Oral health for children with special healthcare needs (CSHCNs)

Oral health is a very important aspect of general health, especially for vulnerable groups such as children with special healthcare needs (SHCNs). The oral care management of these children may require additional considerations, but evidence of the effectiveness of 'different' types of treatment in this population is limited. Pain-free treatment is important to reduce fear and anxiety in children. Different methods have been described for delivery of local anaesthetic with no agreement on which intervention is most successful in increasing its acceptance by children. In additional to professional considerations for oral care management, parents' views and understandings of oral care provision for their children is also of importance. Aims: (i) To assess the quality of clinical guidelines and the underpinning evidence to support oral care recommendations for children with special healthcare needs; (ii) To assess the effect of interventions for increasing the acceptance of local anaesthesia for children with and without special healthcare needs who are receiving dental treatment; (iii) To assess parental perceptions of the provision of oral care that children with special healthcare receive; (iv) To identify potential evidence-based interventions to overcome some of the identified barriers of oral care delivery for children with special healthcare needs. Methods: (i) Guidelines in paediatric dentistry published from 2007 onwards were appraised using the AGREE II instrument. The guidelines were qualitatively assessed to determine if there was a robust body of evidence to support their recommendations; (ii) A systematic review of RCTs, using the Cochrane methodology, was performed in order to determine the effect of methods for acceptance of local anaesthetic (LA) in children with and without special healthcare needs; (iii) A qualitative study, using semi-structured interviews and thematic analysis was undertaken to investigate parental views of the oral care provided for children with special healthcare needs; (iv) A systematic review of evidence aimed at overcoming barriers to the delivery of oral care, was undertaken. Results: (i) The quality and reporting of guidelines for children with SHCNs in paediatric dentistry is very poor. The underpinning evidence that supports recommendations for children with SHCNs is also very limited. (ii) There is insufficient evidence to support any of the assessed interventions to increase the acceptance of LA due to variations in the reported methods, outcomes and timing of outcome measures. (iii) Several themes were identified:importance of oral health, parental roles oral care experiences relating to dental appointments, existing issues with current oral care, and parental views of ideal practice. (iv) Five systematic reviews and five guidelines were identified assessing interventions aimed at improving the delivery of oral care for children with special healthcare needs. Potential interventions include fluoride application, training and education programmes aimed at both caregivers and the dental team. Conclusions: The development and content of clinical guidelines focussing on oral care for children with SHCNs is concerning and the evidence base for their recommendations is limited. Guidelines in this area should be read with caution. The research and dental community need to work together to enhance the current standard of clinical guidelines in paediatric dentistry, specifically for children with special healthcare needs. High quality RCTs of interventions for increasing acceptance of local anaesthetic in children and adolescents having dental treatment are required including children with SHCNs as participants. These should be fully reported according to CONSORT standards. Studies should consider the development and use of core outcome measures to increase the opportunity for pooling of data. The findings of this thesis also point to the need for improvements to the entire network of dental care services to this population. Oral care providers should establish and maintain good communication with the parents of these children and help them in obtaining required support. A number of interventions are needed in order to increase the awareness of parents and caregivers regarding the treatment as well as prevention measures of dental diseases.