Dental Pearls Treating Patients with Special Needs

1. Dental PearlsTreating Patients with Special Needs Tegwyn H. Brickhouse DDS PhD Associate Professor Department of Pediatric Dentistry

2. Learning Objectives • Describe physical, mental, and behavioral challenges of special needs patients and identify approached to management. • Discuss common oral health problems in patients with special needs and strategies for care. • Educate caregivers how to help patients with special needs maintain oral health. • Educate caregivers that: Oral health is an integral part of general health and well-being.

3. Training goals • Observe complex restorative treatment on children undergoing general anesthesia and moderate sedation for dental rehabilitation. • Experience with a clinical simulation of a stainless steel crown preparation and restoration. • Clinical hands-on training to provide infant oral health risk assessment and fluoride varnish application. • A brief pre and post evaluation will be done as a part of this experience to provide insight into the value, appropriateness, and outcomes of this training.

4. Patient’s with Special Health Care Needs • 56 million Americans have some type of disabling condition and 25 million Americans have a severe disability. • Many formerly acute and fatal conditions have become chronic and manageable problems. • Today, 80% of individuals are living in community-based centers or at home with families.

5. Barriers to Oral Care • Physical accessibility - access mandated by law. • Lack of financial resources • Rely more on government funding for health care • Lack access to private insurance • Medical health benefits often do not cover related oral health care • Major reason for personal bankruptcy is medical expenses • Lack of effective communication • Language and cultural considerations • Priorities and attitudes of importance of oral health • Behavior management issues • Limited transportation resources

6. Health Challenges • Mental Capabilities • Behavioral Issues • Mobility Problems • Neuromuscular Problems • Uncontrolled Body Movement

7. Health Challenges • Cardiac Disorders • Gastro esophageal Reflux • Seizures • Visual Impairments • Hearing Loss/Deafness • Latex Allergies

8. Oral Health Problems • Dental Caries • Periodontal Disease • Malocclusion/Malformations • Damaging Oral Habits • Tooth Eruption • Trauma and Injury

9. Treatment Principles • Basic principles of pediatric dental care apply to all children. • Always obtain / thoroughly review medical history. • Dentist must be comfortable obtaining medical consults from treating physicians. • Consider patient’s ability to maintain oral hygiene and to cooperate for appointment when planning treatment and recall timing.

10. Treatment Principles • Consider length and time of day for appointments. • Usually short chair time and early in the day • May need to alter preventive periodicity • Parents maybe helpful in management in operatory

11. Treatment Principles • For patients with mild ID give simple instruction, be repetitive, and use positive reinforcement • Patients with moderate-severe ID may need restraints and sedation for treatment. • With the exception of Craniofacial conditions, dental care needs and treatment are not much different from the general population. • TREATING THE TEETH IS EASY - THE ABILITY TO TREAT WHAT THE TEETH ARE ATTACHED TO CAN BE DIFFICULT

12. Current Trends • Prenatal diagnosis has decreased the incidence of Down’s syndrome and severe DD/ID • Improved medical care has allowed more infants with disabilities to survive • Neonatal screening - PKU, Newborn Hearing • 29 newborn tests in Virginia

13. Common Conditions • Autism • Cerebral Palsy • Down Syndrome • Intellectual Disabilities/Mental Retardation

14. Autism: Pervasive Development Disorders (PDD) • The primary feature of all PDD’s is impairment in social reciprocity. • Impairments in communication, repetitive behaviors, narrow interests, and rituals may be present. • Children with PDD’s are limited in social motivation and emotional recognition.

15. Types of PDD • Autism: Most common PDD • Asperger Disorder: Similar to Autism but with little impairment in language or cognition. Considered to be a higher functioning form of autism • Rett Disorder: X-linked dominant disorder (almost exclusively affects girls), with clinical onset between 6-18 months of age. Progressive neurological disorder characterized by loss of purposeful hand use, spasticity, seizures, and mental retardation. • Childhood Disintegrative Disorder: Very rare disorder in which child progresses normally until age 3-5 years then rapidly declines into autistic behavior • PDD-NOS - Not otherwise Specified

16. Prevalence of PDD • PDDaffects 2-6:1000 individuals • As many as 1.5 million Americans are believed to have some form of Autism • Statistics show that this number is growing at a rate of 10-17%/year. (In a decade it is estimated that 4-5 million Americans will be affected) • Autism is four times more prevalent in males than females • Autism knows no racial, ethnic, social, economic, or educational boundaries.

17. Etiology of Autism • Autism is caused by an abnormality in brain structure or function. • The exact cause is unknown • Genetic link? • Identical twins have higher rate than fraternal twins. • Families have higher rates (5-7% chance of having 2nd child with autism). • There is not yet a definite genetic link.

18. Diagnosing Autism • There are no definitive medical diagnostic test to diagnose Autism. • Enlarged fetal brain maybe seen on scan • By definition symptoms of autistic disorder must be manifest by 3 yrs of age • Characteristic behavior may not become obvious until 2-6 yrs. • Developmental screening during check-ups is key in assessing baby’s progress

19. General Characteristics • Autism is a spectrum disorder therefore patients can exhibit any combination of the general characteristics and any degree of severity. Onset is within first 3 years of life. • Resistance to change, insistence on repetition • Difficulty in expressing needs (uses gestures instead of words) • Repeating word/phrases instead of normal responsive language • Inappropriate reactions (laughing, crying, tantrums) • Prefer to be alone, difficulty interacting with others

20. Characteristics of Autism • Little eye contact • Not responsive to verbal cues, acts as if deaf • Sustained unusual play (spinning objects) • Motor abnormalities (hand flapping, toe walking) • Disruptive behavior • May prefer to play alone • Apparent over/under sensitivity to pain • Noticeable physical over/under activity • Often have sensory integration problems - Smells may make them gag - Ordinary noise may be painful

21. Autism vs. Other Disabilities • Autistic children typically avoid or do not respond to social interaction • Children with ID typically enjoy social contact • Autistic children may test very well in mathematical, musical, or visual spatial skills. Will not test well in verbal and language skills. • Children with ID will test uniformly. • Autism can also present as obsessive compulsive disorder, ADHD, psychiatric disorders. • Early evaluation is critical. The earlier a child is diagnosed with autism, the earlier he/she can begin benefiting from treatment programs

22. Associated Conditions • 2/3 -3/4 of individuals with autistic disorder also have intellectual disabilities. • The severity of autism symptoms increases with severity of MR. • Epilepsy occurs in 25-30% of autistic pts. • Onset can occur in adolescence or infancy.

23. Treatment of Autism • There are no medications that affect the core features of this disorder • Treatment is aimed at education, social development, behavior support, and family assistance • Outcome for a child with PDD is closely linked with their language and intelligence abilities

24. Prognosis • Approximately 50% of all children with Autistic disorder acquire language and learn to communicate with useful speech • Classical behavioral features of autism tend to recede a little over time

25. Dental Treatment • Important to develop a routine, same dental staff, quick and quiet appointments. • Children may have poor muscle tone, poor coordination, and drooling problems. • Tend to prefer soft foods and sweetened foods • React to textures of foods and touch of materials • Because of poor tongue coordination, tend to pouch food • Increased caries susceptibility - poor diet • May need papoose and sedation

26. Attention Deficit and Hyperactivity Disorder • ADHD is a neurobehavioral syndrome that begins early in childhood • Diagnosis is based on behavior patterns that have lasted for at least 6 months and began before age 7. • Incidence is increasing • Actual increase? • Better diagnosis? • Desire to put a name on child’s behavior? • Desire to find something to blame for behavior?

27. Prevalence • The number of individuals diagnosed and treated for ADHD has increased dramatically • Studies suggest that ADHD continues to be under and over diagnosed • Estimated 2-9% of children have ADHD • Impulsive/hyperactive type is more common in boys, inattentive type has an even gender ratio.

28. Associated Impairments • Academic Underachievement • Impaired adaptive skills, social difficulties • Sleep difficulties (insomnia, bedwetting) • Increased risk for injury due to risk taking behavior • Developmental Coordination disorder • Increased risk for physical abuse due to difficult behavior

29. Causes • Heredity: Causes 80% of ADHD • Other causesthat may increase the risk for ADHD: • Prenatal exposure to smoking, lead, alcohol, or cocaine • Prematurity or intrauterine growth retardation • Complications during labor and delivery • Brain infections • Inborn errors of metabolism

30. Treatments for ADHD • Treatment includes education and counseling for child, parents, and teachers; educational interventions; and medication • Most common medications are stimulants (i.e. Aderall, Ritalin, Dexedrine) • Other medications include antidepressants (Zoloft, Paxil), neuroleptics (Valium, Haldol), or alpha-2-adrenergic antagonists (Clonidine, Tenex)

31. Medication Complications • Side Effects • (decreased appetite, rebound, tics, sleep disorders, headaches) • Potential for substance abuse • Monitoring therapy • Stopping medication

32. Prognosis • Most symptoms of ADHD diminish between age 10-25 years. • Hyperactivity declines more rapidly than impulsivity or inattentiveness • In 40% of individuals some symptoms persist into adulthood. Adults with persistent symptoms tend to complete less schooling, have lower status jobs, and have higher rates of antisocial behavior • Best indicators of outcome are family support, level of intelligence, and lack of co-existing conditions

33. Dental Treatment for ADHD • Set clear rules, • Use positive reinforcement and verbal praise, • Be consistent and calm. • If sedation is necessary make sure patient takes meds and remember benzodiazepines like diazepam often increase over-activity. • Time-out is a common disciplining tool.

34. ADHD and Dental Caries Bimstein E. et al. Oral characteristics of children with attention-deficit hyperactivity disorder. Spec Care Dentist. 2008; 28(3):107-10. • Higher prevalence of • Toothache bruxism, bleeding gums, and oral trauma histories than the control group (chi square, p < 0.05) • Pearl – Kids with ADHD may have an increased risk for dental caries

35. Cerebral Palsy • Disorder of movement and posture caused by a non-progressive abnormality of the immature brain • 1.4 - 2.4 cases per thousand • Low birth weight infants at increased risk • Associated disabilities may occur and are permanent • Seizures • Visual and auditory impairments • Strabismus • Hand-eye coordination • Intellectual disabilities • Learning difficulties • Behavioral problems

36. Types of Cerebral Palsy • Spastic - most common • Increased muscle tone • One side more effected, usually arm more than leg • Dysarthria-difficulty speaking • Dyskinetic - abnormalities in muscle tone involving the entire body • Exhibit rigid muscle tone while awake, normal or decreased tone while asleep • Chorea - rapid, jerky movements • Athetoid - slow, writhing movements • Ataxic – rare • abnormalities of voluntary movement involving balance and position in space

37. Mental Capabilities • Mild to moderate mental retardation • 25% severe retardation • May of normal intelligence • Dysarthria, allow time for communication • Talk through computer mechanisms

38. Dental Attributes • Oral development and occlusion often effected • Open bite/anterior protrusion, increased anterior trauma • Tongue thrust • Excessive drooling • Treatment may or may not be possible • Don’t prejudge

39. Tailored Dental Care • Maintain clear paths for moving through treatment setting • Treat in wheelchair/ use of sliding boards • Short appointments • Uncontrolled movements • Relaxation • Anticipation with familiarity • Softly cradle head • Muscle relaxants, sedation, general anesthesia

40. Dental Care • Dental needs essentially the same as for all children • GERD: Gastroesophageal reflux-erosion • Tube-fed, high levels of calculus. • Increased risk due to inability to practice good hygiene • Use adaptive devices • Need for assistance • Cognitive ability may not be as impaired as physical ability • May use passive restraint to assist patient in sitting still • papoose board, soft pillows • Focus on communication • Talking slowly • Eye contact • Short commands

41. Down Syndrome/Trisomy 21 • The most frequently occurring chromosomal abnormality resulting in intellectual disabilities and other abnormalities • Children with Down Syndrome are born at the same rate into families of all social, economic, and racial backgrounds, and to parents of all ages.

42. Prevalence • Children with DS account for 1:800 births • Risk of chromosome disorders increases with maternal age at age 20 (1/1600), at age 35 (1/370) • Risk of having another child with DS is about 1:100 • Sex ratio 3 males:2 females

44. Physical Traits • Characteristic facial features: • Flattened facial profile • Flat nasal bridge • Epicanthal folds • Low-set ears • Transverse palmer crease

45. Behavior • Hypotonia at birth with delayed gross motor skills • Developmental Delay • Affectionate, gentle, cheerful personalities • Can be very stubborn • Temperament and behavior disorders comparable to typically developing children

46. Medical Complications • Approximately 2/3 of DS patients were found to have congenital cardiac defects: • 40% • Mental retardation • IQ ranges from 25 to 50 • Otitis • Atlantoaxial instability • 12-20% • Susceptibility to infections and cancers • Approximately 2/3 of DS patients have some from of sensory impairments • Most common visual problems were refractive errors, strabismus, and nystagmus. • Hearing problems associated with narrow throat structures also lead to recurrent ear infections

47. Medical Complications

48. Complications • Obstructive sleep apnea in about 30% • Dentition • Hypoplasia • Irregular placement • Fewer/same caries • Increased periodontal disease

49. Management Concerns • Frequent compromised immune system leads to higher rate of infection • Frequently linked to epilepsy, diabetes, ALL, hypothyroidism • Extra appointment time to allow for communication • Atlanto-axial instability increased motility between C1 and C2, careful positioning in the dental chair