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Patients with special needs Department of Biomaterials and Experimental Dentistry Justyna Jurga, DDS, PhD Numerous conditions require special patient management The dental professional have to endeavor to treat each patient as an individual with unique needs that may require modifications, additions or deletions to the standard of care People with special needs are those whose dental care is complicated by a physical, mental, or social disability. Numbers Approximately 54 million people (about 20% of the population) currently live with some type of disability and this number is on the rise. More than 6 million residents in the United States (and nearly 200 million people throughout the world) have some form of intellectual disability. Intellectual disability is more prevalent than deafness or blindness, and in most cases, is accompanied by secondary health conditions that place these individuals at greater risk for medical complications than the general population. * 9.3 million residents had a sensory disability involving sight or hearing. * 21.2 million people had a condition limiting basic physical activities, such as walking, climbing steps or carrying things. * 12.4 million individuals had a physical or emotional condition causing difficulty in learning, remembering or concentrating. * 18.2 million individuals age 16 and over had a condition that made it difficult to go outside the home to shop or visit a doctor. The proportion of the population with sensory, physical and mental disabilities generally increases with age, reaching 40% or more for persons 65 years and over Access to appropriate health care for this population is often inadequate and generally of less quality than for the overall population. studies show that the population with intellectual and developmental disabilities has significantly higher rates of poor oral hygiene and periodontal treatment needs than the general population but almost two-thirds of patients with special needs reported that it was difficult to find dentists willing to treat individuals with disabilities Improving oral health for people with special needs is possible mainly through community based dental care systems Education of patients and parents with regard to prevention and treatment of oral disease must be planned from a very early stage This will minimise disease and operative intervention since extractions and surgical procedures often produce major problems Dental healthcare workers need to be educated about this subject Patients with special needs Visually impaired Hearing Impaired ADHD Attention Deficit Hyperactivity Disorder Autism Down’s syndrome Mental Retardation Cerebral Palsy Congenital/Hereditary Syndromes Medically compromised pediatric patients Asthma Congenital Heart Disease Seizure Disorders Coagulation Disorders Oncology : Acute Leukemia Chemotherapy and Radiotherapy Organ Transplants Sensory impairments 1. Visual impairment/ blindness - Legal blindness is defined as a visual acuity of 20/ 200 ( a person sees at 20 feet what a person with normal vision sees at 200 feet ) or less after the best optical correction - Visual impairment refers to sight no better than 20/ 70 after optical correction The leading causes of blindness are: Macular degeneration Diabetes Senile cataracts Vascular diseases Trauma Infections etc. A thorough medical history is essential and aids in the development of creative oral hygiene instructions Other senses are often more sensitive appealing to them is usually the best approach Referring to patient’s memory when describing oral recommendations is only helpful if the individual has acquired blindness Guidelines when working with the vision impaired: 1. Lead the patient by standing slightly in front; the patient will hold onto your bent arm near the elbow for guidance 2. Indicate changes in the floor and prepare a path to the dental chair that is free of obsacles 3. Always describe procedures to the patient in a step by step fashion using the patient’s own mouth to provide instructions 4. If the patient is partially sighted , avoid the glare of light into his eyes Hearing impairment/ deafness Hearing impairment is defined as defective / functional hearing with or without the assistance of hearing aid Deafness is the inablility to understand speech even with the use of a hearing device Deafness can be associated with outer , middle and inner ear mechanisms The leading causes of deafness are: - heredity, prenatal, mother infections - trauma - toxic drug effects During communication with the deaf the following recommendations are advised: 1. Face the patient , remove your mask , speak normally .Pause more frequently than usual, because many patients rely on lip reading 2. Avoid sittting in front of a window or bright light that may cast a shadow on your face 3. Use a pencil and paper to communicate oral care recommendations if necessary 4. Avoid backgroud noise. Ask the patient to turn off a hearing aid when using high- pitched powered scaling and toothbrush devices 5. Become familiar with common sign language signals that may be helpful during appointment, such as close, open, rinse etc. 6. Tell, show and do all procedures to reinforce them and enhance the patient’s understanding Behavior Problems ADHD Condition affecting the CNS characterized by increased motor activity and restlessness, short attention span, and inability to concentrate Incidence: 3-5% / boys 4 to1 Is it really ADHD? Not all children who are overly hyperactive, inattentive or impulsive have ADHD Are they a continuous problem or just isolated episodes? Etiology: neurobiology, genetics environmental factors hstimulated kids Disorders associated with ADHD Anxiety Disorders Learning Disabilities Disruptive Behavior Disorders/Conduct Disorders Mood Disorders/Depression/Bipolar Disorder Strattera (atomoxetine) Non stimulant medication for ADHD Works on neurotransmitter norepinephrine More studies needed but results today indicate that over 70 % children with ADHD given Strattera manifest significant improvement in their symptoms. Dental Management Behavior management techniques In some countries You can use Nitrous Oxide /Oxygen for anxyolisis set rules, give short commands, be gentle but firm, be quick! Morning appointments when meds max Avoid delays in waiting room short appointments (short attention span) Autism Complex developmental disability that affects the functioning of the brain g social interaction/communication skills Wide variety of combinations and severity of symptoms Mild cases are called Asperger syndrome (AS) deficiencies in social skills, prefer sameness, tantrums, obsessive routines, crying, showing distress for no reason can be misdiagnosed with ADHD Autism Marked overall hyperactivity, persistent bruxism, tongue thrust, cariogenic food often used for rewards Unusual and unpredictable response to stimuli very sensitive to certain sounds, textures, tastes, and smells. Seizures 1 of 4 autistic children develops seizures . Usually anticonvulsants g Gingival Hyperplasia and Gingivitis + poor oral hygiene Delayed tooth eruption, high risk dental trauma, bite tongue, cheeks. Dental Management Autistic Children don’t like change short appointments, same chair and assistant, be prepared, firm but gentle, use exaggerated TSD technique. Observe patient’s movements and look for patterns Regular dental examination can be difficult Restraint with bite blocks and sedation Avoid loud voices and bright lights, because they may upset the patient Mental retardation Significantly subaverage general intellectual functioning existing concurrently with deficits in adaptative bx and manifested during the developmental period. 3% US population Classification IQ Impairment 68-83 Borderline 52-67 Mild 36-51 Moderate 20-35 Severe less 20 Profound Ability Slow Lerner Educatable Trainable Dependable Mental retardation Etiology Genetic- Down Syndrome Physical-anoxia, prematurity asphyxia, maternal infection Mental retardation Dental Management MR children can learn in the same way as normal kids, but at a slower rate Limited attention span and less ability to rationalize dental procedures. Positive reinforcements, simple instructions and repeat them constantly Down’s Syndrome Genetic Disorder associated with medical and physical abnormalities Characteristics MR with limited ability to learn and communicate Impaired Speech /Delayed Language development Down’s Syndrome Cardiac Abnormalities :valve defects and dysfunctions. Delayed eruption of permanent teeth and over-retained primary teeth Microdontia/enamel Hypoplasia/Oligodontia. Increased incidence of periodontal Disease Macroglossia Gingival hyperplasia Malocclusion Xerostomia- Down’s Syndrome Frequent 3 months recall visits Determine level of comprehension and ability to cooperate and then use appropriate management techniques. Use simple short instructions and repeat them is necessary. Behavior management The patient’s family or caregiver will be able to guide the dental staff as to what level of communication is appropriate It is important that the dentist communicate directly with the patient- to build a level of trust Patients with Down syndrome should be educated in proper oral hygiene Use of topical and systemic fluoride Fissure sealants are also recommended Scheduling appointments early in the day is beneficial – both patient and operator are more rested First appointments should be for orientation only and subsequent appointments may require a little more time what is usually allowed Cerebral Palsy Non-progressive disorders of the neuromuscular system with wide range of symptoms and disabilities characterized by paralysis, muscular weakness, and dysfunctions Etiology: prenatal dev. defects, anoxia narcotics, infections Classification: extrapyramidal/Ataxia/Spastic Cerebral Palsy Spastic most common type (60%) increased muscle tension and excessive involuntary contractions, Facial contractions, drooling and excessive body movement Following recommentations with CP patients are advised: Scheduling the patients for morning appointments Knowledge of wheelchair transfers Head and arm restraining devices Suitable oral hygiene accessories Use of fluoride gel Proxident brand designed for patients with special needs. The toothbrush, for example, has been adjusted to give those with functionally disabled hands a workable grip while brushing and the Proxident Bite Support helps patients who have difficulty opening their mouths. It also acts as protection for those performing oral care and treatment on others. Proxident Mouth Spray can be useful for certain patient types. There are two variants - one which stimulates salivary flow and one which lubricates to protect the mucosa. Both contain fluor and xylitol and are pleasantly flavoured. Epilepsy Epilepsy is a variable symptom complex that is characterized by reccurent attacks of unconsciousness or impaired consciousness usually accompanied by tonic or clonic spasms These attacks are called seizures Seizures are usually preceded by an aura The following considerations should be taken to prevent a dental emergency ( seizures): Ask your patient if prescribed medications have beeen taken: when was the last seizure, was there an aura, how often do the seizures occur and what events precipitate a seizure? Schedule short appointments in the morning; avoid anxiety or stress-provoking situations and keep a calm atmosphere Metabolic Conditions 1. Diabetes mellitus- is a metabolic disease charakterized by a reduction in carbohydrate metabolism and an increase in lipid and protein caused by a deficiency in insulin produced by the pancreas.Hyperglycemia is the result. Type 1- sudden onset, usually affecting persons younger than 40 Type 2- the most common of the two types, slow onset symptoms affect obese persons usually older than 40 years old Blood glucose levels are directly proportional to blood presure, weight, tobacco use and alcohol consumption Glycemic control is important to prevent systemic complications such as eye, kidney, heart and periodontal diseases Unstable diabetes can exacerbate periodontal disease and periodontal disease can cause blood glucose levels to rise Advise Assess for glycemic control by asking questions about the patient’s lifestyle How often the blood glucose level is monitored What forms of treatment have been prescribed Ask about the condition of the oral soft tissues ( dry cracked lips, dry mouth, burning inflamed mucosa, bleeding, poor wound healing, candidiasis etc.) The patient with uncontrolled diabetes may require premedication with an antibiotic before dental treatment Prescribe mouth rinse with chlorhexidine Asthma Chronic obstructive airway disease caused by edema of mucous membranes, increased mucous secretions and smooth muscle spasm brought on by triggering factors. Exposure to irritants: cold air, dust, pollen, anxiety, stress of dental Asthma * signs and symptoms of asthma: - wheezing, coughing, tightness in chest, dyspnea * management consists of bronchodilators * Oral management involves creating a relaxed , climate- controlled environment * Ask the patient to bring their inhalers with them and place them in an easily accessible location in case of attack * Aspirin and NSAIDs should be avoided because of their allergic potential Asthma Genetic and environmental factors Incidence: 5-10 % children Symptoms: coughing/wheezing chest tightness and dyspnea Dental Management Anxiety management/sedation with Nitrous versed Bring inhalers to appointment Higher caries due to decreased salivary gland function (action of bronchodilators), gingivitis, mouthbreathing Be prepared for emergencies Cardiovascular diseases Heart valve disease Hypertension Myocardial infarction Cardiac arrhythmias Angina pectoris Congestive heart failure stroke Dental care should include: Scheduling short morning appointments Providing a calm atmosphere to reduce anxiety or stress Keeping the patient in a semisupine position Avoiding the use of vasoconstrictor Having nitroglycerin available( angina pectoris) Discontinuing treatment if the patient begins to appear fatigued or has a change in heart rate or rythm Cardiac pacemakers. The chief hazards from dental equipment to pacemakers are from electrosurgery and diathermy, but these are infrequently used but there is also the risk from other equipment such as ultrasonic scalers or pulp testers which is small but must be considered Dental procedures associated with higher incidence of bacteremia Dental extractions Periodontal procedures including surgery, subgingival placement of antibiotics fibers/strips, scaling and root planning, probing, recall maintenance Dental implant placement and replantation of avulsed teeth Endodontic instrumentation or surgery only beyond the apex Initial placement of orthodontic bands but not brackets Intraligamentary and intraosseous local anesthetic injections Prophylactic cleaning of teeth or implants where bleeding is anticipated Bleeding disorders Dental extractions and surgical procedures, including local analgesic injections, can cause problems in patients treated with anticoagulant drugs and those with coagulation defects or severe thrombocytopenic states. Patients treated with anticoagulant drugs must bring blood test results to evaluate the ratio Pregnancy Maintaining good oral hygiene to prevent hormonal- induced gingival changes Nutritional counseling and oral hygiene instructions to reduce the risk of caries ( morning sickness) 1. First trimester a) meticulous plaque control and OHI, b) diet counseling c) elective dental treatment radiographs and local anesthesia shoud be avoided d) urgent dental care only is advised 2. Second trimester a) this is the safest period for dental treatment b) routine dental care is advised 3. Third trimester a) avoiding placind the patient in a supine position- semi supine is better b) turn the patient to the left side if she begins to feel faint or uncomfortable gingivitis Pregnancy tumor Parkinson’s disease Parkinson's Disease affects multiple regions of the nervous system. Sadly, 40 percent of Parkinson's Disease patients suffer from depression. It's the treatment of the depression with antidepressant drugs that can cause increased tooth decay. Many antidepressants lead to Xerostomia (dry mouth). If left unchecked, Xerostomia can lead to serious infection and create compounding health problems for the Parkinson's patient Patients with Parkinson’s disease have stiffness or rigidity of muscles and tremor in one or two hands Dental visits must be short Tooth brushes with comfortable handles and mouth rinses are recommended Immunocompromised patients In this group we can find patients treated with immunosupression in all autoimmune disease Crohn disease Systemic lupus Multiple Sclerosis Rheumatoid arthritis and many more And patients undergoing immune supresion after organ transplants We have also patients with Primary immune deficiency diseases that means disorders in which part of the body's immune system is missing or does not function properly (leukemia) And secondary immune deficiency disease in which the immune system is compromised by factors outside the immune system, such as viruses (HIV)or chemotherapy Oral diseases in immunocompromised people The commonest lesions are candidiasis and herpes viral infections, but others include ulcers, periodontal disease, and malignant neoplasms spontaneous gingival bleeding also are seen in patients with leukaemia drugs such as ciclosporin can cause gingival swelling. Any surgical procedures must be consulted with leading doctor Antibiotic protection may be considered candidiasis Erythematous Candidiasis, hard palate Fungal disease ulcer Herpes virus Cyclosporin gingival swelling PREVENTIVE CONCEPTS FOR SPECIAL ORAL HYGIENE NEEDS High levels of fluoride in toothpastes. Introducing the concept of high-fluoride (5,000 ppm) toothpaste to patients is not difficult, because most of them have been brushing their teeth routinely, and this concept requires only changing the type of toothpaste. I suggest that practitioners keep an adequate quantity of high-level fluoride toothpastes in their offices to be given or resold to patients who need this high level of preventive service. Among the brands of 5,000-ppm fluoride tooth-pastes are PreviDent 5000 Plus (Colgate Oral Pharmaceuticals, Canton, Mass.), Fluoridex 5000 ppm Neutral Sodium Fluoride Toothpaste ( High-level fluoride gel in trays. The provision of high-level fluoride gel (5,000 ppm) in trays is the most cariostatic preventive concept available, but it requires the patient’s cooperation and significant behavioral modification to wear the trays containing fluoride. Rinses. Several excellent preventive rinses are available for potential assistance in controlling periodontal disease. Mechanical toothbrushes. Although long available at considerable expense, in my opinion, new low-cost mechanical toothbrushes are mandatory for both physically compromised patients as well as for caregivers who can assist patients with intellectual disabilities in how to use them. Easy-to-use dental floss. People who need to use floss to clean their teeth often are discouraged because the floss catches on rough restorations. Such patients should be advised to use the thin, slick forms of floss Frequent recall appointments. recall and examination appointment once every six months is not enough for the types of patients described in this article. Many clinicians have recommended that such patients return every two, three or four months until their specific condition is under control, at which time they can return to the standard biannual professionally administered preventive regimen. Tongue cleaning. Cleaning the tongue—a major factor in oral hygiene—often is neglected. If the tongue appears gray-green or gray-brown, tongue cleaning is advocated. Most patients do not clean their tongues. Some brush their tongues, but special tongue cleaners are more effective to remove the debris that collects around the taste buds on the tongue. Scraping of the top surface of the tongue once or twice daily is suggested to reduce the microorganisms in the mouth Antibiotics for treatment of periodontal disease. Use of systemic or local antibiotics for treatment of periodontal disease has been suggested by many clinicians and researchers. Systemic doxycycline hyclate administered in 20milligram doses twice daily has been promoted for assistance in treating periodontal disease. Additionally, antibiotics are being used locally in periodontal pockets Supporting Special Needs In The Office Develop appropriate office procedures – ask at time appointment is made if there are any special needs the patient has, e.g. chemical sensitivities, uses service animals, interpreters Train staff Develop appropriate materials Design appropriate office space Choose most flexible/adaptive equipment Offending Patients With Special Needs Being patronizing Showing fear or discomfort or nervousness “Walking on eggshells” around disabled people Being overly friendly You aren’t perfect How to Ask Question Ask if they have had a similar exam before and if they had problems – Good way to open discussion on disability, etc Asking about helping – offer helping as available option Asking about disability – personal versus professional – Is there anything about the patient which could affect the exam or results Clinician Skills Needed To Support Special Needs Skills in alternative examination methods Excellent hearing and expressive skills Negotiating skills Personal comfort in unfamiliar situations Good problem solving skills Confidence but openness Recognition of personal limits Remember: Be flexible Alternative equipment Alternative positioning with standard equipment Alternative flow of exam Creative problem solving Brain storming with patient – some patients may want clinician to have all the answers Questions ? 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