Previous research has found an unmet need for oral care among people with intellectual disability. The key factors which have been indicated are low expectations, fear of treatment, lack of awareness among carers and problems in accessing dental services. The withdrawal of many general dental practitioners (GDPs) from the National Health Service (NHS) may have exacerbated the latter problem in the UK. The aims of the present study were: (1) to assess the extent of unmet clinical needs in a group of adults with intellectual disability living in the community who were not in contact with the Community Dental Service (CDS); and (2) to explore their perceptions of teeth and contact with dentists to identify how oral care can be improved. Interviews were completed with subjects and/or carers and a dental examination was completed. There were higher levels of untreated caries (decay), and gingival or periodontal (gum) problems among the sample than in either the general population, or in a previous survey of CDS users at day centres and residential facilities. The subjects were largely unaware of dental problems, and used the appearance and absence of pain to judge the condition of their teeth. They depended greatly on their carers for decision-making and support with regard to visiting the dentist and tooth-brushing. Carers requested training in oral care and the use of dental services, and support in dealing with clients who have problems tolerating tooth-brushing. The subjects had experienced a wide variation in the treatment provided by dentists, but had not found it difficult to access a dentist despite recent reductions in the availability of NHS dental care. They expressed a particular need for a good relationship with their dentist and for their dentist to have personal skills in relating to people with an intellectual disability. Dental screening checks and oral care training for carers should be made easily available. Care plans should include tooth-brushing and dietary issues for all clients who have their own natural teeth. There are significant training issues for dentists in developing personal skills in total communication, disability awareness and attitudes which value people with intellectual disability.

The technique involved a small volume of concentrated midazolam (0.25 ml of a preparation of 40 mg/ml midazolam with 20 mg/ml lignocaine) administered intranasally in the form of a fine aerosol, to facilitate intravenous cannulation and the subsequent administration of a standard titrated midazolam regime. This preliminary audit found that in the majority of cases, the technique was effective in facilitating a range of restorative and periodontal procedures, and offered the prospect of being able to provide better standards of dental care for this challenging group of patients. This paper reports on the second stage of the project which involved a detailed prospective study involving additional centres. The objectives were to further validate the technique by obtaining efficacy and safety data of better accuracy than had previously been possible, and to elicit carers' perceptions on acceptability. The following standards were applied:The intranasal dose should be easy • to administer with minimal physical intervention introDuCtion

• This technique can be safely and effectively used in primary care and to treat adults with learning disability.• The option of providing repeat review examinations and a continuing course of treatment, for example endodontics or periodontal therapy, is possible using this technique.• The technique allows for an oral exam and diagnosis within primary care rather than immediate referral for general anaesthetic. I N B R I E F RESEARCH IntroductionThe provision of dental care for adults with severe learning disability presents problems. The approach to treatment has often been provided under general anaesthesia tending to result in exodontia rather than restorative care. This paper presents an alternative to this option using conscious sedation. Methods A multi-centred retrospective audit was reported on using data from Canterbury, Warwick, Dorset and Cardiff. Patients included adults with varying degrees of disability for whom treatment using local anaesthesia, inhalation sedation, and the acceptance of intravenous cannulation was not possible. Sedation was provided by midazolam first administered by the intranasal followed by the intravenous route. Results From a total of 222 episodes of sedation 128 (57.65%) accepted treatment well and 75 (33.78%) presented slight problems which did not compromise treatment. In 19 cases (8.55%) treatment with sedation was not possible and a referral was made for general anaesthesia. Conclusions Results showed that a range of different treatments were carried out including advanced restorative care. This paper proposes that the technique described is safe and effective in providing a good standard of dental care for adults with severe learning disability.

Patients with cardiac disease, cardiac symptoms and related co-morbidities are increasingly being encountered in dental practice. Current methods of medical risk assessment can however be problematic. This paper represents a multi-speciality consensus on how to identify patients that may be more at risk of an adverse cardiac event occurring perio-operatively i.e. during or in the first few weeks after a dental procedure. Drawing on guidelines for surgery and the available literature, we present on an algorithm which aims to inform dental practitioners' decisions about which patients can be managed in primary care and which should be considered for assessment by a dental specialist together with a methodology thereof.