Week 9 PP Flashcards
Who are Special Care Patients
People are considered to have special health care needs if they have physical, developmental, mental, sensory, behavioural, cognitive or emotional impairement OR a condition that requires medical management, health care intervention or use of specialized services or programs.
Oral Health & The Special Care Patient
Patients with special health care needs require delivery of dental care that is beyond what is customary because of their medical conditions or limitations.
a basic understanding of how a disorder can affect a person’s oral health is important.
symprtoms of more than 100 conditions can indirectly affect a patient by causing a person to be less capable of caring for his or her mouth
Special Care Patient Categories
- Elderly
2/ Developmental Disorders - Physical Disorders
- Neurologic Disorders
- Neuromuscular Disorders
- Behavioural and Psychiatric disorders
- Neglected or abused
Developmental disorders - are a diverse group of chronic and potentially severe condtions that:
-Typically manifest in the early developmental period (prenatal to 18 years of age)
-impairment can occur prenatally, during birth, or postnatal
-usually lasts throughout a persons lifetime
-lead to intellectual, social, or physical impairements
-create problems with major life activities such as language, mobility, learning, self-help and independent living
Intellectual disorders are characterized by:
◦ Limitations in intellectual functioning
◦ Limitations in adaptive functioning as expressed through conceptual, social and practical skills
◦ Origination and onset of symptoms during the developmental period (usually before age 18)
Etiology of Intellectual Disorders
- Anything that interferes with normal brain development can result in intellectual disability.
Examples of Intellectual Disorders
◦ Genetic conditions/ chromosomal abnormalities
◦ Alcohol, drug use, or malnutrition during pregnancy
◦ Pregnancy complications such as pre-eclampsia, premature birth, or depravation of oxygen during childbirth
◦ Childhood illness such as whooping cough, meningitis or measles
◦ Childhood injury such as severe head injuries or near drowning incidences
◦ Exposure to toxic substances (Ex. Lead)
◦ Nutritional or social deprivation
Oral Findings for Patients with Intellectual Disorders
Each developmental disorder may present its own unique set of common oral findings.
◦ A higher than average prevalence and severity of periodontal disease
◦ Dental caries
▪ Caries rates are similar to the general population
▪ However the rate of untreated caries is considerably higher
▪ Level of function and soft diet intake are significant risk factors for dental caries
◦ Higher incidence of oral developmental malformations
◦ Tooth anomalies: imperfect formation; delayed or irregular eruption patterns
◦ Oral habits: increased clenching, bruxing, mouth breathing, tongue thrusting
Down Syndrome
Unique group of individuals with intellectual disability caused by a chromosomal abnormality; also referred to as trisomy 21 syndrome.
* The overall incidence of Down syndrome is 8 in 10,000 in the US
* The incidence increases with the age of the mother; at age 45 the incidence is 1 in 32.
* The typical facial appearance includes: slanted eyes, a broad flat nose, and short in stature.
* This disorder also brings about multiple medical conditions that need to be considered in treating the patient.
Common abnormalities in Down Sydrome:
Abnormalities in oral and dental development are common
* small peg-shaped teeth
* Prognathic profile of mandible (class III)
* posterior cross-bite
* open-mouth and protruding tongue
Autism Spectrum Disorder (ASD)
Complex spectrum of developmental disorders marked by limitations in the ability to understand and communicate.
* Signs of this disorder appear during early childhood and persist throughout life – although many individuals with ASD can learn coping behaviors to enhance daily functioning
Characteristics of ASD
- Impairment in social interaction
- Impairment in communication
- Restricted repetitive and stereotyped patterns of
behavior - Delays or abnormal functioning before age 3 years
in:
◦ Social interaction
◦ Language as used in social communication
◦ Symbolic or imaginative play
Cerebral Palsy
A group of non-progressive neuromuscular disorders caused by brain damage sustained during the prenatal or perinatal period or during infancy
- this condition affects 1 to 4 individuals in 1000 live births
-1 in 7 dies during his or her first year of life
Cerebral Palsy is Characterized by:
-Paralysis
-Muscle weakness
-Lack of Coordination
-Other disorders of motor function
-Poor oral hygiene
-Cerebral palsy patients often the most challenging, as they often have both mental and physical disabilities to contend with
Physical Disorders
The patient who is physically challenged must adapt to a very fast-paced and mobile world.
* This patient may need more time for the appointment, and the dental unit may have to be arranged differently.
* Vision impaired
* Hearing impaired
* The wheelchair-bound patient
Vision Impaired
Visual impairments vary from total blindness to limitations in color perception, distance perception, recognition of shapes, and size of visual field.
* The vision-impaired patient has learned to rely on the sense of touch and on oral communication.
* For the person who cannot see his or her surroundings, all procedures should be thoroughly explained first.
* Trip to the treatment area, positioning and smells from materials should be discussed prior to treatment
Causes of Vision Impairment
- age related (due to macular degeneration, diabetic retinopathy, trauma, infections)
- children (prenatal origin resulting from maternal infections such as rubella, syphilis) or sport related injury, retinopathy
When guiding the visually impaired patient:
Offer them your arm
Describe obstacles as you guide them
If a guide dog is used don’t pet or interfere with the dog. Ask the patient how to manage the dog.
Hearing Impaired
- Treated with extra care and courtesy
- May show no visible evidence of hearing loss and may not respond to questions and instructions or may respond inappropriately
Cause of hearing loss:
-congenital
-acquired
- Hearing impairments vary from total loss of hearing to limited hearing
- deaf
- hearing loss (mild to severe)
Assistive measures for hearing impaired:
- remove unnecessary noise when communicating
- Remove mask when speaking
- Use mirrors, models, drawings and written information to support communication
- Keep direction simple
- Sign language interpreter can be valuable
The Wheelchair-bound patient
- Accessibility!
- Specific considerations when an office is designed for all patients:
- Walkways, sidewalks and parking facilities
- Entrance ramps, handrails, hallways and elevators
- Door width and door pressure or ease of opening
- Adequate space around door to maneuver a wheelchair, and
elevator accessibility - Floor surface, carpets, and rugs
- Restroom facilities
- Reception room design, furniture style, and lighting
- Operatory design to allow for wheelchair transfer or inwheelchair treatment
Neurologic Disorders
A neurological disorder deals with the nervous system
* Specifically, it covers all categories of diseases involving the central, peripheral, and autonomic nervous systems, which include the coverings, blood vessels, and tissues such as muscle.
* Alzheimer’s
* Seizures
* Multiple sclerosis
* Cerebrovascular Accident (Stroke)
Alzheimers Disease
A disorder that begins in middle age and is marked by deterioration of mental capacity (dementia).
* The patient starts showing loss of memory and impairment of judgment, comprehension, and intellect.
* Anxiety, depression, and emotional disturbances can occur as well.
* Over time, the person becomes totally dependent and unable to perform activities of daily living without help.
Seizures
Caused by abnormal brain activity and cause recurrent episodes of seizures - Epilepsy
* Patients maybe receiving antiepileptic medication which may cause bleeding disorders, gingival overgrowth and xerostomia
* In most patients these are controlled but under stressful conditions they may still occur
* Categorized by which part of the brain is involved with the seizure. Might experience one type or more than one type
4 Main Categories of Seizures
- Generalized Seizures
- Partial Seizures
- Nonepileptic Seizures
- Status Epilepticus
General Seizures
- Affect the entire brain and can be referred to as
grand mal seizures - Different types of general seizures
-Absence seizures
-Tonic seizures
-Clonic seizures
-Myoclonic seizures
-Atonic seizures
-Tonic-clonic seizures
Patrial Seizures
- Also known as petit mal seizures
- Only affect part of the brain
- Person will often stay awake and aware during the
seizure - Even though they are aware they are unable to
speak and/or move till it is over
Non-epileptic Seizures
- Not related to epilepsy
- Caused by other things like diabetes, high fever or
another cause
Status Epilepticus
- Continuing seizure
- Emergency personnel should be contacted
Clinical Conditions for Seizures
- Be aware of trigger factors – anxiety, stress
- Sedation may help prevent a seizure during a stressful dental visit
- Staff should be prepared to handle an emergency
- Severe cases may require treatment be completed under general anesthesia
- Maintain oral hygiene
- Check with patient before treatment regarding:
Skipping medications or meals
Stress and fatigue
Pain and alcohol consumption
Multiple Sclerosis (MS)
- Most common in people 30 -50
- As it progresses patients experience weakening of the lower extremities
- Causing muscle weakness, unsteady walk, and paralysis
- Adrenal supplements (prednisone) and muscle relaxants (diazepam) maybe prescribed to control muscle spasms
Clinical Considerations for Multiple Sclerosis
- Shorter appointments
- Maybe wheelchair bound
- May have a hard time localizing intra-oral pain
- Some may develop trigeminal neuralgia (chronic pain of trigeminal nerve)
- Respiratory problems can be a result of the disease (muscles that control breathing can be
affected) - Place at a 45 degree angle instead of supine (protects airway)
- Sedation maybe required
Cerebrovascular Accident (Stroke)
- Also known as a Stroke
- Minor to severe
- Loss of central nervous system function caused by a sudden vascular lesion in the brain
- Resulting effects differ based on the area and extent of injury to the brain
◦ Unilateral weakness or paralysis of eyes and facial muscles
◦ Slurring or loss of speech
◦ Numbness, vertigo, visual disturbances
Clinical Considerations for Stroke Patients
-Schedule for mid morning
-Add additional time to the appointment to allow for additional communcation and explanations
-Modified oral hygiene may need to be introduced
Neuromuscular disorders
Affect the nerves that control your voluntary muscles
* Voluntary muscles are the ones you can control.
* Nerve cells (neurons) send the messages that control these muscles.
* When the neurons become unhealthy or die, communication between your nervous system and muscles breaks down.
* As a result, muscles weaken and waste away.
* The weakness can lead to twitching, cramps, aches and pains, and joint and movement problems.
* Muscular Dystrophy
* Parkinson’s Disease
* Cerebral Palsy
* Lou Gehrig’s Disease
* Arthritis
Muscular Dystrophy
- Characterized by progressive atrophy and weakness of the skeletal muscles
- Increases disability and deformity
- Muscle fibers degenerate and are replaced by fatty and fibrous tissue
- Disease is eventually fatal due to the onset of infectious and respiratory disease as well as pulmonary dysfunction
- Atrophy of the muscles involved in breathing reduces the capacity of the lungs and the person’s ability to cough
Parkinson’s Disease
- Motor system disorder that is the result of the loss of dopamine-producing brain cells
- Primary symptoms are:
-tremors, trembling in hands, arms, legs, jaw and face
-rigidity or stiffness of the limbs and trunk of the body
-slowness of movement
-impaired balance and co-ordination - As symptoms progress patients will have difficulty walking, talking or completing other simple tasks
Amyotrophic Lateral Sclerosis
- Commonly referred to as Lou Gehrig’s Disease
- Degenerative nervous system disease
- Results in loss of motor neurons in the cerebral cortex, brain stem and spinal cord
- Causing muscle atrophy, weakness and spasticity
- Progressive
- Patient survival is 3 to 5 years
- No cure and unknown origin
Clinical Conditions for Neromuscular Disorders
- Require short appointments
- Patient may be transferred from a wheelchair into the dental chair
- Dental dam maybe useful if the patient can breathe through their nose
- Place the patient at a 45 degree angle in the chair
(not supine position) - Nitrous oxide, sedation and general anesthetic should be avoided because of impaired breathing function
Two most common types of arthritis are:
-Rheumatoid
-Osteoarthritis
Clinical Conditions for Arthritis
- Schedule in the morning and keep appointments short
- Can limit the patient’s ability to hold a toothbrush
- Arthritis of the jaw joint can limit the patient’s ability to open their mouth or chew comfortably
Cardiovascular Disorders
Heart disease continues to be one of the most serious threats to the health of an individual
* It is the leading cause of death among men over the age of 40 and among women over the age of 65
* It can manifest in many ways, such as hypertension, stable or unstable angina, congestive heart failure, and myocardial infarction
◦ Congestive heart failure
◦ Hypertension
◦ Angina
◦ Endocarditis
Congestive heart failure
Heart can’t pump enough blood to the body’s other organs
* People with this condition become short of breath upon exertion
* Can result from the following:
-narrowed arteries
-scar tissue from past heart attacks
-high blood pressure
-heart valve disease
-heart defect or infection of heart valve or
muscle
Hypertension
High blood pressure
* Heart has to work harder as it pumps against resistance
* Most patients are on a drug therapy program as well as diet limitations, exercise routine and stress reduction
Angina
- Decrease in blood supply to the heart results in chest pain
- Stable – Pain is Predictable
- Unstable – Pain is Unpredictable
- A sign that the patient is at risk for a heart attack
- On a program of drug therapy, exercise, weight control and smoking cessation and salt restriction
Endocarditis
- Cardiac disease and prosthetic replacements are at an increased risk of bacteria that’s carried in the blood system
- What’s the term for bacteria in the blood?
- Infective endocarditis is a severe infection of the cardiac valves and supporting structures
- Patient may require antibiotic therapy for dental treatment
Clinical Considerations for Cardiovascular Disorders
- Avoid stressful, lengthy appointments
- Assess vital signs before and during the appointment
- Psychotropic premedication and nitrous oxide maybe used to reduce stress
- Supplemental oxygen maybe used during the procedure
- Consult patient’s cardiologist about using prophylactic sublingual nitroglycerine immediately after treatment
- Vasoconstrictors maybe administered within limits for some patients
- Maybe more comfortable in a semi-supine position than a supine position
Behavioural and Psychiatric Disorders
- Biologic, genetic, psychological, and social components can contribute to many types of behavioral and mental disorders.
- Psychiatric disorders can affect the treatment of dental patients because of the drugs prescribed, which influence the function of the brain.
Common Behavioural Psychiatric Disorders
- Anxiety is a feeling that “all is not well.”
- Depression is a condition of general emotional rejection and withdrawal.
- Eating disorders are marked by extremes.
* Anorexia nervosa, binge eating disorder, bulimia nervosa - Bipolar disorder is characterized by extreme elation followed by depression.
- Substance abuse can affect all aspects of life.
- Post traumatic stress disorder is “re-experiencing” a traumatic event.
- Schizophrenia is a psychotic disorder characterized by varying degrees of personality disorganization.
Treatment Categories
Category 1 - Healthy Patients
Category 2 - minor medical, some treatment modifications, timing of apts, breaks during apt
Category 3 - moderate medical, moderate tx modifications, positioning, anesthetic choice, material choice
Category 4 - significant medical with multiple conditions, significant tx modification, blood work, or booking additional staff
Category 5 - serious medical condition, not expected to survive (pallative care), emergency treatment only
What is Geriatric Dentistry?
- This is the dental specialty dealing with the unique problems of senior citizens
- In past generations, geriatric dentistry was often equated with denture construction and adjustment
- More and more seniors are keeping their teeth for a lifetime
- The average age of seniors is getting older due to advances in health care
Communication with seniors:
- Geriatric people may find that their concerns are not addressed/heard * ensure that we take the time to listen and respond appropriately
- Less distractions may enable the patient to be more comfortable discussing their dental concerns * more privacy
- Remember that geriatric patients may have difficulty hearing you if you speak quickly or softly, also their eyesight may not be as sharp as that of a younger patient * write large if necessary
Observing a Geriatric Patient
- When escorting the geriatric patient to the operatory, observe the way they walk and talk
- There may be clues to some of the medical conditions that they have
- slow and pained movements are indicative of arthritis
- asymmetric movement of the face and mouth may indicate that the patient has had a stroke
- redness of the face may indicate high blood pressure
Adapt Chair Position for Seniors
- Tip chair back slowly
- Hand on patient’s shoulder
- Adjust chair in steps
- Chair back raised for patient with respiratory or
cardiac complication - Body adjustments
Multiple health issues or medications:
- Adequate time must be allocated for review and discussion of the health history questionnaire for geriatric patients
- Often the dentist will need to confer with one or more physicians prior to active treatment beginning
- Medication Profile
- An addition to the medical history
- Regular med histories may not have enough space
- Changes occur regularly
- Med Hx becomes messy
Self-Care Aids
- Benefits to patient
- Self-esteem, accomplishment
- Adaptations/Modifications
- General prerequisites for aids
- Disinfectable
- Durable
- Can withstand exposure to water and saliva
- Resistant to absorption of oral fluids
- Replaceable
- Inexpensive
Benefit Plus Triple Head Toothbrush
is ideal for people who need to reduce wrist or arm twisting. Benefit Plus comes with a wide, padded easy to
hold handle. With a top brush and two side brushes at an optimal 45 degree angle, it cleans all sides of each tooth with every stroke.
Because the Triple Head Toothbrush reduces the need to twist the arm or wrist, it is great for people with arthritis, Parkinson’s, MS or other similar conditions. Its padded handle protects the sensitive mouth area and is the best brush for use by a caregiver when assisting a person with physical challenge
Double sided brush
Double-sided brush has two suction feet that securely hold the base in place. Larger
brush has even-length bristles. The Suction Denture Brush is ideal for independent one-handed denture care.
Easy Out Tube Squeezer
A unique feature of the Easy Out Tube Squeezer allows the last drop to be
squeezed from the nozzle of the tube after the tube has been expelled up to the collar. Ideal for toothpastes,
lotions, salves, silicones, and other household products
Denture Care
Denture cleaning products
– Denture brush or other stiff bristled brush
– Denture paste or liquid hand soap
– Disinfecting tablets
NOTE: Toothpaste is too abrasive and removes the finish off the denture.
- use a towl in the sink to avoid breaking from dropping
Remove dentures at night if possible or 4-6hrs a day to let the tissues rest
* Soak dentures in a container with denture cleanser and water or plain water
Denture Supports
- Products to make dentures feel more comfortable for
the patient - Denture Cushions
- Dental Adhesive
- Polygrip
- Analgesic for sore spots
Changes in enamel with age:
- teeth become yellow to yellowish gray
- Cracks appear
- Wear, abrasion, exposed dentin
- Increased transparency
Changes in dentin with age;
Decreased permeability
* Dentinal canals become narrower
Changes in pulp with age:
- Calcification
- Obliteration of root canals
- Shrinking of the pulp cavity
aids to help ease dry mouth symptoms:
- Sugar-free candy or sugar-free gum can help trigger the mouth to make more saliva.
- Non-prescription saliva substitutes may give temporary relief.
- Sip water often
- Skip sugary, acidic, or caffeinated drinks.
- Drinking water or milk with meals helps with chewing and swallowing.
- Sleep in a room with a humidifier to ease dry mouth symptoms.
