Management of Dental Patients

withSpecial Health

Care Needs

Background:

-The American Academy of Pediatric Dentistry (AAPD) defines special health care needs as “any physical, developmental, mental, sensory, behavioral, cognitive, or emotional impairment or limiting condition that requires medical management, health care intervention, and/or use of specialized services or programs.

-Patients with mental, developmental, or physical disabilities who do not have the ability to understand, assume responsibility for, or cooperate with preventive oral health practices are susceptible as well. Oral health is an inseparable part of general health and well-being.

-The Americans with Disabilities Act (AwDA) defines the dental office as a place of public accommodation.11 Thus, dentists are obligatedto be familiar with these regulations and ensure compliance.

Recommendations

The main objectives of care are:• to motivate the patient and caregiver tomaintain oral health;• prevent infection and tooth loss; and• prevent the need for extensive treatment thatpatients may not be able to tolerate due totheir physical or mental condition; and makeappointments pleasant and comfortable.

1)Creating a Barrier–Free Environment:

-The Americans with Disabilities Act (ADA) of1992 sets standards and building codes for newconstruction to create barrier–free or universaldesign environments that make facilities andservices usable by everyone.

Design characteristics for a Barrier–Free Facility areoutlined in Table :

2)Special Care Dentistry (SCD):

“Special care dentistry is the delivery of dentalcare tailored to the individual needs of patientswho have disabling medical conditions ormental or psychological limitations that requireconsideration beyond routine approaches.”

-SCD may be necessary for persons with severe movement disorders, chronic mental illness, persons who are adults in age but who function at a child’s level, and those with serious medical conditions who are at risk for adverse outcomes in the dental settingunless treated by a knowledgeable practitioner.

-Communication with all members of the health care team, family, caregiver, physician, social services, and the dental team is essential.

The following questions will help each dental officeassess preparedness to offer the needed services:

• Does the office have handicap access?

• Are members of the dental team comfortableor have experience with transferring patients tothe dental chair?

• Is the dental health team familiar with theoral health problems faced by people withdisabilities?

• Does the office have mouth props or supportivedevices to aid patients who may havedifficulties in opening their mouths?

• Is the dental health team knowledgeable aboutassistive devices to enable these patients to bemore independent in managing their own oralhygiene?

• Are members of the dental healthcare teamable to develop a personal oral hygieneprogram for an individual with intellectual/physical disabilities based on his or her level ofunderstanding and ability?

3)Assessment, Planning and AppointmentScheduling:

-Most patients with a disability, or their caregivers,will be prepared to discuss treatment issueswhen they first contact the office to schedule anappointment.-An accurate and current healthhistory is essential. Depending on the disabilityand/or medical condition, a consultation with thepatient’s physician, counselor, and other membersof the rehabilitation team may be necessary toensure treatment is safe and effective.

-Pretreatment planning helps to determinewhat preparation needs to be taken before theappointment.-A phone interview can provide a disability profile detailing problems or limitations that impact care.

For example, if thepatient is using a wheelchair, what is the degreeof mobility and will there be a need for help intransferring the patient to the dental chair?

-Does the patient need antibiotic premedication fortreatment?

-Who will legally provide consent fortreatment?

-What are the patient’s likes, dislikes,fears and limitations?

-Appointments may be dependent ontransportation issues such as reserving specialVehicles.

-There should be no conflict with bowel and bladder elimination, meals or medicine schedules. For the young patient, naptime can be a consideration.

-A mid–morning appointment may bethe most ideal time.-Persons with disabilities often need time to prepare for the visit, wait time is usually minimal, and early in the day the patient and the staff are at their best.

4)Desensitization:

-Individuals with special needs may benefit frommethods that help desensitize them to dentaltreatment.

-Before the visit family members orcaregivers can familiarize the patient with oralcare and a daily tooth brushing routine at home infamiliar surroundings.

-Dental team members can instruct caregivers in proper technique to avoid any injury.

Illustration of proper procedure allowing for head stabilization during toothbrushing:

Protective Body Stabilization:

-Disabled patients frequently have problemswith support, balance, and even aggressivebehavior.

-In the office, stabilization may be used to makethe patient feel comfortable and secure.*Pillows, rolled blankets or towels may be placedunder the patient’s knees and neck to preventmuscle spasms and provide additional support.*A beanbag chair placed on the dental chair willconform to the patient’s body while filling thespace between the patient and the dental chair.

-To minimize movement a member of the dentalteam or caregiver may gently hold the patient’sarms and/or legs in a comfortable position.

-A team member can sit across from the operatorand lightly place their arm across the patient’supper body to keep the working field clear.

-A child may lay on top of a parent in the dentalchair, with the parent’s arms around the child.

-Mouth props may be necessary to provide caredue to a lack of ability, or unwillingness to keeptheir mouth open.

-Use of a mouth prop not onlyprovides protection from the patient suddenlyclosing their mouth but can improve accessand visibility for the dental team.

5)Informed consent:

-Informed consent from the patient or legalcaregiver must be obtained before treatment.

-An explanation regarding the need for stabilization,proposed methods, risks and benefits, andpossible complications is necessary.

Documentation in the record must include:

• Informed consent• Indication for use• Type of protective stabilization• Duration of application• Behavior evaluation during procedure• The level of success or failure of theProcedure.