall performance is to be welcomed and initial costs will quickly be recovered. With correct equipment to handle the patient the focus of the work can return to the clinical requirements of the dental procedure.
The key to the treatment of wheelchair dependent patients is to leave them in their chair
The key to the treatment of wheelchair dependent patients is to leave them in their chair. This eliminates any problems associated with transfer and stress related to handling or lifting. Treatment can then proceed in a calmer environment that will lead to more successful and complete outcomes. The chances of subsequent treatments is increased and dental health improved. All this benefit requires equipment to place the patients head in the correct attitude and position, an illustration of the Compact Wheelchair Recliner is provided. (Fig. 1)
The clinical benefits are clear and the elimination of the need to prepare and hoist a patient saves significant time reducing the treatment time to a near normal period. The elimination of the time to hoist enables clinical staff to undertake short procedures such as descaling and check-ups again improving the overall dental health of the patient.
The disability community is not generally part of the affluent society. Poor diet and low esteem contribute to obesity, poor health and dental decay and provision of specialist services for this group are generally placed within community dental services and dental hospitals. There is no large commercial incentive to serve this population leaving the state and local government to implement strategies and allocate funds. The absence of any funded network leaves a large sector of the population vulnerable.
Dental Surgery design is a major factor in efficient use of the space
Dental Surgery design is a major factor in efficient use of the space. It is a fundamental requirement to get full use of the equipment. To achieve this adequate access for wheelchairs, bariatric wheelchairs, transport chairs and treatment staff must be a priority. Access for trolleys for GA patients may be necessary. The conventional clinic with the dental chair placed centrally surrounded by cabinetry and equipment is not the best solution, it always leads to serious compromises when attempting to do disability work in the same space. These compromises often eliminate many of the benefits offered by specialist wheelchair recliners. A picture is given illustrating the situation in which treatment space is seriously restricted. (Fig. 1)
Flexible Dental Clinic Space
The concept of a ‘Flexible Clinic Space’ has been developed by Design Specific Ltd. that addresses all the major issues surrounding special care surgery design. No one item of equipment can cater for all the needs to be met, the variety of patients and their condition make this impossible. It is possible to reserve a single clinic space for special care only and site all the devices there but this may not result in full utilisation of the space and in a busy community facility this may not be an acceptable solution.
The Flexible Clinic Space requires that the all the services are focussed on a single point in space. The imaging unit, the suction spittoon, and the tool storage device are arranged to serve that point and the various patient support devices are moved in and out as required. The storage footprint of all the devices needs to be kept to a minimum. The range of equipment to service this approach include a ‘Compact’ Wheelchair Reclining Platform’; a ‘Bariatric Bench’ for the Compact Platform; a ‘Shifter Base’ to make conventional chairs moveable; a ‘Bariatric Treatment Chair’ a large knee break chair; a ‘Universal Headrest’ for cases of spinal deformation and a ‘Bariatric Conveyance Chair’ for moving and handling and treatment.
The Compact Wheelchair Platform
The Compact Wheelchair Platform is the essential item of equipment for the treatment of wheelchair patients and for those who are not necessarily confined to them. It is easily moved into position on ball castors and can accommodate all wheelchairs including battery driven versions and take loads up to 300kg. The head is positioned to be treated in a seated position with a recline angle of up to 60deg. It can be folded for storage to fit under a work surface. The back rest is height adjustable and the headrest can be either a profiled standard design or a Universal Headrest that can have the headrest pad adjusted sideways and rotated to suit spinal deformation cases. (Fig. 3) The unit is battery operated to prevent supply wire trips and operation is by a remote handset or fixed switches. (Figs. 2)
The Bariatric Bench
The Bariatric Bench is an accessory to the Compact Platform. It caters for walking bariatric patients and is locked in place onto the compact Platform. The backrest of the platform forms part of the bench and supports the spine of the patient whilst the wide curved back gives full soft tissue support. The bench can be used for seating when not used for treatment. The Compact and Bariatric Bench together Provide facilities for all patients from children to obese adults in wheelchairs and seated ‘normal’ patients to the walking obese. (Fig. 4)
The Shifter Base
The Shifter Base gives the facility to move a standard dental chair to a storage position. They are specific to the chair manufacturer and model. The chair is fixed onto the Shifter Base and can be raised on ball castor pods by compressed air to allow it to be pushed to a storage position. The changeover from chair to Compact Platform is approximately 30 seconds. This short changeover time is far shorter than any transfer technique to a fixed dental chair. (Fig. 5)
The Bariatric Treatment Chair
The Bariatric Treatment Chair is a new addition to the range. It is a knee break chair with a capacity of 500kg and size to suit. The chair is suitable for normal sized patients when using additional side cushions. It has patented features such as a backrest that is adjustable in height and a combined movement of backrest height and recline to keep the head in the same place on the headrest cushion when going back. The seat height is a low 500mm when down to 1000mm at the highest, it is therefore suitable for standing or seated treatments. (Fig. 6). The chair is mounted on concealed retractable ball castors so that it can be moved away to a storage position.
The Bariatric Conveyance Chair
The Bariatric Conveyance Chair is a new concept design. The function is to take people with low mobility from the reception area to the clinic waiting room and then directly into the dental surgery. The dental chair is reclined to 45 degrees. So that dental treatment can take place. The dental chair is then returned to a suitable angle for transport back to the reception area. There are no transfer or mobility issues and the patient is relaxed ready for treatment. This is a significant breakthrough in technique. (Figs 7 & 8)
The need for a comprehensive solution to service the disabled and obese sector of the community has never been greater. This paper has drawn attention to a new wave of products that can significantly contribute to an efficient and effective approach. The Flexible Surgery concept with its moveable equipment provide opportunities not available until this time.
The company leading the change and providing high quality equipment is Design Specific Ltd. who have received two innovation awards for their insight and products. They have changed the ideal of ‘Best Practice’ and seek to improve the experience of disabled person’s worldwide.
- Fig. 1 Correct head positioning but with space constraints
- Fig. 2 Battery operation and a radio handset to eliminate all wire trip hazards
- Fig. 3 Universal headrest
- Fig. 4 Bariatric Bench mounted on a Compact Platform
- Fig. 5 Convention chair mounted on a Shifter Base
- Fig. 6 Bariatric Treatment Chair with removable side cushions
- Fig. 7 Bariatric Conveyance Chair used for treatment
- Fig. 8 Bariatric conveyance Chair in a waiting room setting
Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2011 Sep;54(9):1073-82. doi: 10.1007/s00103-011-1341-y.