Patients with Special Needs

1. Patients with Special Needs Wichita Dental Hygienists’ Association January 10, 2008 Barbara M. Gonzalez, RDH, MHS

2. Disabilities • Disability = one or more life skills is altered by physical or mental impairment • ADA = Americans with Disabilities Act • Passed in 1990 • Employment • Environment

3. Not your dentist’s ADA • The Americans with Disabilities Act • enacted in 1990 • Covers employment, public services, public accommodations, etc. • http://www.usdoj.gov/crt/ada/statute.html

4. What is a “Disability”? • Social Perceptions • The Obvious • Wheelchair… • Spinal cord injury • Cerebral Palsy • Muscular Dystrophy • ALS (Lou Gehrig’s)

5. “You don’t look disabled…” • Social Perceptions? • The Not-so-Obvious • Sensory Deficits • e.g. hearing impaired • Seizure disorders • Chronic managed • e.g. multiple sclerosis, lupus • Infectious diseases • e.g. HIV

6. The Dental Hygienists’ Role • Make good use of anecdotal notes • Meet basic patient needs, i.e. • Modified oral hygiene techniques & aids • General Practice • Learn special techniques or skills, i.e. • Sign language • Wheelchair transfers • Specialized Practice

7. Physical Impairments

8. Visual Impairment • Half of legally blind Americans are 60+ • Legal Blindness • Visual acuity of 20/200 or less with optimal correction • 10% of legally blind Americans are school age children or younger

9. Etiology • Trauma • Incidence is markedly decreased due to better workplace safety controls • Disease • i.e. macular degeneration, etc. • Structural / development defects • Cataracts, etc.

10. Major Problems Encountered • Unsolicited and inappropriate assistance by strangers • Mistaking blindness for DEAFNESS • Addressing companions and not person • Verbalizing pity • Visually impaired usually independent and productive sans other disabilities

11. Barriers to Care • Accessing “yellow pages” to find dentist • Transportation • Release time from work • Negative attitudes about service dogs in office setting • Financial • Physical environment

12. Physical Environment • Loose rugs • Poor lighting • Legal blindness vs. total blindness • Steps • Small print / written forms • Unwieldy doors • Sudden changes in surface texture

13. Assisting Your Patient • Verbal questioning to gain information • Schedule additional time • ASK for patient’s preferences

14. Oral Manifestations • Same as general peer population • Oral hygiene may be compromised • Poor OH may contribute to oral disease

15. Patient Management • Greet patient upon arrival • Describe office layout • Escort patient while describing changes, obstacles • Offer physical assistance • Do NOT take by hand! • Allow service dogs in operatory

16. Patient Management • Introduce patient to other staff members • Designate one as primary communicator • Minimize noise! • Identify sounds, smells, equipment • Allow them to touch • Inform patient upon approach to mouth

17. Patient Management • Inform the patient upon leaving and returning to operatory • OHI – use hand-over-hand technique • OHI – good verbal descriptions • OHI – use typodonts

18. Hearing Impairments • Can exist with no other disability • Often accompanies other disabilities • Cleft palate – 90% • Cerebral palsy – 20% • Down’s Syndrome – 70%

19. Oral Manifestations • Bruxism • Others as general population

20. Barriers to Care • Difficulty contacting office • TDD • Telecommunications device for the deaf

21. Patient Management • Allow interpreter into operatory • BUT, speak to the Patient! • Do not shout, unless directed to by patient • Maintain voice volume • Learn simple ASL / SEE signs

22. Patient Management • Write out information in advance of appointment • For children, use drawings or pictures • Use touch to communicate • Hearing aids often turned off • OHI – use disclosing, visual cues

23. Neuromuscular Disorders • Cerebral Palsy… • Muscular dystrophy • ALS • Neurological Disorders • Multiple Sclerosis

24. Cerebral Palsy • A static, non-progressive neuromuscular condition resulting from damage to brain, often peri-partum • Motor dysfunction, weakness, un-coordination, paralysis • May be accompanied by other diagnoses

25. Classifications of CP • Spastic – 50-75% • S. diplegia, s. hemiplegia, s. quadriplegia • Athetoid dyskinetic – 15 – 25% • Ataxic – 10% • Hypotonic (Flaccid)- <10% • Mixed – 5-10%

26. Limb Involvement Classifications • Monoplegic • Hemiplegic • Paraplegic • Diplegic • Quadriplegic • Triplegic

27. Oral Manifestations • Bruxism • Malocclusion • Clenching • Food retention / pouching • Caries • Plaque control • Periodontitis • Gingivitis

28. Patient Management • Schedule initial interview to acquaint with patient • Assess • muscle / reflex patterns • Communication and comprehension • Medical conditions • Caregiver should participate

29. Patient Management • Speak to adult patient as an adult • Speak to a child patient as a child • Gear information to patient’s level of intelligence, not communication

30. Managing Reflex Patterns • Tonic labyrinthine reflex • Occurs when head tilts backward • Asymmetric tonic neck reflex • Occurs when head turns to side or away from midline • Gag reflex • Cough reflex • Bite reflex • Swallow reflex

31. Gag and Cough Reflex • If Hypoactive • At risk for aspiration • Use small bursts of water • Use frequent suction • If Hyperactive • Flex patient’s head with chin to chest • Introducing items intraorally will probably induce reflex

32. Bite Reflex • Mouth prop may be helpful • Tie off! • Treat lingual as quickly as possible

33. Mouth Gag (molt) • Adjustable

34. Swallow Reflex • Swallow Reflex • Avoid mouth props • Be patient!

35. Retraction Issues • Tongue retraction may be difficult

36. Patient Management • Allow adequate time • Be aware that un-coordination (ataxic) becomes aggravated with time • Support patient with pillows, bean bags, restraints, as needed • Control tonic neck reflex by cradling • May require second person • Sedation / Gen. Anesthesia

37. Oral Hygiene Needs • Food retention a big problem! • Frequent toothbrushing • Lubrication of gingival tissues • Nutritional analysis • Cariogenicity • Fluoride • Frequent prophylaxes • Modified oral hygiene aids

38. Spinal Cord Injury • Location of injury determines extent • 70% < 40 years of age • Overwhelmingly male • 50% auto or motorcycle accidents • 18% sporting accidents • 20+ % occupational • Remaining GSW, falls, etc.

39. Other Considerations • Grieving Process • Shock • Denial • Reaction • Mobilization • Coping

40. Other Considerations • Anger • Depression • Withdrawal

41. Oral Manifestations • Depends on degree of injury • Lower limb involvement only • Upper limb involvement • Depends on nature of injury • Fractured teeth • Broken jaw / facial bones • Attrition • mouthstick

42. Patient Management • Inspect office and operatories for barriers • Parking availability • Accessible entrance • Doorway widths (32 “+) • Flooring materials • Hallway width (36”+) • Turnaround space (60”+) • Restroom access

43. Patient Management • Operatory Accessibility • Wheelchair transfer access • Follow the patient’s lead • Use the brakes • Have adequate physical support • Check urinary catheters during and after

44. Oral Hygiene Needs • Extremely important • Mouth and teeth often substitute for arms and hands • Modified aids • Engage caregiver

45. Mental Disabilities • Mental Illness • Mental Retardation

46. Mental Illness • “an illness with psychological or behavioral manifestations and/or impairment in functioning due to social, psycholgic, genetic, physical/chemical, or biologic disturbance. The disorder is no limited to relations between the person and society. The illness is characterized by symptoms and/or impariment in functioning.”

47. Mental Retardation • “A significant subaverage general intellectual functioning which originates during the developmental period and is associated with impairment in adaptive behavior”

48. Adaptations • Mental illness requires adaptations in both physical and emotional realms • Mental retardation requires adaptations in both physical and educational realms

49. Mental Illness • Affects one-sixth of Americans at some point in their lifetime • Chronic major depression affects 3-5% of total population

50. Mental Illness • For women • Phobias • Depression • For Men • Chemical dependence • Phobias • 2-5% of population • Anxiety disorders