Dentistry for children with special needs Flashcards
what are ‘special needs’?
- umbrella term*
- Huge range of diagnoses and disabilities
Individuals who require special help or care related to their disability
In children the main causes of disability are genetic and congenital
- Adults are mainly more acquired
4. 3% of the paediatric population
who treats the teeth of children with mild disability
- GDS
- GDPs can claim for enhanced capitation fee
- Non specialist led PDS (public dental service)
- Specialist service for access to treatment planning or advanced behaviour management
who treats the teeth of children with moderate/severe disability
- Specialist led PDS
- HDS
- Shard care HDS/GDP or PDS/GDP
- Majority high caries risk so important seen 4 times a year – 2 GDP, 2 hospital
dental implications for children with special needs (5)
- Fewer teeth
- More untreated dental caries e.g. sugary medications
- Greater prevalence of periodontal disease
- E.g Down Syndrome
- Dental Fear & Anxiety
- More likely to be both dentally and medically anxious
- More barriers to delivery of dental care
- Need a scale and polish but have a compromised airway – risk of aspiration
- Bleeding tendency needs a block or extraction
5 impacts of dental disease of children with special needs
- Delayed diagnosis
- E.g. significant autism and is pre co-operative – unable to explain dental pain beyond self-harming and/or challenging behaviour and unexplained change in eating, drinking and sleeping habits
- Delayed management
- Direct result of delayed diagnosis
- Additional time required to acclimatize and upskill a child to accept dental Tx
- Need to be on waiting list for GA
- More multidisciplinary planning
- E.g. leukaemia or congenital heart disease
- Greater risk of pain/sepsis if optimal preventative care is not present
- Reduce quality of life may already be compromised
NEED TO ACCESS EFFECTIVE EFFICIENT PREVENTION – both pt and carer
what prinicples should paediatric dentist consider when treating children esp children with special needs
Principles of GIRFEC and liaising with other healthcare teams is essential to optimise care for children with special needs
- What is getting in the way of this child’s wellbeing? Education?
- Do I have everything I need to help this child or young person?
- What can I do now to help this child or young person?
- What can my agency/profession do to help this child or young person?
- Car parking – ensure they have access to reserved disabled space to reduce stress
- What additional help, if any, may be needed from others?
prevention for children with special needs has 4 points to cover
- Ensuring regular dental visits
- Provision of good mouth care
- Safe eating and drinking habits
- High Caries Risk?
- Esp if cardiac condition – get decay à high risk mortality
SDCEP guidance – preventative care, minimally invasive approach and when not (e.g. cardiac conditions need to have no decay – parents understand link with IE so they are on board with their child attending regularly and optimal preventive care)
dental aims for children with special needs
prevention
Support with normal oral function
- Eating
- Speech development
- Promote self esteem
- Maintain good appearance
- Confidence to smile
Saliva/drooling control
why is it important to support children dentally to have normally oral function (e.g. eat and speech development) esp special needs
Reassure parents with children who have particular eating or speech development issues
importance of dental care to promote self esteem
esp in special needs
- Important as special needs children may already be aware of their differences compared to peers*
- Most children (regardless if special needs or not) wish to be happy with their appearance and smile*
4reasons why important of dealing with saliva/drooling
- Social embarrassment
- Parental upset
- Skin irritation
- Aspiration risk
- Can be cause of severe recurring chest infections
3 methods of saliva/drooling management for children with special needs
- SLT speech and language team - ensure saliva level ok to prevent caries
- Improve lip seal
- Improve swallow
- Pharmacology
- Scopolamine/hyoscine path
- Botox injection
- Surgical
how to tackle barriers to regular dental attendance, mouth care, dietary habits
in general be aware of the multitude of barriers and manage them in a collaborative, empathetuc and problem-solving way
e.g. barrier to regular dental attendance for children with special needs
- other apointments
- challenging behaviour/anxiety
- parking/access
- frequent illness
- parental attitudes
be empathetic and supportive as well as collaborative and help plan solutions
e.g. barriers to mouth care for children with special needs
- manual dexterity issues (CP in child, and parent)
- involuntary movements (CP in child -> anxiety in parent)
- oral aversion/nil by mouth pts
- parent aversion to bodily fluids
- gag reflex issues/ high aspiration risk pts -> parents unable to access
- challenging behaviour (CAMHS) -> parent exhaustion
- sensory issues / not a priorty for parent/lacks time
take time to acclimatise and educate both child and parent on OH regimes and empathise with them and support them in their journey of building into their routine
collaborate with them and other services
e.g. barriers to dietary changes for children with special needs
- atypical food clearance (musculoskeletal problem, CF)
- food holding/regurgitation
- restricted/limited diet
- pureed foods
- fortified foods
- surgary medicines
- food treats as rewards
Collaborate, empathise, don’t judge, support, understand
Consider additional mouth care
- Consider 2800 ppm paste (10+)
Set achievable realistic goals
Work with other healthcare professionals
4 broad grousp of distability
physical
medical
sensory
mental
e.g. physical disabilties
cerebral palsy
spina bifida
muscular dystrophy
e.g. medical disabilities
cardiac defect
oncology
bleeding disorders (haemophilia, von Willibrand)
e.g. sensory disabilities
blind
deaf
ASD
e.g. mental disabilities
impairent learning ability
ASD
ASD
autism spectrum disorder
cerebral palsy prevalence in children
most common physical disability in childhood (1-2 per 1000)
cause of CP
occurs from brain damage before, during or shortly after birth
affects of CP
movement and posture
may also have visual, hearing, learning, speech problems and epilepsy
types of CP
many
spastic (50%)
- monoplegic - only one limb
- paraplegic - lower extremities
- hemiplegic - one upper and one lower limb on same side
- double hemiplegic - all limbs but mainly arms
- diplegic - all limbs but mainly legs
- quadriplegic - all limbs equally
Athetoid (15-20%)
- athetosis
- chorea
- chreoathetosis
Ataxic (10%)
- rigid
- mixed
dental features and considerations for CP
- Poor oral hygiene
- Gingival hyperplasia
- Esp epilepsy medication
- Enamel hypoplasia
- Bruxism
- Malocclusion
- Dental trauma
- Drooling/saliva
- Access
- Uncontrollable movements
- Enhanced gag reflex
OH issues for CP
- Can be hard for them to brush their teeth themselves – movement*
- Can modify toothbrushes*
- Impressions o hands so easier grip on brush*
bruxism in children
Common in children
- Daytime habit for special needs whereas night-time habit for children without special needs
Not directly managed – do not tolerate wearing mouth guards/BRA
Parental assurance needed – TMJ pain in pre-teens very uncommon
CP malocclusion caused by
Related to the influences on growth by atypical head posture and altered neuromuscular control of cheeks, tongue and lips
dental trauma and CP
Increased risk of falls in the ambulant child
- Reduced ability to use their upper limbs to protect their face in a fall
- More likely to have a poor lip seal and a class II incisor relationship
Non-abulant child also increased
- Falls out of wheelchair
- Being transferred in and out of chair, bath, bed etc
drooling/saliva in CP
Often have a head forward posture – important to treat and teach oral hygiene in this position as it means they don’t swallow their own saliva and end up with aspirations
issue with access, uncontrollable movements and possible enhanced gag reflex in CP patients
- Making safe and effective access into the oral cavity not always possible in severe cases*
- For you and their parents
- Worth working with parent so you can both work on best option for access for them and pt*
8 medicall conditions linked with CP
- cardiac malformation
- epilepsy
- renal
- diabetes and other metabolic disorders
- cystic fibrosis
- oncology
- haemophilia and other coagulopathies
- presumed adrenal insufficiency
impact of diabetes and other metabolic disorders in dental care
Common
Have understanding of regimes (certain number injections a day, insulin pumps)
- Understand benefits and limitation
Commonly seen after meal and injection – less likely to go hypoglycaemic
- Not necessarily if they have long good diabetic control
But extractions – ask them to bring their testing kit – test blood sugar level just prior to starting treatment
- Additionally, advise if they are going to be numb that they should have liquid form of sugar for snacks after – less risk of chewing or biting gum/lip (bleeding, trauma)
why essential to have a thorough and accurate medical history
esp in special needs
- Essential to identify any special precautions, interventions, or cover required prior to undertaking any planned dental treatment*
- Liaise effective with the medical consultants and specialist nurses to obtain info
cystic fibrosis dental impact
Increased caries risk – repeated antibiotics and enzymes they take, and high nutritional content as unable to absorb foods correctly
- Enhanced prevention so can manage CF and caries risk
dental impact of presumed adrenal insufficiency
liasing with colleagues in case of needing steroid cover
prevelance of congenital heart defects
- Occurs in 8 per 1000 live births
- 20% have other congenital anomalies part of syndromes
most common congenital heart defect
VSD
aetiology of congenital heart defects
mostly unknown
- Congenial rubella, CMV, maternal drug misuse
- Syndromes- Down, Marfan, Noonan, Elhers-Danlos
dental aspects of congenital heart defects (4)
- Susceptibility to infective endocarditis
- Possible increased bleeding tendency if on warfarin or aspirin
- e.g. post valve replacement
- Higher risk under general anaesthetic
- Careful use of adrenaline containing LA
Liaison with medical colleagues
paediatric oncology prevelance
1600 children diagnosed every year in UK
- Acute leukaemias account for one third
- Brain tumours account for one quarter
8/10 children have a 5 year survival
dental importance in paediatric oncology
Need to be caries free (esp in palliative care) as at some point may have no neutrophils
- Screen children to ensure they are decay free prior to oncology treatment
oral symptoms of paediatric oncology
- Mucosal/gingival haemorrhage
- Gingival enlargement
- Mouth and throat infections - anything else going on in connection?
- Immunosuppression
- Thrombocytopenia
- Oral mucositis
- Use low level light laser which promotes healing and reduce amount
- also releases endorphins so helps to reduce pain - may facilitate eating and drinking so preventing chemotherapy stopping due to pain
- Use low level light laser which promotes healing and reduce amount
- Developing dentition
what is the result of radiotherapy on this child with developing dentition
- Tx as the 4s and 5s forming and incisors roots*
- Root length shortened and teeth diminutive in size*
- Orthodontics implications
most common inherited bleeding disorders
- Von Williebrand’s disease – platelet defect
- Haemophilia A - insufficient factors
- Heamophilia B - insufficient factors
how to dentally manage pts with bleeding disorders
Safe dental management requires multidisciplinary planning
The cover needed will depend on the subtype:
- of the disease in Von Willebrands and severity
- of the disease in Heamophilia
e.g of Tx plan for pt with bleeding disorder
any Tx that have no implications for bleeding
- e.g. small filling, filling needing infiltration using STA or wand
Then do all that has bleeding implications in same appointment – Tx plan for this
- (scale and polish, extractions, block)
Anything that might cause bleeding try and do all the treatment at the same appointment
most common acquired bleeding disorders
- Warfarin therapy for CHD
- Chemotherapy induced thrombocytopenia
4 areas of sensory disability
- sensory impairment
- visual impairment
- hearing impairment
- ASD
e.g tool for sensory impairment
communication aid
e.g. tool for visual impairment
braille
e.g. tool for hearing impairment
BSL interpreting service
hearing loops
e.g. tool for ASD
makaton
Boardmaker pictures
Widget symbols
- (dentist, OPT, metal crown)
- Useful for anxious pts as well as special needs – able to understand better what will happen
definition of learning disability
“A state of arrested or incomplete development of mind..’ WHO
Significant impairment of intellectual, adaptive and social functioning
IQ classifications for learning disability
- Mild 50-70
- Moderate 25-49
- Severe 20-24
- Profound <20
autism spectrum disorder
Lifelong neurodevelopmental disorder perceive the world slightly differently
- Social interaction
- Social communication
- Can be non verbal
- Need to be direct and clear
- Limited and restricted patterns in behavior reflects limited imagination
- Don’t like change – like prediction
- Challenging for parents
- Don’t like change – like prediction
Symptoms and characteristics varies widely
8 related conditions to ASD
very few have diagnosis of ASD alone
- ADHD
- Dyslexia
- Down Syndrome
- Dyspraxia
- Learning disability (about 50%)
- Epilepsy
- Gastrointestinal issues
- Sleep disorder
sleep disorder impact on dental diagnosis
common for ASD, many on melatonin
harder to tell if pain affects
verbal communication for ASD
- Takes things very literally – so remain clear*
- Struggle more the further down in the triangle*
- potential to cope when rules outlined to them
communication in children with mild autism
- Some with mild autism have learnt and adapt to communicate*
- able to attend mainstream school, thus may not need to use communication devices
3 non verbal communication techniques for ASD
- Makaton
- PECS – Picture Exchange Communication System (PECS)
- widget
potential likes in surgery for ASD pt
- Computer
- Water taps
- Predictable – falls in some way
- Dental unit controls
- Allow them to ‘play’ to engage them and make them feel more at ease
- E.g. aspirate water out of cup
- Allow them to ‘play’ to engage them and make them feel more at ease
potential dislikes in surgery for ASD pt
- Touch
- Dental light
- Noise
- Smells
- Textures
- Tastes
5 steps on how to be prepared for ASD pt
- Obtain a profile of the likes and dislikes from the parent or school
- Send out social story explaining dental journey using PECS
- preparatory information
- Send out a plastic mirror
- So they can familiarise themselves with it
- Be ready and on time
- They have limited and restricted behaviours – don’t want to keep them out of their comfort zone for longer than necessary
- De-clutter
- Avoid sensory overload
6 dental features of Down Syndrome
- Maxillary hypoplasia
- Class III occlusion
- Macroglossia
- Large tongues can make it hard to see lower teeth
- Anterior open bite
- Hypodontia/microdontia
- Positive – spaces between teeth make easier to clean so reduce caries risk
- Predisposition to periodontal disease
potential learning problems in down syndrome
a spectrum
e.g. ASD
4 possible medical problems for Down Syndrome pts
- Cardiac defect
- Leukaemia
- Epilepsy
- Alzheimer’s/dementia
examination options for dental tx of down syndrome pt (4 main)
- Knee to knee
- On parent’s lap – support in cuddle – feel secure
- In wheelchair
- Some have tipping motion – good as often wheelchair supports them well
- Standing up
- Sitting or lying on floor, whilst brushing teeth (not with toothpaste)
- Parents can be keen as they want assurance their child’s mouth is ok*
- Esp if child in pain, behaviour changed
Restraint (ensure informed consent gained)
- Not for me personally – at most ask parent to hold their hand whilst examining – help keep still and reassure
4 aids for toothbrushing
Down Syndrome
- finger pops
- open wide disposable mouth rest
- Use on one side, brush the opposing and then flip to do other arch - prop to gain access
- 2-sided toothbrush
- technique of 2 brushes
- get child to chew on one brush on side whilst you brush the other and then switch sides
recommended toothpastes for children with special needs
-
OraNurse Toothpaste
- Contains Fluoride
- Good for sensory issues
- No flavour
- Non foaming
- Duraphat
- For High caries children with Special needs for supervised use Age 10 +
- E.g. haemophilia, cardiac issues
- Cannot swallow – supervised
- For High caries children with Special needs for supervised use Age 10 +
OHI and demostrations for parent/carer and pt
Teaching the parents an effective method of brushing can be extremely helpful in giving them the necessary skills and confidence to do a good job.
first technique is brushing from the front which has the advantage of direct vision into the oral cavity.
- Note that the brusher is at eye level with the child and that the non-dominant hand is retracting the cheek to improve access.
Disadvantages
- may be visual sensory overload and invasion of personal space for the child with sensory issues
- insufficient head support unless a high backed chair is used
main message for OHI for special needs
Have a system
If start in the morning in top right maybe start at night in bottom left – because can be struggle and don’t want any area of the mouth neglected
dental treatment - concious sedation in special needs
inhalation
IV
support
Inhalation sedation selection criteria is the same as with ‘non’ special needs patients
- Need to have sufficient understanding and ability to use the nasal hood and effectively nose breathe
- but should be avoided in those undergoing Bleomycin therapy (High O2) and those with musculo-skeletal disorders
IV sedation with midazolam can be of benefit in some anxious special needs adolescents and is ‘protective’ in those with epilepsy
- Additional detail may be required in pre and post-operative instructions
- E.g. when giving EMLA for use prior to IV sedation cannulation, emphasise that the pts hand will feel normal again once the EMLA cream is removed in approx. 3-5 mins
- Those with severe autism and those attending additional needs units in schools may struggle with IV
Consider the help of an anaesthetist in ASA III and above – only managed in hospital setting with access to A&E and ICU
5 aims of general anaesthesia treatment
- Atraumatic anaesthetic induction (e.g. oral midazolam)
- High priority in those with sensory issues and additional learning needs
- use support from play specialists, psychology team beforehand or premed on the day
- High priority in those with sensory issues and additional learning needs
- Complete comprehensive dental treatment
-
Future proof the need for further dental care
- FSs, FV and scaling undertaken as well as restoration and extraction of teeth to eliminate pain and infection
-
Future proof the need for further dental care
- Eliminate pain and infection
- Establish a basis for continued preventive care
- Short, uncomplicated recovery
2 indication for GA in dental
- no co-operation
- extensive treatment
maybe more prevalent in special needs
3 consideration when planning on GA use in dental Tx
- Joint cases
- Send a courtesy email to other consultants treating the child – find out if anything else needed under GA to minimise the child’s GA exposure
- Medical preassessment
- ASA III and IV will require specialist anaesthetist
importance of preventative care in dental Tx
minimise GAs
- Preventative care is as effective as it can be to ensure pts are effectively managed and free the limited GA and staffing resource available from NHS*
- If unable to see inside their mouth refer on early to try and prevent further development of any dental disease
3 parts stages in child/adolescent consent
- Usually, parents will sign the consent form for younger children
- Teenagers deemed ‘Gillick’ competent may sign the consent form and agreeing to treatment at the pre assessment appointment and then refuse treatment on the day - No treatment undertaken.
- Age 16 and over: a conversation is needed to ensure if appropriate an adult with incapacity certificate is available
3 legislations for special needs
- AWI (Scotland) Act 2000
- Disability Discrimination Act 1995
- Equality Act 2010
