SPECIAL NEEDS (7/10/13) Flashcards
Special needs 2:
define Disability?
A disabled person is someone with a physical or mental impairment which has a significant and long-term adverse effect on his/her ability to carry out normal day to day activities. So, Reasonable adjustments may need to be made to enable people with disability to be able to access health care.
Special needs 2:
dental services should be provided in a way that:
- Recognises everyone as an individual
- Recognises that everyone has a right to participate in decisions that affect their lives
- Support them to enable everyday living including adequate healthcare
Special needs 2:
define Children with special dental needs?
A child has a condition that:
- Puts his general health at risk if he/she suffers dental disease and needs dental treatment
- Makes his access to dental care difficult
- So, makes providing a dental treatment difficult
So, makes the dental disease more likely to occur and progress
Special needs 2:
types of disability?
Intellectual impairment
Physical impairment
Medical impairment
Sensory impairment
Emotional
Oral development problems
Special needs 2:
Intellectual impairment:
mention Prevalence, Classification according to IQ scoring, Causes:
- Prevalence = 2-3%
- Classification according to IQ scoring (normal IQ = 80-120):
1) Mild to moderate (IQ 50–70)
2) Severe to profound (IQ <50 )
- Causes:
Many cases lack of well-defined aetiology (poorly understood) but there are some causes are well-known:
1) Down’s syndrome (Most common genetic cause of intellectual impairment)
2) Fragile X syndrome
3) Cerebral Palsy (They may have intellectual impairment but often IQ is normal)
4) Birth Anoxia (low O2)
5) Autism (Autistic Spectrum Disorder “ASD”) including Asperger’s syndrome (not always):
→ Although Autism (Autistic Spectrum Disorder “ASD”) can be a cause of intellectual impairment but Asperger’s syndrome which is a High Functioning Autism could have IQ>70 which means there is no intellectual impairment but they will suffer from Behavioural and communicative disorders, so still being special needs
6) Meningitis
7) Rubella
8) Microcephaly
Special needs 2:
what is Down’s syndrome, implications and features
Down’s syndrome (Most common genetic cause of intellectual impairment):
→ Trisomy 21 defect (chromosome 21 has 3 copies instead on 2) occurs in 1:1000 live births, leading to:
a) Intellectual impairment (very variable)
b) Hypotonia (muscle movement difficulty)
c) Cranio-facial anomalies:
- Oval and Flattened face, Flat occiput, Short neck
- Straight hair, Epicanthic folds with upward slant to eyes, Flat nasal bridge and Short dysplastic ears
d) Abnormal hand creases
e) Abnormal tooth morphology, Abnormalities in tooth number, Delayed eruption, Small, conical or malformed teeth, Small maxilla, Class 3 malocclusion, Large, protruding, fissured tongue
f) Less likely to develop dental caries but more prone to periodontal disease
g) Congenital cardiovascular disease in 30-40%
h) Increased risk of acute leukaemia
Special needs 2:
Physical impairment types?
► Physical impairment:
1) Cerebral Palsy (most common)
► Musculo-skeletal disorders:
1) Muscular Dystrophy
2) Juvenile rheumatoid arthritis (Stills Disease)
► Visual impairment
►Hearing impairment
Special needs 2:
what is Cerebral Palsy?
A motor manifestation of cerebral damage due to birth anoxia (low O2), leading to Abnormal muscle tone and reflexes (Spasticity and Athetoid “Uncontrollable movement”).
Special needs 2:
mention what medical impairment do children might have?
1) Heart disease (Childhood Cardiac Diseases):
a) Congenital Heart Defects
b) Cyanotic heart disease
c) Endocarditis
d) Poly-cythaemia
e) Thrombo-cytopenia
f) Abnormal clotting and anti-coagulants
2) Bleeding disorders
3) Respiratory Disease
4) Kidney disease
5) Diabetes
6) Organ transplants
7) Malignancy
8) Using Drugs (Steroids, Anti-coagulants)
Special needs 2:
Sensory Impairment types:
1) Blindness
2) Visual impairment
3) Deafness
4) Deaf-Blindness
5) Speech and Language delay
6) Sign Language User
7) Hearing impairment
8) Background noise
9) Multi-sensory impairment
10) Communication aids
Special needs 2:
what are the causes of emotional needs?
1) Abuse
2) Neglect
3) Non-Accidental Injury
Special needs 2:
Oral developmental problems:
types and a brief about each one?
1) Cleft lip and/or palate:
→ Diagnosed either in uterus or at birth
2) Ectodermal dysplasia:
→ Large group of inherited disorders where there is a Primary defect of 2 or more structures derived from ectoderm (outer layer of embryo), leading to defects in Hair, Skin, Nails, Sweat glands and Teeth
Special needs 2:
what is Hypo-hydrotic Ectodermal Dysplasia?
Commonly X-linked inherited mutation occurs in 1:100,000 children where they have:
a) No sweat glands so easily become hyper-pyrexic (having High temperature)
b) Absent teeth (Both Primary and Permanent)
Abnormal teeth morphology (Conical, Small, Peg-shaped)
Special needs 2:
who is the high priority group?
Disabled children are more likely to get a disease (eg: caries)
disabled children with Dental disease may have more serious implications
Disabled children with disease are more difficult to treat
Special needs 2:
how a medical condition/disability affects the treatment plan?
Sometimes it can be helpful to formulate an initial plan ignoring the disability so you don’t get distracted by the disability. Then, discuss with the patient, parent or carer and modify the plan based on their needs. Then, take their CONSENT (check who has Parental Responsibility and/or mental capacity)
All children with a medical condition should be considered to be high priority for dental prevention
Special needs 2:
children with special needs require Full prevention programme (the 4 pillars of prevention), mention them?
- OHI:
- Modification of Toothbrushing technique with e-TB with the correct handling way (Plaque control)
- Unflavoured non-foaming Fluoride toothpaste (Ora-nurse) can be tolerated
- Chlorhexidine MW
- Regular Professional cleaning
-
Patients are unable to brush their teeth, instruction should be given to their carer. Pts are able to brush should be encouraged to do so.
- Systemic / Topical Fluorides
- Fissure Sealants
- Dietary advice
Special needs 2:
what are the Challenges in delivering oral care?
- Dental health being of Low priority
- Difficulties in accessing dental care
- Difficult Communication and understanding:
- Lack of providing the necessary care
- Practical difficulties in delivery of dental care
- Fear and Anxiety
Special needs 2:
who are the Providers of dental care?
General Dental Practitioners
Community Dental Service (CDS)
Hospital Dental Service
Special needs 3:
What are the 4 pillars of Full Preventative programme?
OHI
Diet
Flourides
Fissure Sealants
Special needs 3:
What are the 2 divisions of Congenital heart disease in children?
Acyanotic
Cyanotic
Special needs 3:
Describe Acyanotic Congenital Heart Disease
Left to Right shunt
Blood does not bypass the lungs
Deoxygenated blood not found in systemic
Oxygenated – as it goes through lungs
Special Needs 3:
Describe Cyanotic Congenital Heart Disease
Right to left shunt
Blood bypasses lungs
Deoxygenated blood found in systemic circulation
Cyanosis
Special Needs 3:
What are the 4 key features of Tetralogy of Fallot?
Ventral septal defect (VSD)
Right Ventricular Hypertrophy
Pulmonary stenosis
Overriding aorta
Special Needs 3:
Name top 2 oral bacteria that are a significant cause of Infective Endocarditis?
Viridans streptococci
Staphylococci
Special Needs 3:
Do we need antibiotic prophylaxis against Infective Endocarditis? and Why? Look at NICE guidelines
Antibiotic prophylaxis against infective endocarditis is no longer recommended for people undergoing dental procedures.
No evidence that it works
Dental intervention insignificant as a cause of infective endocarditis compared to “everyday” bacteraemia
Special Needs 3:
What are the 3 exceptions that DO NOT increase risk of Infective Endocarditis?
– Isolated atrial septal defect
–Fully repaired ventricular septal defect
–Fully repaired patent ductus arteriosus.
Special Needs 3:
What are the symptoms of Asthma?
- Coughing
- Wheezing
- Breathlessness
- Chest tightness
- Chest Pain
- Leads to seasonal symptoms (e.g. worse in cold weather)
Special Needs 3:
Name 3 oral manifestations of asthma
Erosion
Caries
Thrush
Special Needs 3:
What are the Anatomic areas affected by Cystic Fibrosis?
Respiratory system
GI
Liver
Special Needs 3:
What are the oral manifestations of Cystic Fibrosis?
- Salivary gland dysfunction - alterations in flow, viscosity, sodium, calcium, lipid concentrations, pH, buffering capacity
- Dental caries is decreased
- Low levels of plaque-induced gingivitis but higher levels of calculus
- Enamel defects in 25% patients
- Delayed dental development & eruption
Special Needs 3:
What is the dental management for patients with Cystic Fibrosis?
- GA is avoided if at all possible
- Narcotics & sedatives are avoided due to risk of respiratory depression
- Diet assessment & advice with paediatrician
- Universal Infection prevention measures.
Special Needs 3:
Factor VIII deficiency is what type of Haemophilia?
Haemophilia A (X-linked recessive)
Special Needs 3:
Factor IX deficiency is what type of Haemophilia?
Haemophilia B (X-linked recessive)
Special Needs 3:
Factor XI deficiency is what type of Haemophilia?
Haemophilia C (Autosomal recessive)
Special Needs 3:
What is the most common type of Haemophilia?
Haemophilia A
What are the presenting features of Haemophilia?
Increased bleeding
Decreased clotting
Easy bruising
Nose Bleeds
Family history
Special Needs 3:
How do you treat Haemophilia?
Adequate replacement of deficient factor:
-Factor VIII
-Factor IX
-Factor XI
Desmopressin (DDAVP) which stimulates the release of factor VIII
Antifibrinolytic agents (EACA) / tranexamic acid:
- prevent clot lysis
Avoid NSAIDS & aspirin
Special Needs 3:
What are the Dental Aspects of Haemophilia?
- Communication with haematologist/paediatrician
- LA infiltrations and intraligamentals are unlikely to cause problems
- IDB/lingual infiltration contraindicated as risk of haematoma
- Pulp therapy is preferable to extraction
- Extractions in hospital setting
- Consider GA if factor replacement required for multiple quadrants
- Dental care often avoided by parent/clinician/GDP who are afraid of bleeding
- No distinct oral findings
- Increased caries risk due to poor oral hygiene and lack of professional care
- Regular dental care and prevention must be implemented early, before teeth erupt
Special Needs 3:
What is Sickle Cell Anaemia?
-Autosomal recessive disorder
-Substitution of a single amino acid in the haemoglobin chain
-Sickle cell disease: homozygous
-Sickle cell trait: heterozygous, has one abnormal allele for the haemoglobin beta gene
-Most common in the black African population
Special Needs 3:
Is Sickle cell disease homozygous or heterozygous?
homozygous
Special Needs 3:
Is Is Sickle cell trait homozygous or heterozygous?
heterozygous - has one abnormal allele for the haemoglobin beta gene
What is the difference between homozygous and heterozygous and trait?
Homozygous – affected genes from both parents
Heterozygous – carry 2 different alleles for the same gene (carries 1 gene for HbS)
Trait – does not have the two abnormal alleles so does not show symptoms
Special Needs 3:
What is the half life of RBC in Haemolytic Anaemia?
30-60 days
Special Needs 3:
What are the complications of Sickle cell anaemia?
- Affected children are anaemic, tired, weak & breathless
- Painful joints, swelling of hands and feet
- Failure to thrive & delayed growth
- Increased susceptibility to infection
Special Needs 3:
What is the Dental Management of Sickle Cell Anaemia?
- Risks with GA
- At risk patients must be tested for prior to GA
- Hb electrophoresis is the definitive test
-Preventative & conservative approach to dentistry
-Consider prevent infections by use of post-operative antibiotics
-Inhalation sedation is safe but ensure 100% oxygen for 4-5 minutes at the end of treatment
Special Needs 3:
What is the most common childhood cancer in the UK?
Leukaemia
Special Needs 3:
The most common type of Leukaemia is…..
Acute Lymphoblastic Leukaemia ~ 75% incidence, peak age 4 yrs
Special Needs 3:
What may be one of the first signs of Leukaemia?
Oral mucosal bleeding
Anaemia & thrombocytopenia are common initial symptoms
Special Needs 3:
What are the treatment modalities for Paediatric oncology?
Chemotherapy
Radiotherapy
-Proton Beam Therapy
Surgery
Bone Marrow Transplant
Special Needs 3:
Describe the Chemotherapy effects on oral health
DIRECT - directly caused by the drug
methotrexate mucositis
INDIRECT - indirectly caused by the drug
(usually a result of bone marrow suppression)
Hits platelets and neutrophils
Neutropenic ulceration
Petechiae and bullae
Infection
–Viral - eg Herpes simplex
–Fungal - eg Candida
–Dental - acute exacerbation of chronic infection
Special Needs 3:
What are the oral problems associated with radiotherapy?
Oral mucositis and ulceration
Hyposalivation and xerostomia
Infection esp candida
Radiation caries
Loss/altered taste
Gingivitis/periodontitis
Osteoradionecrosis
Trismus
Special Needs 3:
True/ False
Dental screening as soon as possible post diagnosis
True
Special Needs 3:
True/False
Should have Close collaboration between Paediatric Dentist and Paediatric Oncologist
True
Special Needs 3:
What are the dental management PRIOR TO CHEMOTHERAPY STARTING (for paediatric oncology)?
Prior to chemotherapy starting:
—Removal of infected teeth
—Dressing of other carious teeth
—Organise mouthcare/mouthwashes etc
Special Needs 3:
What are the dental management DURING CHEMOTHERAPY (for paediatric oncology)?
During chemotherapy:
—support and encourage maintained mouthcare (via nursing staff)
—Help/advice with management of specific oral problems
Special Needs 3:
What should we do if we see patients in remission?
Treat as normal
Be aware of:
–Poor salivary gland function
–Caries
–Poorly formed teeth
–Psychological health
Special Needs 3:
Poorly controlled diabetes results in…
Periodontal disease
Reduced Salivary Flow
Increased Caries
Special Needs 3:
What are the implications of diabetes?
Monitor Blood sugar levels to maintain well controlled
Care to avoid hypoglycaemia
Avoid GAs (due to fasting)
Special Needs 3:
When thinking about any implication always think about 3 things…..
★ Bleeding?
★ Infection?
★ Risk of GA?
