Behavior Management Lecture 8 PDF

# Behavior Management ## Lecture 8 ### Management patient with special health care needs in the dental clinic "**Special health care needs**" - physical, developmental, mental, sensory, behavioral, cognitive, or emotional impairment or limiting condition that requires medical management, health car...

# Behavior Management ## Lecture 8 ### Management patient with special health care needs in the dental clinic "**Special health care needs**" - physical, developmental, mental, sensory, behavioral, cognitive, or emotional impairment or limiting condition that requires medical management, health care intervention, and/or use of specialized service or programs. **Classification:** - Mental - Physical - Medical It is important that the dentist understand all the emotional, stressful and financial conditions that the parents may go through as: "No parent is prepared in advance to become a parent of a disabled child". **Special Need Guardian:** **Stages through which parent will pass:** 1. Disorganization. 2. Reintegration. 3. Mature adaptation. 4. Extreme behavior: overprotection (blind). 5. Rejection (Cerebral Palsy). **Parents deserve some understanding as they go through many difficulties:** - Waiting long times in medical office. - Driving many miles to special clinics. - Constantly in and out of hospitals. - Special home adjustments. - Financial difficulties. - Accepting scorn from ignorant society. **First dental visit:** The initial demonstration of sincere interest in the child often proves advantageous and saves time throughout the entire treatment process. ### Variables affect the provision of dental care (Barriers): - Access (Free space). - Degree of independence giver on others. - Availability of professional care (lack trained). - Type of disability (medical experience &oral neglect). - Attitude of care. - Effect of (illness& poly pharmacy). - Systemic disease (health& dentistry). - Finance. It is not accessibility, availability or acceptability that determine the extent to which a disabled patient will be treated by a dentist. Rather, it is the perception of the situation by the parents (care givers) and the dentist. (Case : Down Syndrome, Porcelain Crowns) ### Treatment considerations: - Diagnosis and treatment planning. - Infection control. - Treatment modifications. ### Common dental disorders in special patients: - Dental caries. - Oral and dental defects. - Malocclusion and oral habits. - Trauma. - Gingival and periodontal disease. Most of the problems of special patients are very similar to those of normal patients. Many of the problems are problems of degree rather than kind. ### Dental caries: - There is no significant difference in caries rate between normal and disabled persons. Anyhow, in some disabilities as Down's syndrome, patients have lower than average caries rate whereas, cerebral palsy patient show an average caries rate. - It was found that severe cases of physical and mental disabilities where maintaining good oral hygiene is difficult there is a higher caries rate. ### Gingival and periodontal disease: - As intelligence level decreases, oral hygiene gets poorer. - The patient having the most severe periodontal involvement are those having severe disability. ### Trauma: **Epileptic patient:** - have been cited as the only group exhibiting a high rate of traumatic injuries to teeth otherwise patients with other disabilities have average trauma rates. **In blind children:** - there is some risk of trauma although not documented. ### Malocclusion and oral habits: - Are common in disabilities affecting facial development and/or musculature functioning in the head and neck. (Case: Cleft) ### Prevention of dental disease is of prime importance: - Home care. - Diet and nutrition. - Fluorides. - Pits and fissures sealants. - Regular professional supervision. ### Positions for tooth brushing: - Reclining in bed position - Reclining on couch position ### Modification of toothbrush handles to assist handicapped child in holding brush-grasp: Many individuals with mental impairment are still capable of some understanding and/or can assist in providing their own care. ### Managing the special patient: - Behavior shaping. - Physical restraints. - Sedation. - General anesthesia. ### Physical restraints/ Protective Stabilization **Indications:** - A patient that requires immediate diagnosis cannot cooperate because of Physical or mental disability. - A patient who requires urgent care and uncontrolled movements may risk safety of the practitioner, patient or staff if the restraints were not used. - A sedated patient who requires limited stabilization. ### Mechanical aids for maintaining mouth in open position: - Wrapped tongue blade. - Molt mouth prop. - Open wide mouth prop. - Rubber bite block: - Various sizes. - Fit on occlusal surface of the teeth. - Floss. - Rubber bite block. Physical restraints should not be used as punishment and should not be used solely for the convenience of the staff. The patient should feel secure rather than threatened. ### Mental Retardation **Classification:** - Border line 70-85 - Mild (Educable MR) 50-70 - Moderate (Trainable MR) 35-50 - Severe 20-35 - Profound 0-20 Intelligence Quotient (IQ) according to Stanford-Binet. ### Difficulties with mental retardation: - Short attention. - Restlessness and hyperactivity - Span Distractibility. - Poor motor coordination. ### Mental retardation management alterations: - For hyperactive & restless children reduce distractions and use mild sedation. - For short attention span give short visits. - For poor motor coordination use assistance or physical restraints. - For difficulty with verbal communication, non verbal communication means as body language and contact are helpful. Dental problems of mentally retarded patients are not usually problems of technique per se. Rather they are difficulties in behavior management due to their social, emotional and intellectual immaturity. ### Hyperactivity Usually occurs due to hypocalcemia, encephalitis or nutritional deficiency. ### Characteristics: - Short attention span and restlessness. - Lack of social integration with behavior problems. - Care should be taken to schedule appointments of short duration. - Restraints, sedation & general anesthesia may be used. ### Management: - Assess degree of mental disability with physician. - Brief office tour with family - no separation. - Keep appointment short due to restlessness. - Start with easier / gradually progress to more difficult procedures. - Give a.m. appointments. - Be repetitive, speak slowly in simple terms. - Give one instruction at a time. ### PHYSICAL: - NEUROMUSCULAR. - BLINDNESS & DEAFNESS. ### Cerebral palsy - It is a neuromuscular dysfunction resulting from damage to the brain. - The motor disability is manifested as a loss or impairment of voluntary muscle control. - The etiology is related to anoxia to the brain. - Prenatal - anoxia (decreased oxygenation), infection. - Natal - anoxia, hemorrhage. - Postnatal - infection, trauma (damaged brain). ### Clinical manifestations: - 60% are mentally retarded. - Seizure disorders - Sensory dysfunction: both hearing and visual. - Speech disorders. ### Symptoms: - Muscle weakness. - Poor balance. - Stiffness. - Irregular gait. - Paralysis. - Involuntary movements. ### Types of Neuromuscular dysfunction: - Monoplegia 1 limb. - Hemiplegia 1 side. - Paraplegia both legs. - Diplegia severely both legs + min both arms. - Quadriplegia all limbs. ### Oral findings: - Average dental caries. - Trauma to anterior teeth. - Tongue thrust. - Bruxism. - Drooling of saliva. - Poor oral hygiene with increased periodontal disease. ### Impaired oral reflexes: - Gag reflex increases. - Cough reflex is depressed. - Bite reflex is disturbed. - It is sometimes easier to drill a cavity than to obtain a bite wing X ray film. - Swallow reflex is depressed. ### Management: - Medical consultation. - Oral hygiene measures. - Provide a comfortable position. - Premedication. - Physical restraints to stabilize head and control movements. - Mouth props and rubber dam. - Short appointments. ### Hints: - Avoid noise making instruments. - Avoid intra oral gag. - Put in dental chair or keep in wheel chair. - Chair should be pre set, do not seat patient then drop the chair backward. - A simple bite wing X ray may be difficult to obtain in 1st visit. - Drilling a cavity can be easier. ### Dental office access **Barrier free facility access** - It is important to know that when many of these children try to cooperate, their muscular incoordination increases. - Therefore, the patient should be handled gently. **Barrier free facility access:** - Walkways, sidewalks & parking facilities. - Entrance ramps. - Door width, threshold height, door pressure or ease of opening, adequate space to maneuver a wheelchair & elevator accessibility. - Floor surface, carpet or rug style, furniture, reception room design, lighting, telephone & toilet facilities. - Operatory design to allow for wheel chair transfer or in-wheel chair treatment. ### Communication abnormalities - Hearing impairment - Visual impairment ### Hearing impairment: - Hearing impairment may accompany: - Cleft palate. - Cerebral palsy. - Down's syndrome - Other craniofacial anomalies. - Communication: - Hearing aid. - Lip reading. - Manual communication. - Levels: - Level (1) Mild hearing loss Hard of hearing. - Level (2) Partial hearing loss Using hearing aids. - Level (3) Severe hearing loss Severe difficulties in learning language. - Level (4) Profoundly deaf Using lip reading and manual methods. - Thus, deaf children can communicate through a hearing aid, lip reading or manual communication depending on degree of hearing loss. ### Oral findings: - No abnormal dental findings. ### Management: - Complete medical history. - Prepare patient and parent before 1st visit. - A parent should accompany the child. - For lip readers you have to face them. - Avoid blocking the patient's visual field and always remain in child's view. - Any movement in the dental office should be preceded by pointing at it to avoid surprises. ### Management (cont.): - Deaf children are very impatient with delays and are more active than most children. - Communication techniques are modified as in TSD, pictorial materials, posters, writing pads.. Show and do. - Always reassure the patient with physical contact. ### Visual impairment (blindness): - Either congenital, acquired or accompanying other handicapping conditions. ### Oral findings: - No special dental findings, but usually there is poor oral hygiene and sometimes trauma to anterior teeth. ### Blind children: - Enjoy stories. - Passive inactive. - Great tactile sensitivity. ### Blindness behavior management techniques should be modified as blind children compensate for the lack of visual input by increased use of the auditory, tactile& olfactory senses. - All new sounds or smells should be identified & child should be allowed to feel new objects. ### Management: (cont.): - Behavior management techniques should be modified as in tell, show and do- it is told feel a do where the show part is done by the increased use of auditory, tactile and olfactory senses. - Again, physical contact is used for assurance. - In contrary to deaf children, blind children are less active, they have great tactile sensitivity and they enjoy stories. ### Management: - Complete medical history. - Verbal communication is very important. - Prepare patient and parents before 1st visit. - A parent should accompany the child. - All new sounds and smells should be identified. ### Sight impaired individuals are not hearing impaired and should be addressed in a normal tone of voice. - Blindness + Deafness + Mental retardation may be all associated with brain damage which further complicates communication.