Special Needs

1. Special Needs Dentalelle tutoring

2. Definitions to know Labeling – process of classifying people for educational, medical, or financial reasons Barrier-free environment – facilities that are physically accessible to people with all types of disabilities Normalization– making available patterns and conditions of everyday life that are as close as possible to the norms and patterns of the mainstream of society Mainstreaming– integration of people with special needs into regular communities and services Access to oral health care – opportunity for each individual to enter into the oral health care system and make use of all available services

3. Goals for Normalization Ensure legal and civil rights Guarantee appropriate education for continued learning Increase or maintain social skills and problems solving abilities Increase employment options and decrease employer discrimination Ensure comprehensive network of community resources

4. Factors Contributing to Dental Disease 1. Tooth anomalies including the size, shape, and texture of teeth 2. Variable patterns of tooth eruption 3. Salivary flow and consistency 4. Oral microflora present 5. Diet and feeding practices 6. Oral hygiene habits 7. Use of fluoride supplement 8. Effect of medications such as anti-convulsant drugs 9. Related systemic diseases 10. Oral motor dysfunction 11. Occurrence of accidents or abuse or both 12. Degree of professional care provided, if any 13. Degree of dependence on others and for what 14. Type of disability

5. What is needed for Special Needs Clients Dental Professionals have a significant role in planning and conducting preventive oral health programs for individuals and groups of people in the private and public sectors. In developing such programs for disabled persons, several factors should be given consideration. These are: Understanding the psychosocial and medical issues affecting the individuals Alteration of mechanical plaque removal techniques to accommodate disabilities Use of chemical agents to promote optimum oral health Providing in-service presentation for those caregivers responsible for oral health care of disabled individuals Providing appropriate patient education so patients can increase their ability to perform oral care techniques Cooperation and working with other health professionals to achieve oral health for disabled persons Program should provide for frequent recall Program should provide for frequent therapeutic intervention such as periodontal scaling, pit and fissure sealants, and fluoride therapy to maintain health Preventive program must be individualized. It’s more than likely that patient education and oral physiotherapy aids will have to be modified for the handicapped patient

6. Types of Disabilities

7. Classification A. Developmental Disabilities Are present from birth. Include mental retardation, autism, epilepsy, cerebral palsy, and muscular dystrophy. B. Communication Disabilities Often are related to neurologic damage to parts of the brain responsible for language or speech development. Include aphasia, apraxia, and dysarthria. C. Cognitive Disabilities Are associated with reduced mental capabilities Include mental illness, Alzheimer’s disease, eating disorders, and Cerebrovascular disorders. D. Medical Disabilities Are associated with conditions that affect major organs of the body. Include arthritis, heart disease, cancer, diabetes, drug and alcohol abuse, respiratory disease, kidney disease, endocrine disease, and blood disorders.

8. Continued E. Orthopedic Disabilities Are conditions associated with use of the legs and arms. Include paralysis and loss of limbs F. Sensory Disabilities Are conditions associated with the senses Include varying degrees of blindness and hearing loss. G. Nervous system Disabilities Commonly involve degeneration of the nervous system Include disorders such as myasthenia gravis, Parkinson’s disease, Alzheimer’s disease, Bell’s palsy, and multiple sclerosis.

9. LEVELS OF FUNCTION

10. Levels of Function The assessment of a patient’s functional level involves an evaluation of the patient ‘s ability to perform activities of daily living (ADL) such as bathing, eating, dressing, speaking, and walking. The higher the functional level the greater a patient’s ability to take care of him/herself. ADL assessments have different rating scales and levels.

11. High Function • I. High Functional Category • Is limited to individuals who are able to attend to most of their ADL needs with some supervision or encouragement. • Patients typically require a daily reminder to brush the teeth and encouragement to go slowly and thoroughly; may require assistance with transportation. • Is typically categorized as level I or II • Patients typically are capable of giving informed consent.

12. Moderate Function • II. Moderate Functional Category • Is limited to individuals who need supervision or assistance with some of their care. • May require the use of gesture of demonstration, or the use of adaptive equipment for communication. • Is typically classified as level III • Patients typically are unable to give informed consent; power of attorney or guardianship documentation must be obtained to determine with whom to discuss patient treatment.

13. Low Function • III. Low Functional Category • Is limited to individuals with little or no ability to perform ADLs themselves. • Patients require a second or third party to provide daily care. • Patient typically homebound. • Is typically classified as level IV • Patients typically are unable to give informed consent; power of attorney or guardianship documentation must be obtained to determine with whom to discuss patient treatment.

14. Potential Barriers • A. Communication Barriers • Include attitude of health care workers about treating and communicating with compromised individuals, and patient and family attitude toward dental care. • Involve hearing and visual losses and speaking difficulties • 1. Always talk directly to the patient, even when the caregiver is present, unless the patient is unable to communicate. • 2. Patient consent is required (when the patient is cognizant) before patient care can be discussed with caregivers or others

15. Physical • B. Physical Barriers Include: 1. Stairs, small-print signs, narrow doorways, heavy doors, distant parking, area rugs or other floor coverings that cause tipping, lack of elevators, narrow rest room stalls, restricted access to drinking fountains, telephones, and rest room. • Are addressed by the Americans with Disabilities Act, which requires dental office to have: • 1. Ramped access to the office building • 2. Room for wheelchair transport in the waiting room, operatory, and rest rooms • 3. Parking spaces for disabled individuals

16. Transport • C. Transport Barriers • Are common for disabled individuals • 1. Many of these individuals prefer the safety of their homes to the problems associated with public or private transportation • Related to public transit include: • 1. Difficulty accessing public transit, include: • i. Reading time schedules • ii. Finding the appropriate bus or train • iii. Getting to and from the station • Can be eased through: • 1. Senior citizen buses similar transportation • 2. Private transportation • i. Requires reliance on family members or friends to provide rides to appointments or stores. • ii. Can influence a disabled person’s ability to reach important destinations

17. Economic • D. Economic Barriers • Are the greatest limitations to receiving necessary dental care • 1. Many disabled people have only Social Security or other governmental programs as a means of economic support • 2. Those who are employed typically earn low wages • 3. Any money received is needed for primary needs such as shelter and food • 4. Medical and dental care often are relegated to the bottom of the list of needs • 5. Those on Medicaid or Medicare have difficulty finding providers who are willing to accept less than customary fees for their services. Make paying for dental services difficult because most are paid out of pocket and are not covered by insurance

18. Motivational • E. Motivational Barriers • Are the common among the disabled, who rely on others for partial care • May be complicated by communication difficulties. • 1. Although cognizant, disabled individuals may be unable to communicate their needs to caregivers • 2. Some disabled individuals also may be forgetful; written instructions in addition to verbal instructions should be given to both patient and caregiver.

19. Provision of Care • F. Provider philosophy / provision of care • Surveys indicate that about 20% of dental professionals are willing to treat persons who are physically or mentally challenged • Reasons for not treating individuals with special needs include: • 1. Inadequate facilities and equipments • 2. Inadequate training (therefore, knowledge and skills) • 3. Not wanting to expose “normal” patients to “special” patients • 4. Inability to collect adequate fees • 5. Additional effort and time required • 6. Personal discomfort about perceived “differences” of special patients

20. Psychosocial G. Psychosocial Concern Over 50% of Americans express positive attitudes towards the elderly and people with disabilities, yet most really perceive them as different and inferior Society perceives disabilities, differences, and disease states before recognizing similarities Feelings of guilt, anxiety, apathy, inadequacy, embarrassment, depression, anger, and resentment about their special needs interfere with attempt to seek care Fear of or inability to comprehend dental procedures, antisocial or atypical behavior, or over dependency on oral health care providers interferes with provision of care Basic daily needs and activities are often overwhelming and can determine priorities for oral healthcare Preparation of self-image and worth can affect treatment planning

21. Medical H. Medical Concern Situations compromising the provider or patient 1. Inadequate infection control procedures 2. Inadequate or inaccurate health histories 3. Inadequate precautions for potential emergencies Type of treatment / conditions 1. Medication 2. Therapies that compromise oral health 3. Conditions or situations that contraindicate treatment 4. Terminal illness or the aging process may change treatment planning or the prognosis of treatment 5. Medical problems or disabilities may necessitate provision of care in a setting other that the office

22. Mobility I. Mobility / stability concerns Impaired ambulation or use of a wheelchair may hinder access to care Uncontrolled or sudden movement may interfere with home care or dental hygiene intervention s Uncontrolled or aggressive behavior may endanger the care providers and the patient Spatial disorientation may interfere with patient relaxation in the dental chair or performance of oral care procedures

23. Factors Causative factors for compromised individuals, such as trauma, birth defects, or adult onset diseases, allow impairment pattern to appear along stratification line, the age of the individuals per se must not be the main determining factor in deciding the quality and quantity of preventive dental instruction provided for that person. Instead, this decision should be made after consideration of a number of other factors, including the individual’s sensory perception, cognitive abilities, functional expertise, and oral hygiene condition.

24. Sensory To communicate ideas and instructions successfully, the patient and the practitioner must first be able to see or hear each other. Communication channels are impeded if the patient’s hearing or vision is significantly impaired, in which case a modification in communication modalities must be made. Otherwise recommendations for an oral health home care program will not be understood, much less carried out

25. Visual What are your feelings when you meet or observe a person who is blind? Concern? Pity? Amazement they can maneuver by themselves? Have you ever wondered whether you should offer assistance? Many people do not know how to respond to such situations or know enough about blindness or visual impairment to be comfortable. As a result, the true abilities and talents of blind and visually impaired persons often are underestimated. An understanding of the abilities and limitations of those suffering from this handicap will help to facilitate the provision of quality dental care. Often a staff member sensitized in the skills of observation can easily identify visual impairment before the patient reaches the operatory. For example, a staff member may observe that the patient is unable to read and respond to the medical history questionnaire without assistance.

26. Continued Instructional materials to be used with patients who have decreased visual acuity could include selective use of commercial products that have been developed for pediatric dentistry programs. Routinely, such products have large pictures. Custom-made instructional sheets may be produced by the dental office using large black letters of at least 12-point type on off-white or white paper. Cassette tapes for recording personalized hygiene instructions are also recommended. Chair side instructions of tooth brushing and flossing should be demonstrated on oversized models of the dentition with a giant- sized toothbrush

27. Demonstrate To demonstrate brushing and flossing techniques in the office, all inexpensive magnifying mirror should be employed to assist the patient in observing his or her own performance. Many patients with visual problems experience an increased sensitivity to light or glare. Indiscriminate positioning of the dental light so that it shines in the eyes of a patient can result in significant discomfort for such a patient. Careful focusing and positioning the operatory light can avoid this.

28. Hearing Disabilities Individuals with hearing impairments face a number of problems unique to this handicapping condition. Ironically, perhaps the most significant and socially devastating problem arises from their normal appearance. Hearing-impaired persons are usually not distinguishable from others around them until communication is attempted. The commonest problem in communicating with the hearing disabled, however, is that the speaker does not sit directly in front of the patient, at the same eye level, and speak face to face. Most patients with hearing disabilities do some lip reading to augment their hearing, but even the best lip reader is able to decipher only 26% of a message conveyed entirely through this method. The hearing disabled patient relies heavily on the communicator's facial expression and body language to understand the message. Do not speak to the patient with any equipment running. Similarly, it is not desirable to speak while performing other functions, such as writing with your head down, looking at radiographs with your face turned from the patient, or while entering or exiting the room. If preventive instructions are to be given to a patient with a hearing aid, be sure the Patient's aid is in place and turned on.

29. Speech and Language Disorders One cannot discuss the role of communication between the patient and the dental care provider without considering speech and language. With practice, a clinician who listens carefully and patiently to such speech can become adept at understanding much of it. This is the same sort of technique many dental providers have already achieved in learning to understand patients who attempt to speak with a rubber dam in place. The substitution of written for verbal communication is a possible option for individuals in whom the recognition of language is still intact. Unfortunately, many of the causes of speech disorders result in slight or pronounced paralysis, or tremors that prevent the patient from writing legibly. One solution is to provide the patient with a lapboard containing preprinted letters, common words, or pictures. In summary, both verbal and nonverbal techniques play roles in the communication process between a dental care provider and a compromised dental patient. Speaking directly to the patient from a sitting position in front of the patient in a well modulated, well-articulated voice and reinforcing each step of the communication with nonverbal cues are all techniques that should be used to produce a successful relationship with a patient who has impaired communication skills.

30. Cognitive Capacities The functional capacity of a patient is of far greater importance than that person's intelligence quotient (IQ) test results in determining his or her capacity to benefit from preventive dentistry instructions. For example, a cognitively impaired individual is expected to have low IQ, short attention span, and difficulties in understanding oral hygiene instructions. Yet many of these patients, when properly taught and motivated can successfully perform oral hygiene procedures. To attain this success the dental care provider must first determine the patient's level of cognitive ability and then direct all instruction to that level. Often clinicians in their diligence to get their message across to the cognitively or intellectually impaired patient tend to do and to say too much. It is important to keep these instructional periods short with frequent repetition of the information. Use a level of language that is readily comprehended by the patient without being insulting. Written or tape recorded reminders can be given for homework. At each appointment the individual should be requested to state or show what he or she has been doing since the last visit. Family members or guardians, teachers, or other caregivers must assume responsibility for oral health care programs of patients with little cognitive ability. The selected individuals should be thoroughly instructed by the dental staff in the proper techniques for that patient's oral health.

31. Functional Performance Tooth brushing and flossing require not only the fine motor skills or dexterity of the small muscles of the fingers and hands but also the gross motor skills of the larger muscle groups in the upper extremities. Numerous muscles and nerves of the head, neck, and upper extremities are all involved, as is the range-of-motion capability of the joints, especially the shoulders and elbows. In many disabilities one or more of these elements may be adversely affected or limited. An accurate assessment of a patient’s expected functional performance depends on evaluation of each task necessary to perform the oral hygiene. Once a difficulty has been identified, either a device or a person is needed to compensate for the patient’s inadequacy. Gross motor skills such as grasping a toothbrush handle can often be improved by orthotic appliances

32. Continued Dexterity such as is necessary for the production of the small vibratory strokes recommended in tooth brushing usually cannot be enhanced through medical or orthotic techniques, although for certain patients, appliances specifically the electric toothbrush may serve as a highly effective substitute for this lack of dexterity.

33. CONDITIONS

34. Special Needs Conditions Individuals with special needs include the developmentally disabled, the communication disabled, the sensory disabled, the elderly, the patient with an eating disorder, the medically disabled, the patient with cancer, the patient with an orthopedic disorder, the patient with nervous system degeneration, the patient with cleft palate or Bell’s palsy, the abused patient, and the pregnant patient.

35. Developmental Disabilities • Developmental disabilities are those that a person is born with. Common disabilities include mental retardation, cerebral palsy, autism, epilepsy, and cleft lip or palate. • I. Mental Retardation • A. Is the most common developmental disability • B. Is below average intellectual functioning (IQ below 70 to 75) • C. Oral manifestations • 1. Delayed or irregular toot eruption • 2. Small, cone-shaped, fused, or missing teeth • 3. Malocclusion • 4. Repercussion of mouth breathing and tongue thrusting • 5. Cracked lips • 6. Increased risk of gingivitis and periodontal disease • 7. Caries

36. D. Barriers to care include: • 1. Dependence on the caretaker to make and keep appointments • 2. The cost of dental care • 3. Mental limitations • i. Build patient’s trust • ii. Communicate at his / her developmental level • iii. Speak simply • iv. Reward good behavior; restrain and sedation to manage behavior are recommended only when absolutely necessary

37. E. Professional and home care includes: • 1. Frequent oral prophylaxis to reduce the risk of periodontal disease • 2. Lubrication of lips to reduce the risk of cracking • 3. Awareness that the gag reflex may be strong • F. Patient / Caregiver education emphasizes: • 1. Repetition of simple, demonstrable home care procedures with the patient and caregiver • i. The caregiver supervises and/or performs oral hygiene procedures depending on the abilities of the patient • 2. Discussion of periodontal risk and the need for excellent daily home care, frequent progressive oral prophylaxis, and examination

38. Cerebral Palsy A. Is a developmental, neuromuscular disorder that results in an inability to control muscular movement (spasticity); limitation ranges from mild to severe B. Oral manifestations of the condition include: 1. Lack of control of facial muscles, which makes speech (dysarthria), chewing, and swallowing (dyphagia) difficult 2. Difficulty keeping mouth open during dental appointments 3. Tempromandibular dysfunction (TMD) 4. Tongue thrusting 5. Mouth breathing 6. Bruxing 7. Attrition 8. Caries and periodontal disease related to the inability to practice good oral hygiene measures because of limited coordination 9. Gingival hyperplasia in those talking phenytoin

39. C. Barriers to care include: 1. Communication difficulties between patient and dental professional; low self-esteem may influence desire to communicate also. 2. Unfamiliarity of dental office; causes emotional distress and thereby increases spastic movement 3. Dependence on caregiver 4. Lack of mobility 5. Inability of the dental professional to provide thorough treatment because of the patient’s physical limitations

40. D. Professional and home care include: 1. Building a trust 2. Desensitizing the patient to dental routine 3. Encouraging complete communication 4. Avoidance of injury to the patient or operator from uncontrolled movements of the patient during instrumentation (fulcrums are a must) 5. Protecting the patient during from aspiration of water or other materials placed in the oral cavity 6. Assisting the patient during seizures (during seizure activity, the patient should not be moved; the area should be cleared of items that may hurt the patient during convulsive movement) 7. Wheelchair transfer 8. Realizing that communication barriers don’t indicate incomprehension 9. Involvement of the caretaker 10. The use of an assistant during treatment to avoid injury and to expedite treatment 11. The use of sedation and general anesthesia 12. Consultation with a medical physician regarding a change in medication if hyperplasia is a concern

41. E. Patient / caregiver education should emphasize: 1. Adaptation of toothbrushes or floss handles as needed 2. Evaluation of the need for mechanized cleaning devices (toothbrushes and oral irrigators) 3. Explanation and demonstration of all home care procedures; great patience may be necessary but most patient are willing to learn 4. Daily disclosing of plaque 5. Assistance with daily plaque removal if the patient is unable to thoroughly cleanse own mouth 6. The use of fluoride and chlorhexidine to control disease as needed; chlorhexidine gluconate sprays effectively reduce plaque when they are used twice daily 7. Explanation of the need for frequent oral prophylaxis

42. Autism • A. Is a lifelong, behavioral developmental disability of unknown cause • B. Oral manifestation includes: • 1. Typically are no different for these patients than for others, unless patient has received insufficient care • 2. May include a tendency for oral trauma because some patients may be aggressive or injure themselves when brushing • 3. May include an increased risk of caries if patients has a high carbohydrate intake • C. Barriers to care include: • 1. The stress of the dental visit • 2. Communication difficulties because of poor behavior control (caregivers may be embarrassed about child’s behavior) • i. Managing behavior may include: • a. Desensitization over multiple appointments • b. Reinforcing good behaviors • c. Using physical restrain when safety is a concern • d. Sedation and/or general anesthetics (if other methods fail) • e. Reliance on the caregiver to make and keep appointments

43. D. Professional and home care includes 1. Consistency in care and among care providers; the patient’s preference for routine dictates that the same dental team member should see the patient at each visit 2. Shorter, more frequent appointments in a quiet, calm environment are preferable to longer, infrequent visit; noises, movement, and other changes are disconcerting to the patient and should be avoided or introduced slowly as needed 3. Involving the caregiver in preparing the child for the dental visit i. Procedures should be explained to the caregiver so that some can be practiced at home in preparation for the dental visit ii. Home care instruction should be performed consistently on daily schedule E. Patient/Caregiver education should emphasize: 1. The use of both verbal and nonverbal techniques of communication to demonstrate simple oral care instructions 2. Discussion with the caregiver about the patient’s need to eat fewer cariogenic foods 3. The need for frequent preventive dental visits to create routine and avoid the need for extensive treatment

44. Epilepsy A. Is a central nervous system disorder; convulsions and/or loss of consciousness are common symptoms B. Oral manifestations include: 1. Gingival hyperplasia secondary to phenytoin use; plaque control is vital to the prevention and limitation of gingival overgrowth 2. Trauma from seizure activity such as cheek, tongue, or lip-biting, falling and tooth chipping (from biting instruments or clenching) C. Barriers to care include: 1. Economic cost; particularly if the disability affects employability 2. Lack of transportation, if the patient is unable to drive 3. Lack of communication, if fear of embarrassment about having a seizure in public is strong

45. D. Professional and home care includes: 1. Frequent (even monthly) oral prophylaxis, depending on the severity of the gingival condition 2. A calm atmosphere 3. Careful preparation for dental appointments; a medical kit or medical consult may be necessary 4. Demonstration and explanation of thorough home care procedures; should include sulcular brushing and flossing 5. Consulting with physician regarding medical change if gingival overgrowth is excessive or uncontrollable; surgical excision of gingival overgrowth may be required E. Patient/Caregiver education should emphasize: 1. Discussion of oral health and the need for excellent plaque control 2. Repetition of instruction if patient’s memory is impaired by medication 3. Positive reinforcement to bolster self-esteem

46. Muscular Dystrophy A. Is an inherited, progressive skeletal muscular disorder B. Oral manifestations are related to a loss of muscle control and may include injury or infection. Irritated gingival may be caused by an open mouth; poor oral hygiene may occur because of a reduced ability to provide self-care C. Barriers to care include: 1. Economic issues; caregivers are needed to provide full care as the disorder progresses 2. Dependence on the caregiver to make and keep dental appointments 3. Lack of communication; speech difficulties occur as muscle weakness affects muscle of the head and neck 4. Immobility or difficulty controlling movement

47. D. Professional and home care includes: • 1. Frequent oral prophylaxis to reduce the risk of infection • 2. Short dental appointments • 3. The use of a bite-block to keep the mouth open after muscle loss prevents it • E. Patient/Caregiver education should emphasize: • 1. Supervision and/or performance of oral hygiene procedures by the caregiver if the patient is unable • i. Power-assisted devices enable the patient to continue self-care • ii. Adaptive aids accommodate muscle weakness • 2. Discussion with the patient and/or caregiver about the risk of infection and the need for excellent daily home care, frequent professional oral prophylaxis, and examination • 3. The use of petrolatum on lips and oral tissues irritated by open mouth

48. Cleft Lip and Palate A. Is a craniofacial deformity that range from a mild unilateral clefting of the lip to a wide, bilateral clefting of the lip and palate; typically is not life threatening but requires much care (minor clefting associated with the uvula and soft palate requires little if any medical care); defect is associated with inadequate fusing of the lip, palates, or uvula during the 4th to 12th weeks of gestation

49. B. Oral manifestations include an increased risk of oral infection (including periodontitis and dental caries) from malpositioning of the teeth, wearing of a dental appliance (obturator), mouth breathing, and oral deformity, which also make oral hygiene procedures more difficult C. Barriers to care include: 1. Economic issues; multiple oral and facial surgeries and care by professionals from different disciplines are required to correct the defect and associated conditions 2. Difficult communication, because of inadequate speech production, hearing loss related to the defect, or self-consciousness

50. D. Professional and home care includes 1. Frequent oral prophylaxis (3 to 4 times annually) to reduce the risk of infection 2. When the premaxilla is unfixed or immediately after surgical procedures, fulcruming in the site should be avoided or limited 3. Fluoride treatment to reduce the incidence of dental caries