Special Patients in Dentistry

Special Patients in Dentistry

• Increased life expectancy has led to a greater demand for dental treatment for patients with special needs (SNP).
• Planning treatment for SNP requires a comprehensive and often multidisciplinary approach by the dentist.
• Many professionals face difficulties due to a lack of training, uncertainty, ergonomic challenges in the consultation room, and insufficient knowledge.
• Collaboration difficulties in some patients can make outpatient treatment challenging.
• Dental care for SNP should be risk-assessed, considering general health status and collaborative levels against dental requirements.
• Behavioral management techniques should be initially used; if unsuccessful, sedation can be an alternative to general anesthesia.
• General anesthesia is necessary when sedation fails, allowing total oral treatment in one hospital session. This covers prophylaxis, restorations, pulp therapy, extractions, and preventive procedures.
• Home dental care is a necessary modality for bedridden patients or those with limited mobility or developmental disabilities.
• This covers palliative care patients, those with dementia, and those with immediate post-surgical dental emergencies.
• Dental literature lacks comprehensive organization across therapies, making it hard for professionals to choose the appropriate treatment.
• The Commission on Dental Accreditation (CODA) defines SNP as anyone with medical, physical, psychological, or social conditions requiring individualized dental care.
• SNP comprises a range of genetic and/or acquired diseases.
• Neurological motor disorders (e.g., Down syndrome, cerebral palsy), chronic systemic diseases (e.g., diabetes, heart issues, hypertension), onco-hematological disorders (e.g., leukemia, lymphoma), infectious diseases (e.g., HIV, hepatitis B or C), physical disabilities (e.g., paraplegia), sensory impairments, and acquired diseases (e.g., rubella, tuberculosis) are commonly seen categories of SNP.
• Dentists must adapt their psychological approach, surgical techniques, and material choices to each individual patient's needs.
• General health status greatly influences the dental treatment plan.

Management of Patients with Special Needs

• Initial clinical assessment includes a comprehensive health questionnaire (filled by guardians), reviewing medical history, hospital treatments, medications, health problems, habits, and other pertinent information.

• Oral health evaluation considers previous treatments, reasons for consultation, and conducting a clinical examination.

• Dental, periodontal, and soft tissue examinations are performed with at least one panoramic X-ray, plus additional required periapical and/or occlusal X-rays.

• Behavioral analysis using the amended Frankl scale and the Houpt scale evaluates patient cooperation levels and movements during the examination.

• Treatment plans are categorized by quadrants or sextants.

• Prioritizing treatment approaches for preventive, conservative, surgical, and other needs is as follows: preventative treatment (including scaling/cleaning, fluoride, and sealant procedures), restorative treatment (covering both primary and permanent teeth with endodontic and restorative treatment), and surgical treatment (involving extractions, gingivectomies, biopsies, and minor oral surgeries).

• Conditioning techniques/physical support are used for smooth/uneventful treatment, preventing patient escape attempts and protecting the team from trauma. Holding therapy is a physical support option.

• Techniques are used to support patients—depending on age and capabilities—with physical support, such as "knee-to-knee" positions for younger children or head support for all ages.

• Multiple options are available for use with short dental office visits including but not ltd to sedation.

• Sedation, through oral medication (mild or moderate), can be helpful and safe for outpatient treatment, respecting patient airway and response mechanisms.

• Sedation techniques can include: benzodiazepines, nitrous oxide, hypnotics and antihistamines. Deep sedation typically uses propofol and neuroleptics.

• Guidelines for administering sedation include a scale for selecting appropriate medications.

• Home dental care is offered as a distinct modality, including specific care provided by a qualified professional, often involving relatives. The objective is targeted removal of odontogenic infections and preventive care.

• Home care may be challenging due to space limitations, inadequate lighting/posture, difficulty with imaging, and lack of biosecurity, but home care is important for many patients.

• Four categories of home care are based on patients' abilities:

  • Required emergency treatment (treating pain/disease)
  • Necessary severe treatment (maintaining health)
  • Necessary moderate treatment (allowing medication or treatment in coordination with the patient’s limitations)
  • No treatment (patient needing no further intervention)

Classifications, Guidelines & Decisions

• The ADA uses ASA classifications (I-VI) based on patient physical condition to determine the safest anesthesia approach.
• The WHO suggests 8% of individuals with disabilities require general anesthesia for dental care.
• A comprehensive evaluation including medical history, physical assessments, and level of cooperation (using scales for behavioral analysis), determining any systemic or oral health conditions that present complications for dental care
• The clinical assessment and treatment must align with the patient's individual needs and the required support and resources.
• The dental team should provide clear pre, intra, and postoperative instructions and obtain informed consent.

Treatment Modalities

• Multiple treatment modalities, such as mild to moderate sedation and general anesthesia, can be used according to the severity of patient needs and the complexity of dental intervention.

• Mild/Moderate Sedation guidelines emphasize the protocols and needed equipment.

• The General Anesthesia modality requires a multidisciplinary team and a hospital setting.

Summary of Patient Types

• Cardiovascular: Heart failure, congenital heart disease, arrhythmias, oral complications (avoiding oral foci, limited treatments, and effects of stress/anticoagulants)
• Breathing: Respiratory diseases (e.g., COPD), physical limitations, special handling needed, avoid prolonged visits
• Renal: Chronic kidney failure, hypertension, anemia, potential infections, oral complications
• Digestive: Gastrointestinal disorders, including esophageal stricture, reflux disease, ulcerative colitis, pernicious anemia, Crohn's disease, bleeding tendency, medication issues, attention to infections
• Endocrine: Pancreatic/adrenal/thyroid/parathyroid diseases, general/neurologic/oral/cardiovascular manifestations, periodontal infection, frequent infections and abnormal oral mucosa, sensory disturbances, tooth decay
• Cancer: Oral complications from illness/treatments, secondary treatment issues (immunodeficiencies), preventing complications
• Immunosuppressed: Immunity pathology (e.g., congenital primary immunodeficiencies, Acquired immunodeficiencies [virus, HIV], and/or clinical management [transplanted]) Oral foci issues, post-transplant classifications and risk categorization, and necessary equipment are important issues in this group.
• Anticoagulated: Coagulation pathology, including congenital disorders (e.g., haemophilia, Von Willebrand disease) or secondary conditions (e.g., cardiovascular patients), classification of risk and appropriate treatment needs
• Neurological: Neurological diseases (e.g., Alzheimer's, Parkinson's), communication issues, difficulty with taking medicines, technical challenges.
• Psychiatric
• Disabled (including Down Syndrome and Cerebral Palsy)
• Liver