Transcript Patients with special needs

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
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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.
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* 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.
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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
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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
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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
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Visually impaired
Hearing Impaired
ADHD
Attention Deficit
Hyperactivity Disorder
Autism
Down’s syndrome
Mental Retardation
Cerebral Palsy
Congenital/Hereditary
Syndromes
Medically compromised
pediatric patients
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Asthma
Congenital Heart
Disease
Seizure Disorders
Coagulation Disorders
Oncology :
Acute Leukemia
Chemotherapy and
Radiotherapy
Organ Transplants
Sensory impairments
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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.
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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
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Guidelines when working with the vision
impaired:
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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
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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
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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
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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
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Disorders associated with ADHD
Anxiety Disorders
 Learning Disabilities
 Disruptive Behavior
Disorders/Conduct Disorders
 Mood Disorders/Depression/Bipolar
Disorder
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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.
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Dental Management
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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
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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
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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
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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
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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
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Etiology
Genetic- Down Syndrome
Physical-anoxia, prematurity
asphyxia, maternal infection
Mental retardation
Dental Management
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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
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Down’s Syndrome
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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.
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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
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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
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Cerebral Palsy
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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
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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
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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
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The following considerations should be
taken to prevent a dental emergency
( seizures):
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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
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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
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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
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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
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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
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Cardiovascular diseases
Heart valve disease
 Hypertension
 Myocardial infarction
 Cardiac arrhythmias
 Angina pectoris
 Congestive heart failure
 stroke
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Dental care should include:
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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
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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
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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.
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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)
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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
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Immunocompromised patients
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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
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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.
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Any surgical procedures must be
consulted with leading doctor
 Antibiotic protection may be considered
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candidiasis
Erythematous Candidiasis, hard
palate Fungal disease
ulcer
Herpes virus
Cyclosporin gingival swelling
PREVENTIVE CONCEPTS FOR
SPECIAL ORAL HYGIENE NEEDS
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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.
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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
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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
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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
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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
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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
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How to Ask Question
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Ask if they have had a similar exam before
and if they had problems
– Good way to open discussion on disability, etc
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Asking about helping
– offer helping as available option
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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
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Remember:
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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 ?
Thank you…