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Dental Pearls Treating Patients with Special Needs

Dental Pearls Treating Patients with Special Needs. Tegwyn H. Brickhouse DDS PhD Associate Professor Department of Pediatric Dentistry. Learning Objectives. Describe physical, mental, and behavioral challenges of special needs patients and identify approached to management.

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Dental Pearls Treating Patients with Special Needs

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  1. Dental PearlsTreating Patients with Special Needs Tegwyn H. Brickhouse DDS PhD Associate Professor Department of Pediatric Dentistry

  2. Learning Objectives • Describe physical, mental, and behavioral challenges of special needs patients and identify approached to management. • Discuss common oral health problems in patients with special needs and strategies for care. • Educate caregivers how to help patients with special needs maintain oral health. • Educate caregivers that: Oral health is an integral part of general health and well-being.

  3. Training goals • Observe complex restorative treatment on children undergoing general anesthesia and moderate sedation for dental rehabilitation. • Experience with a clinical simulation of a stainless steel crown preparation and restoration. • Clinical hands-on training to provide infant oral health risk assessment and fluoride varnish application. • A brief pre and post evaluation will be done as a part of this experience to provide insight into the value, appropriateness, and outcomes of this training.

  4. Patient’s with Special Health Care Needs • 56 million Americans have some type of disabling condition and 25 million Americans have a severe disability. • Many formerly acute and fatal conditions have become chronic and manageable problems. • Today, 80% of individuals are living in community-based centers or at home with families.

  5. Barriers to Oral Care • Physical accessibility - access mandated by law. • Lack of financial resources • Rely more on government funding for health care • Lack access to private insurance • Medical health benefits often do not cover related oral health care • Major reason for personal bankruptcy is medical expenses • Lack of effective communication • Language and cultural considerations • Priorities and attitudes of importance of oral health • Behavior management issues • Limited transportation resources

  6. Health Challenges • Mental Capabilities • Behavioral Issues • Mobility Problems • Neuromuscular Problems • Uncontrolled Body Movement

  7. Health Challenges • Cardiac Disorders • Gastro esophageal Reflux • Seizures • Visual Impairments • Hearing Loss/Deafness • Latex Allergies

  8. Oral Health Problems • Dental Caries • Periodontal Disease • Malocclusion/Malformations • Damaging Oral Habits • Tooth Eruption • Trauma and Injury

  9. Treatment Principles • Basic principles of pediatric dental care apply to all children. • Always obtain / thoroughly review medical history. • Dentist must be comfortable obtaining medical consults from treating physicians. • Consider patient’s ability to maintain oral hygiene and to cooperate for appointment when planning treatment and recall timing.

  10. Treatment Principles • Consider length and time of day for appointments. • Usually short chair time and early in the day • May need to alter preventive periodicity • Parents maybe helpful in management in operatory

  11. Treatment Principles • For patients with mild ID give simple instruction, be repetitive, and use positive reinforcement • Patients with moderate-severe ID may need restraints and sedation for treatment. • With the exception of Craniofacial conditions, dental care needs and treatment are not much different from the general population. • TREATING THE TEETH IS EASY - THE ABILITY TO TREAT WHAT THE TEETH ARE ATTACHED TO CAN BE DIFFICULT

  12. Current Trends • Prenatal diagnosis has decreased the incidence of Down’s syndrome and severe DD/ID • Improved medical care has allowed more infants with disabilities to survive • Neonatal screening - PKU, Newborn Hearing • 29 newborn tests in Virginia

  13. Common Conditions • Autism • Cerebral Palsy • Down Syndrome • Intellectual Disabilities/Mental Retardation

  14. Autism: Pervasive Development Disorders (PDD) • The primary feature of all PDD’s is impairment in social reciprocity. • Impairments in communication, repetitive behaviors, narrow interests, and rituals may be present. • Children with PDD’s are limited in social motivation and emotional recognition.

  15. Types of PDD • Autism: Most common PDD • Asperger Disorder: Similar to Autism but with little impairment in language or cognition. Considered to be a higher functioning form of autism • Rett Disorder: X-linked dominant disorder (almost exclusively affects girls), with clinical onset between 6-18 months of age. Progressive neurological disorder characterized by loss of purposeful hand use, spasticity, seizures, and mental retardation. • Childhood Disintegrative Disorder: Very rare disorder in which child progresses normally until age 3-5 years then rapidly declines into autistic behavior • PDD-NOS - Not otherwise Specified

  16. Prevalence of PDD • PDDaffects 2-6:1000 individuals • As many as 1.5 million Americans are believed to have some form of Autism • Statistics show that this number is growing at a rate of 10-17%/year. (In a decade it is estimated that 4-5 million Americans will be affected) • Autism is four times more prevalent in males than females • Autism knows no racial, ethnic, social, economic, or educational boundaries.

  17. Etiology of Autism • Autism is caused by an abnormality in brain structure or function. • The exact cause is unknown • Genetic link? • Identical twins have higher rate than fraternal twins. • Families have higher rates (5-7% chance of having 2nd child with autism). • There is not yet a definite genetic link.

  18. Diagnosing Autism • There are no definitive medical diagnostic test to diagnose Autism. • Enlarged fetal brain maybe seen on scan • By definition symptoms of autistic disorder must be manifest by 3 yrs of age • Characteristic behavior may not become obvious until 2-6 yrs. • Developmental screening during check-ups is key in assessing baby’s progress

  19. General Characteristics • Autism is a spectrum disorder therefore patients can exhibit any combination of the general characteristics and any degree of severity. Onset is within first 3 years of life. • Resistance to change, insistence on repetition • Difficulty in expressing needs (uses gestures instead of words) • Repeating word/phrases instead of normal responsive language • Inappropriate reactions (laughing, crying, tantrums) • Prefer to be alone, difficulty interacting with others

  20. Characteristics of Autism • Little eye contact • Not responsive to verbal cues, acts as if deaf • Sustained unusual play (spinning objects) • Motor abnormalities (hand flapping, toe walking) • Disruptive behavior • May prefer to play alone • Apparent over/under sensitivity to pain • Noticeable physical over/under activity • Often have sensory integration problems - Smells may make them gag - Ordinary noise may be painful

  21. Autism vs. Other Disabilities • Autistic children typically avoid or do not respond to social interaction • Children with ID typically enjoy social contact • Autistic children may test very well in mathematical, musical, or visual spatial skills. Will not test well in verbal and language skills. • Children with ID will test uniformly. • Autism can also present as obsessive compulsive disorder, ADHD, psychiatric disorders. • Early evaluation is critical. The earlier a child is diagnosed with autism, the earlier he/she can begin benefiting from treatment programs

  22. Associated Conditions • 2/3 -3/4 of individuals with autistic disorder also have intellectual disabilities. • The severity of autism symptoms increases with severity of MR. • Epilepsy occurs in 25-30% of autistic pts. • Onset can occur in adolescence or infancy.

  23. Treatment of Autism • There are no medications that affect the core features of this disorder • Treatment is aimed at education, social development, behavior support, and family assistance • Outcome for a child with PDD is closely linked with their language and intelligence abilities

  24. Prognosis • Approximately 50% of all children with Autistic disorder acquire language and learn to communicate with useful speech • Classical behavioral features of autism tend to recede a little over time

  25. Dental Treatment • Important to develop a routine, same dental staff, quick and quiet appointments. • Children may have poor muscle tone, poor coordination, and drooling problems. • Tend to prefer soft foods and sweetened foods • React to textures of foods and touch of materials • Because of poor tongue coordination, tend to pouch food • Increased caries susceptibility - poor diet • May need papoose and sedation

  26. Attention Deficit and Hyperactivity Disorder • ADHD is a neurobehavioral syndrome that begins early in childhood • Diagnosis is based on behavior patterns that have lasted for at least 6 months and began before age 7. • Incidence is increasing • Actual increase? • Better diagnosis? • Desire to put a name on child’s behavior? • Desire to find something to blame for behavior?

  27. Prevalence • The number of individuals diagnosed and treated for ADHD has increased dramatically • Studies suggest that ADHD continues to be under and over diagnosed • Estimated 2-9% of children have ADHD • Impulsive/hyperactive type is more common in boys, inattentive type has an even gender ratio.

  28. Associated Impairments • Academic Underachievement • Impaired adaptive skills, social difficulties • Sleep difficulties (insomnia, bedwetting) • Increased risk for injury due to risk taking behavior • Developmental Coordination disorder • Increased risk for physical abuse due to difficult behavior

  29. Causes • Heredity: Causes 80% of ADHD • Other causesthat may increase the risk for ADHD: • Prenatal exposure to smoking, lead, alcohol, or cocaine • Prematurity or intrauterine growth retardation • Complications during labor and delivery • Brain infections • Inborn errors of metabolism

  30. Treatments for ADHD • Treatment includes education and counseling for child, parents, and teachers; educational interventions; and medication • Most common medications are stimulants (i.e. Aderall, Ritalin, Dexedrine) • Other medications include antidepressants (Zoloft, Paxil), neuroleptics (Valium, Haldol), or alpha-2-adrenergic antagonists (Clonidine, Tenex)

  31. Medication Complications • Side Effects • (decreased appetite, rebound, tics, sleep disorders, headaches) • Potential for substance abuse • Monitoring therapy • Stopping medication

  32. Prognosis • Most symptoms of ADHD diminish between age 10-25 years. • Hyperactivity declines more rapidly than impulsivity or inattentiveness • In 40% of individuals some symptoms persist into adulthood. Adults with persistent symptoms tend to complete less schooling, have lower status jobs, and have higher rates of antisocial behavior • Best indicators of outcome are family support, level of intelligence, and lack of co-existing conditions

  33. Dental Treatment for ADHD • Set clear rules, • Use positive reinforcement and verbal praise, • Be consistent and calm. • If sedation is necessary make sure patient takes meds and remember benzodiazepines like diazepam often increase over-activity. • Time-out is a common disciplining tool.

  34. ADHD and Dental Caries Bimstein E. et al. Oral characteristics of children with attention-deficit hyperactivity disorder. Spec Care Dentist. 2008; 28(3):107-10. • Higher prevalence of • Toothache bruxism, bleeding gums, and oral trauma histories than the control group (chi square, p < 0.05) • Pearl – Kids with ADHD may have an increased risk for dental caries

  35. Cerebral Palsy • Disorder of movement and posture caused by a non-progressive abnormality of the immature brain • 1.4 - 2.4 cases per thousand • Low birth weight infants at increased risk • Associated disabilities may occur and are permanent • Seizures • Visual and auditory impairments • Strabismus • Hand-eye coordination • Intellectual disabilities • Learning difficulties • Behavioral problems

  36. Types of Cerebral Palsy • Spastic - most common • Increased muscle tone • One side more effected, usually arm more than leg • Dysarthria-difficulty speaking • Dyskinetic - abnormalities in muscle tone involving the entire body • Exhibit rigid muscle tone while awake, normal or decreased tone while asleep • Chorea - rapid, jerky movements • Athetoid - slow, writhing movements • Ataxic – rare • abnormalities of voluntary movement involving balance and position in space

  37. Mental Capabilities • Mild to moderate mental retardation • 25% severe retardation • May of normal intelligence • Dysarthria, allow time for communication • Talk through computer mechanisms

  38. Dental Attributes • Oral development and occlusion often effected • Open bite/anterior protrusion, increased anterior trauma • Tongue thrust • Excessive drooling • Treatment may or may not be possible • Don’t prejudge

  39. Tailored Dental Care • Maintain clear paths for moving through treatment setting • Treat in wheelchair/ use of sliding boards • Short appointments • Uncontrolled movements • Relaxation • Anticipation with familiarity • Softly cradle head • Muscle relaxants, sedation, general anesthesia

  40. Dental Care • Dental needs essentially the same as for all children • GERD: Gastroesophageal reflux-erosion • Tube-fed, high levels of calculus. • Increased risk due to inability to practice good hygiene • Use adaptive devices • Need for assistance • Cognitive ability may not be as impaired as physical ability • May use passive restraint to assist patient in sitting still • papoose board, soft pillows • Focus on communication • Talking slowly • Eye contact • Short commands

  41. Down Syndrome/Trisomy 21 • The most frequently occurring chromosomal abnormality resulting in intellectual disabilities and other abnormalities • Children with Down Syndrome are born at the same rate into families of all social, economic, and racial backgrounds, and to parents of all ages.

  42. Prevalence • Children with DS account for 1:800 births • Risk of chromosome disorders increases with maternal age at age 20 (1/1600), at age 35 (1/370) • Risk of having another child with DS is about 1:100 • Sex ratio 3 males:2 females

  43. Physical Traits • Characteristic facial features: • Flattened facial profile • Flat nasal bridge • Epicanthal folds • Low-set ears • Transverse palmer crease

  44. Behavior • Hypotonia at birth with delayed gross motor skills • Developmental Delay • Affectionate, gentle, cheerful personalities • Can be very stubborn • Temperament and behavior disorders comparable to typically developing children

  45. Medical Complications • Approximately 2/3 of DS patients were found to have congenital cardiac defects: • 40% • Mental retardation • IQ ranges from 25 to 50 • Otitis • Atlantoaxial instability • 12-20% • Susceptibility to infections and cancers • Approximately 2/3 of DS patients have some from of sensory impairments • Most common visual problems were refractive errors, strabismus, and nystagmus. • Hearing problems associated with narrow throat structures also lead to recurrent ear infections

  46. Medical Complications

  47. Complications • Obstructive sleep apnea in about 30% • Dentition • Hypoplasia • Irregular placement • Fewer/same caries • Increased periodontal disease

  48. Management Concerns • Frequent compromised immune system leads to higher rate of infection • Frequently linked to epilepsy, diabetes, ALL, hypothyroidism • Extra appointment time to allow for communication • Atlanto-axial instability increased motility between C1 and C2, careful positioning in the dental chair

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