This article was first published in the ADA's News Bulletin magazine in April 2022.
A past presenter on the ADA's CPD Portal on the subject of special needs dentistry, Dr Warren Shnider has been a committed advocate since before he attained his qualification in Special Needs Dentistry from the RACDS in 2006. Now Head of Unit of the Special Needs Dentistry department at the Royal Dental Hospital of Melbourne, and the Academic Lead in Special Needs Dentistry at La Trobe University, he admits he found himself specialising in SND "by accident".
I spent a lot of time in my undergraduate years being the slowest cat in the alley. I thought I was pretty hopeless as a practitioner because I needed to know everything about my patients: what was their medical condition; what medications they were taking; what was their emotional and behavioural expression about health in general and dentistry in particular; did their toothbrushes see teeth twice a day and did cola beverages see their teeth most of the day? Some years later, I was accepting patients on referral as a general practitioner from other general practitioners.
I did really long consults where I'd sit and have a chat with patients in a tea room away from the surgery. I learned so much about my patients as well as their oral health and disease, that the oral examination often became a mere affirmation about what was invariably predictable from the conversation/consultation.
I really enjoyed the health provider/patient relationship that patients afforded me and I spent a lot of time with patients who were fearful of operative procedures. I did a lot of anxiolysis inhalation sedation.
Although it was really rewarding, I felt somewhat underachieving in the context that my skill and knowledge up to that point was by osmosis, not by any particular specialist training. I decided I needed to do more study and training to specialise in this area of practice.
For all specialties, not just special needs dentistry, there is a moment of epiphany: You wake up one morning, and there is a conscious realisation that there is a burning unfulfilled passion. Specialisation is a quintessential paradox: it is the easiest and yet most difficult area of practice. Easy, because you know pretty much who and what is going to come through that door, and hardest, because you're expected to have all the answers to the deepest, darkest most complex situations. If you get out of bed and are fool enough to still have your hand up for all of that, you know you have to pursue that further training. I guess reassuringly, too, you know you will get through and even enjoy the journey. The training and subsequent clinical practice are a labour of love.
In the early days of advocating and agitating with the then Dental Board of Victoria leading up to the recognition of the specialty I found myself and my SND colleagues marginalised and patronised. "It's only dentistry" was a common argument. "You do exactly the same as other dentists do" was another. But soon enough, those early criticisms tended to disappear and along came referrals and the 'please help' calls from the very same practitioners that objected to the Board's initial considerations.
In the late 80s I went out to do a home visit for a man who had broken his denture. He was blind, incontinent and non-ambulant, mostly attributable to poorly controlled diabetes (neuropathy, nephropathy, angiopathy). He had a couple of loose teeth remaining in his lower jaw too. I thought I could grab those and make new dentures. I remembered something about diabetes and periodontal disease and wound healing so I went off to the library to read up. Armed with little knowledge I removed the teeth and made new dentures.
Some time later I returned to see how he was getting on. He was amazing. Now that he could chew and eat properly, his blood sugars had stabilised. Now that his diabetic control was better, his recurrent urinary tract infections diminished. Now that the infections diminished, his continence improved. Being more confident, he socialised more and went out to meet friends in the mall. Now that he was out and about, his antidepressant medications ceased. Now that his xerostomic medications stopped, his saliva was better. With better oral lubrication, his dentures were more comfortable in function. With superior mastication and deglutition, he had a more balanced variety of foods that further stabilised his diabetes.
I rushed back to the library. I read all the fat textbooks and journals. The inextricable link between oral health and general health was obvious to me but poorly researched. It's really important to recognise that what may be small dental interventions can become major modifiers of quality of life for people who are living with disability.
Go to the ADA's CPD Portal to access Dr Shnider's piece and other items on special needs dentistry.
