Dental Care for Special Needs Children Flashcards
Children who require special consideration for dental treatment with physical or learning disability is defined by the academy if paediatric dentistry as:
- those with chronic, physical, developmental, behavioural or emotional conditions
- they usually have limitations on daily activities and require more extensive dental and medical services
What are categories of impairment?
- intellectual - genetic disorders, problems during pregnancy/child birth, illness or injury, or none of these
- physical - cerebral palsy, spina bifida, muscular dystrophy
- sensory - visual impairment and blindness, deafness and hearing impairments
What is intellectual impairment?
Intellectual disability: below average level of intelligence or mental cognitive ability and a lack of skills necessary for day to day living (down’s syndrome, fragile X)
Learning disability: children can be of normal intelligence but have difficulty in learning specific skills (dyslexia, autism, ADHD)
What are the features of down’s syndrome?
- chromosomal disorder - trisomy 21 (extra or partial copy of chromosome 21)
- susceptible to congenital heart disease and a variety of other disorders
- prone to periodontal disease, added risk as plaque control is difficult in these patients
- large tongue, chubby fingers and hands, - toothbrushing can be difficult
- delayed exfoliation of primary teeth - associated with congenitally absent teeth or teeth becoming ectopic
- hypoplastic teeth - abnormal development of enamel - absence or poor quality enamel
Management: Prevention is most important factor - may need to modify toothbrush to support manual dexterity
What is fragile X syndrome?
- genetic disorder - faulty X chromosome, gene makes protein responsible for brain development
- largely undiagnosed in past, more commonly affects males
- intellectually impaired/learning disabilities
- management most importantly prevention
- patients may have problems understanding/tolerating LA, treatment etc
- short appointments more frequently may be beneficial
- treatment plan adjustment - assess what patient can cope with
Give an overview of autism:
What is makaton?
- usually early onset but may take much longer to diagnose
- profound adaptive problems in thinking, language and social relationships
- cause unknown, but thought to be prenatal, not social - MMR link completely discredited
- routines and rituals very important to patient
- world may feel overwhelming
- familiarity - same operator/surgery, appointments that suit patients routine
- difficulty with social communication, interaction and imagination
Makaton: language for patients who struggle with verbal communication, reading and writing, visual symbols to communicate - a form of sign language
What is asperger’s syndrome?
-similarities with autism, but less problems with speaking and are often of average or above average intelligence
- do not usually have the accompanied learning disability associated with autism, but may have specific learning difficulties
- these may include dyslexia and dyspraxia or other conditions such as an association between ADHD and epilepsy
What are signs and symptoms of schizophrenia?
Rare in children due to difficult diagnosis:
- social withdrawal, slow development
- hostility and suspiciousness
- deterioration of personal hygiene
- flat, expressionless gaze
- inability to cry or express joy
- inappropriate laughter or crying
- depression, oversleeping, insomnia
- odd or irrational statements
- hallucinations, delusions, muddled thoughts, behavioural changes
How should you manage patients with autism/schizophrenia?
- prevention
- treatment must be limited to what the patient can tolerate
- dont keep patient waiting
- short treatment sessions
- hospital admission highly undesirable
What is dyslexia and how should we manage this?
- main problem understanding reading and writing
- usually causes problems with cognition - difficulty processing or holding information
- can vary in severity - mild to profound
Management: may need little or no adjustment - take treatment at a slow pace
- explain procedures in simple terms i.e. no written communication with jargon or complicated language
What is ADHD?
Attention Deficit Hyperactivity Disorder
- difficulty staying still outwith norm of child without ADHD
- unpredictable, chaotic behaviour
- has difficulty responding to requests e.g. sit in chair, open mouth
- likely to have problems maintaining OH at home
Management:
- short appointments
- keep tasks simple and of short duration
- keep taking breaks from patients mouth
- parental support often required to distract or encourage patient to cooperate
What is physical impairment and give examples of conditions?
- varying degrees of physical impairment, restricted movement and/or uncontrolled movement
- spina bifida
- cerebral palsy
- muscular dystrophy
What is cerebral palsy?
- neurological condition that affects movement and coordination (not progressive)
- damage to brain before or after birth (cerebrum) - part of brain that controls muscles and responsible for communication skills, memory and ability to learn
Causes: - infection in early pregnancy
- difficult or premature birth
- bleeding in foetus brain
- abnormal brain development in foetus
What is spina bifida?
What is muscular dystrophy?
Spina bifida: vertebrae overlying spinal cord poorly formed, remains unfused at birth
- may be due to low levels of folic acid during pregnancy
- management = prevention
Muscular dystrophy: group of muscle diseases which present as progressive atrophy and weakness of skeletal muscles which result in disability and deformity
- prevention is key in management
- mainly rely on parent/carer to provide OH
What are some dental challenges faced in physically impaired children?
- gag and cough reflexes
- hypoplastic or hypomineralised teeth –> hypersensitive
- access to mouth, either limited opening or uncontrolled patient movement (cerebral palsy)
- manoeuvring of a wheelchair
- transferring to a dental chair
- excessive saliva - some severely disabled children do not have a swallow reflex
- self-inflicted intra=oral wounds
How to manage physically impaired patients?
- aggressive prevention
- operative intervention early
- modify treatment plan if necessary
- patients may require sedation or GA –> treatment should be radical, extract any teeth of a poor prognosis or potential poor prognosis to reduce the risk of repeat GA
- may need modification of toothbrush
- electric toothbrush may be easier
- specialist surgeries may have special lifting equipment to place a wheelchair in a supine position
= wheelchair accessible dental units - if possible, carry out all treatment at one visit - if patient and operator can cope
Carry out prevention at every visit - reinforce, fluoride varnish etc
Disabled children fall into high risk category and should receive fluoride varnish application 4x yearly
Give an overview of blindness/visual impairment in relation to dental health
- no more susceptible to caries and periodontal disease than rest of population
- explain treatment to patient, allow to feel equipment/instruments in a tell/feel/do approach
- start off slowly, reinforce stop signal and give reassurance
- patient cannot see you or equipment –> trust
- OH may be impaired
- may be sensitive to operating light
Management: - dental treatment should be manageable as normal
- tell then do
- try to keep a low reassuring voice
- if patient is given written information, ensure it is relevant to their level of sight
- may not be able to see OHI, rely on tactile sensation
- always address patient, not parent/carer
Give an overview of deafness and hearing impairment:
- may use hearing aids, varying degrees of impairment
- depending upon age, may use sig language and or be able to lip read
- you must arrange BSL interpreter for patients if necessary
- dental challenges: communication, often find vibratory sensation of handpieces and USS very uncomfortable - some may opt to remove hearing aids
Management: - find out early extent of deafness and record this
- use visual aids where necessary - flashcards, books, props etc
- always use positive body language and sit directly infront of child when communicating
- full face visor in place of mask
- so not assume patient can read/write English proficiently - BSL is normally their 1st language
Any type of impairment meant that treatment should be avoided if at all possible, so what measures can we take to support this?
- OHI and expectations should be realistic
- patients carer must be fully informed and willing to cooperate and assist any prevention programme
- of patient is able to brush their own teeth, parent should supervise
- an electric/power toothbrush should be considered
- if unable to brush own teeth, carer should be given a demo and requires great commitment from carer
- modified handle grip may help patient clean more effectively
- chemical agents - chlorhexidine - may be used on gauze swabs if patient cannot tolerate toothbrush/toothpaste in mouth
- Oranurse: no flavour toothpaste 1450ppm fluoride
- dietary advice should follow the same guidelines as for other children
