Lesson 9 Special Patients in Dentistry PDF

Special patients in dentistry T 9- SPECIAL PATIENTS IN DENTISTRY ODONTOLOGY Agustina Muñoz Rodríguez Once the expectation of population lifetime has increased, the demand for dental treatment for patients with intellectual disability, physical limitations, social and / or emotional deficit also gre...

Special patients in dentistry T 9- SPECIAL PATIENTS IN DENTISTRY ODONTOLOGY Agustina Muñoz Rodríguez Once the expectation of population lifetime has increased, the demand for dental treatment for patients with intellectual disability, physical limitations, social and / or emotional deficit also grew. In dentistry, the planning therapy of the special needs patients (SNP) requires an extensive vision of the dentist, often leading to a multidisciplinary approach. Special patients in dentistry Introduction 2 Ø However, many professionals still find difficulty while providing such assistance. Ø Such difficulties can range from a lack of professional training, insecurity, posible ergonomic limitations, changes in the routine of the consulting room requiring physical adaptations and special equipment, to the lack scientific knowledge. Ø Moreover, it is common for patients with different levels of cooperation, a difficulty or even an impediment of the dental treatment in an outpatient setting. Ø Thus, the health care professionals can reduce barriers using different techniques. Special patients in dentistry Introduction 3  riska Ø Clinical care of the SNP should be based on risk assessment, in which the general health status is correlated to the level of collaboration level with the dental treatment, versus the dental needs. Ø Thereafter, techniques for behavioral management must be initially used, but in case of failure, sedation is an alternative to the patient who is not to be subjected to general anesthesia. Special patients in dentistry Introduction 4  Ø From the moment that the patient's clinical condition derails the attempt of sedation, the dental treatment should be performed by general anesthesia technique in a hospital setting. Ø This approach offers the possibility of total oral readjustment in only one session, including prophylaxis of the entire oral cavity, dental restorations, pulp therapy, extractions, coronary reconstruction and preventive procedures. Special patients in dentistry Introduction 5  Ø In the context of dentistry directed to the support of SNP, the modality of home dental care proposes to take care of all bedridden patient or those with limited mobility and developmental disabilities. treat symptoms Ø In this modality, we can consider patients in palliative care, patients with a dementia, or even patients in several post surgical that show a dental emergency setting, for example. Special patients in dentistry Introduction 6  The scientific literature is not concise in addressing all these therapies and organizes them on an increasing scale in order to direct professionals to the best treatment choice. Special patients in dentistry Introduction 7 Ø The Commission on Dental Accreditation (CODA) defines SNP as every individual with a medical, physical, psychological or social condition that requires individualization of the dental treatment. Ø Once it is a general concept, the theme 'special patient' comprises a heterogeneous group of genetic and / or acquired diseases, which in practice can be divided into: v neurological motor disorders (Down syndrome, cerebral palsy, etc.), v chronic systemic diseases (diabetes, heart diseases, hypertension), v onco-hematological malignancies (leukemia, lymphoma), v infectious diseases (HIV, hepatitis B or C), v physical disability (paraplegia, hemiplegia), uses v sensory impairments (hearing impairment, visual disability), v acquired diseases (rubella, tuberculosis) Ø This classification helps the dentist to choose the best therapeutic approach while analyze the underlying disease of the patient and the consequent physical and / or mental impairment. Special patients in dentistry Introduction 8 Ø The dentist must to adapt to the psychological approach, the surgical techniques and the choice of dental materials for every type of individual and for every need. Ø In this context, the identification of the dental problems and implementation of the treatment plan may change dramatically from one case to another, since the general health status will influence this behavior. Special patients in dentistry Introduction 9  Management of the patients with special needs For patients with neurological motor disorders, the initial clinical assessment requires three steps: A. Evaluation of General Health: The first step starts with a complete health questionnaire to be fulfilled by the parents of the SNP. The medical history must explore physician reports, including any hospital treatment, medications in use, health problems, warning situations, alimentary habits and other important medical information. B. Evaluation of Oral Health: The evaluation of oral health status starts considering prior treatments and the reasons of consultation, before performing the clinical examination. Special patients in dentistry Management 10  Management of the patients with special needs If possible, any dental, gingivo- periodontal and soft tissue pathology must be noted. At least one panoramic X-ray must be taken as complementary exam. If necessary for the diagnosis, additional periapical and/or occlusal X-rays must be taken as well. C. Evaluation of Behavior: For the dental treatment, the evaluation of behavior is a relevant aspect. In this matter, the behavioral analysis is based on the amended Frankl scale (Table 1), which consider the level of cooperation and the scale developed by Houpt and co- workers (Table 2), based on movement during examination (whether or not associated with shouting, crying, and other manifestation of non-cooperative behavior). The application of the scales might be a good indicator as to whether outpatient care can be performed or not. Special patients in dentistry Management 11  Management of the patients with special needs Table 1: Frankl Scale for Evaluating Behavior Modified by De Nova Garcia Category 1: Clearly Negative Total lack of cooperation Category 2: Negative Signs of lack of cooperation Category 3: Positive Accepts treatment with caution. May require reminders (open mouth, hands down, etc.) Category 4: Very Cooperative No sign of resistance. Very cooperative Table 2: Scale for Evaluating Movement (Houpt and Co-Workers), Modified by De Nova Garcia 1. Violent movement constantly interrupting examination 2. Constant movements that hinder examination 3. Controllable movements that do not interfere with the procedure 4. Lack of movement. Special patients in dentistry Management 12  Management of the patients with special needs After completing the three steps of the clinical assessment, the most appropriate treatment plan for each patient must be drawn and classified by quadrants/ sextants. Prioritization of therapeutic needs (preventive, conservative, surgical) must be performed as follows: v Preventive treatment, which includes systematic scaling/cleaning and fluor application, also the placement of sealants. v Restorative treatment, which includes endodontic and restorative treatment in both primary and permanent teeth. v Surgical treatment, which includes tooth extractions, gingivectomies, biopsies and other minor oral surgery. Special patients in dentistry Management 13  Management of the patients with special needs Ø Some conditioning techniques or even physical support can be suggested and necessary, so that the dental treatment elapses uneventfully. Ø Some people recommend to limit the movement and must be used in order to prevent that the patient movement difficults the dental assistance. Ø Also, this technique avoids "escape attempts" of the patient, while protects the work team of possible trauma and accidents, as bites. Ø Based on authors clinical experience, below are some suggestions: Special patients in dentistry Management 14  Management of the patients with special needs v The “holding therapy” is a physical support technique suitable for children, that remain in the lap of the responsible person, who stabilizes, trunk and arms while embrace the patient (Figure 1); v The “knee to knee” position is suitable for children of 1-3 years old. The technique consists to lay the child supported on the legs of the dentist and the responsible person, both touching knees to each other and forming a kind of hammock (Figure 2); v The technique where the auxiliary holds the patient’s head can be applied to patients of all ages. The aid sustains the patient's head in order to stabilizes or support it (Figure 3); Special patients in dentistry Management 15  Management of the patients with special needs Special patients in dentistry Management 16  Management of the patients with special needs These techniques may be employed to short dental visits, in which preventive, restorative, and/or surgical treatments - as described above - can be performed before the attempted pharmacological restraint. Special patients in dentistry Management 17  Management of the patients with special needs Sedation obtained through oral medication - mild or moderate - may be an important and very useful option in dental treatment of SNP, since the sedatives are a safe and effective way to contain the patient, with the advantage of being prescribed by the dentist for outpatient use. According to the American Dental Association, sedation represents a minimal depression of levels of consciousness that keeps the patient’s ability to maintain independently and continuously his airway, responding appropriately to physical stimulation or verbal communication. The loss of consciousness levels is produced by pharmacological or non-pharmacological method, or a combination of both. Special patients in dentistry Management 18  Management of the patients with special needs The sedation procedure can be performed using an evolutionary scale for choice of drug, namely: v benzodiazepines, v nitrous oxide, v antihistamines and v hypnotics(barbiturics and non-barbiturics). It is also possible to prescribe opioids for ambulatorial use, although with some more caution. For deep sedation, the drugs used are propofol and the neuroleptics, but these medications should be used in a hospital setting. Special patients in dentistry Management 19  Management of the patients with special needs Table 3 shows the different types of medication that may be used in an outpatient setting by the dentist in order to perform mild and / or moderate sedation for implementing dental treatment. The table also presents the side effects of each sedative. Special patients in dentistry Management 20 Management of the patients with special needs Special patients in dentistry Management 21  Management of the patients with special needs The guideline developed by the Australian and New Zealand College of Anesthesiologists, indicates the risks involved in this technique, such as: v depression of protective airway reflexes and loss of airway permeability; v breath depression; v depression of the cardiovascular system; v drug interactions or adverse reactions, including anaphylaxis; v unexpected high sensitivity to drugs used for sedation and / or procedural analgesia that could result in inadvertent loss of consciousness, respiratory depression and / or cardiovascular depression; v individual variations in response to medicines used, particularly in the children, the elderly and those with pre-existing disease. Special patients in dentistry Management 22  Management of the patients with special needs In order to minimize or avoid these risks, the dentist must have a basic service support emergency kit, composed of: ü Ambu (manual ventilator), ü stethoscopeand sphygmomanometer, ü oxygen cylinder, ü Guedel cannula, ü insulin syringe, scalpel, oximetry, epinephrine, antihistamines, Captopril 12.5 mg, Hydrochlorithiazide 25 mg, Dimenhydrinate 50 mg and Pyridoxine Hydrochloride 10 mg, physiological saline, children's aspirin, Isosorbide Dinitrate 5mg and sachet of carbohydrate or glucose 50%. The dentist also must have the course of Basic Life Support (BLS), so that in any situation, the professional knows how to handle emergency situations that endanger the life and physical and / or mental integrity of the patient. Special patients in dentistry Management 23  Management of the patients with special needs Ø Due to severe health impairments and the less cooperative level of some patients with the dental treatment, procedures under general anesthesia are very useful in some clinical situations. Ø The ADA considers general anesthesia as a procedure that causes loss of consciousness where the individual does not respond to painful stimuli and losses the ability to maintain ventilatory and neuromuscular function independently. Ø Mandatorily, this approach should be performed in a hospital setting, with the assistance of the anesthesiologist. Special patients in dentistry Management 24  Management of the patients with special needs In dentistry there is not a determining classification that helps the dentist in the choice of general anesthesia. Thus, the SNP risk analysis indicated for general anesthesia must be directed to the American Society of Anesthesiologists (ASA), based on the physical condition of each patient : v ASA I - Patients without organical, physiological, biochemical and / or psychological alterations. There are no systemic changes; v ASA II - Patients with mild or moderate systemic disease caused by pathophysiological phenomenon or by the condition to be treated surgically; v ASA III - Patients with very intense organical changes or pathological disorders of any cause, even if it is not possible to define the degree of the organical incapacity; v ASA IV – Patients with severe general disorders, endangering their lives, not able to be corrected by surgery; v ASA V -Moribund patient, with few chances to survive, they undergo surgery as a last resort; and v ASA VI – Patient with declared cerebral death. Special patients in dentistry Management 25  Management of the patients with special needs Ø According to the World Health Organization (WHO), approximately 8% of people with disabilities present indication of dental treatment under general anesthesia. Ø In a dental context, systemic health condition should be evaluated together with the anesthesiology team and the costs and benefits of the therapeutic approach discussed between both teams and family. Special patients in dentistry Management 26  Management of the patients with special needs Among the contraindications of the technique are: v the old age, v decompensated systemic diseases, v physical limitations that may interfere with physiological functions, v specific syndromes with psychological and anatomical abnormalities, pediatric patients with congenital heart disease and / or physical disabilities, v mental illness or cognitive disorder, and other complex medical conditions. Absolute contraindications are, so the professional should be aware of febrile conditions, colds, respiratory infections or decompensated heart failure that compromise the general anesthesia execution. Table 4 shows the advantages and disadvantages of the anesthesic modality in dentistry. Special patients in dentistry Management 27  Management of the patients with special needs Special patients in dentistry Management 28  Management of the patients with special needs r Ø Different than other therapies, home care aims to target the dental approach for those bedridden individuals or unable to get around their homes. Ø The purpose of home care is to provide differentiated dental service, offering specific care by a qualified professional, including the participation of relatives or guardians. Ø The procedures performed in the home setting aim at removing odontogenic infection, in addition to performing preventive procedures such as higiene instructions to the patient, carers and guardians. Ø Although the home dental care might be a challenge for the dentist - due to space limitations, inadequate posture, insufficient lighting, reduced access to imaging exams, less control over unforeseen events, emergencies and lack of biosecurity –it is an extremely important activity for the care of the SNP. Special patients in dentistry Management 29  Management of the patients with special needs There are four main types of home care, according to the physical and cognitive status of the patient: 1)Required emergency treatment: aims to treat pain or diseases that severely influence the general health of the patient. In these cases, the treatment is performed independently of the patient's collaboration; 2) Necessary treatment - Severe: aims to preserve oral and general health of the patient, the latter being able and /or aware of receiving dental treatment; 3) Necessary treatment - Moderate: the patient may have restrictions to cooperate and may require prior medication (sedatives) to the dental care, in this case it is evaluated the benefit of the treatment in relation to the stress that the patient might have; and 4) No need for treatment: in this case, the patient may be in a persistent vegetative state, or may have a good oral function, not presenting oral diseases. Special patients in dentistry Management 30 Decision- making about treatment modality-behaviour scales Ø The indications described below were based on clinical experience, the amended Frankl scale (Table 1)and the scale developed by Houpt and co- workers (Table 2). Ø This should not be used systematically for the convenience of the dental team, but rather should be seen as the last resource for protocol treatment. Ø The proposed protocols were classified in three main groups: Special patients in dentistry Decision-making 31 Decision- making about treatment modality-behaviour scales - Conditions Techniques and / or Physical Support: Patients in categories 3 and 4 (Tables 1 and 2) who are cooperative with dental treatment but, eventually, do not show clear signs of interacting verbally with the dentist. Many patients are collaborative even though they are not able to carry out interactive communication with the dentist because their special conditions; Special patients in dentistry Decision-making 32 Decision- making about treatment modality-behaviour scales - Sedation Technic: For patients in category 2 (Tables 1 and 2), and in cases of failure in the use physical support techniques, the dentist may use ambulatory care with sedation. Selecting the most appropriate drug for sedation should take into consideration the dental need, the underlying disease of the patient, and the advantages and disadvantages of using each of them (Table 3). The outpatient sedation technique should only be performed by qualified professionals. All support for any complications must be available and ready for use at the dental appointment. Regarding the assessment of the underlying disease, it is suggested this technique for patients ASA I and ASA II Special patients in dentistry Decision-making 33 Decision- making about treatment modality-behaviour scales - General Anesthesia: We advocated that general anesthesia must be considered for patients classified in categories 1 and 2 (Tables 1 and 2). The use of the technique requires the participation of a multidisciplinary team in a hospital setting. The hospital routine must be respected. The cooperation of the patient is not required in this modality. Regarding the assessment of the underlying disease, it is suggested this technique for patients ASA I to ASA IV. Special patients in dentistry Decision-making 34  Guidelines of Service Mild / Moderate Sedation The sequence of service proposed builds on the guidelines of the American Dental Association, the Australian and New Zealand College of Anesthetists. The sequence for use of sedation by the oral route in SNP: Sedation sequence: v Materials used: Midazolam, distilled water, disposable syringe, 2 ml of gooseberry juice. v Mixture of the macerated sedative with the distilled water, and addition of 2 ml of the gooseberry juice. v Sedative administration. Special patients in dentistry Guidelines of Service 35  Guidelines of Service Step 1 - Initial Assessment of the Patient: Completion of a health questionnaire, including medical history, physician reports, hospital treatments, medications in use, health problems, alimentary habits and behavior. Patients included in category 2 (Tables 1 and 2) are potential for intervention. Step 2 - Preoperative Evaluation: Medical assessment by the team which manage the patient; request of laboratory exams about the clinical state; verbal and written instructions to the patient and / or guardian about the pre, intra and postoperative procedures; informed consent form of the patient and / or guardian; dietary restrictions of 4 hours without ingesting solids and liquids; evaluation of the patient's vital signs (blood pressure and respiratory rate). Special patients in dentistry Guidelines of Service 36  Guidelines of Service Step 3 - Professionals and Equipment: At least one person, besides the dentist, with training in BLS must be present, and monitoring equipment of vital signs and resuscitation equipment must be easily accessible. This professional will be responsible for monitoring the patient's vital signs. For the accomplishment of the dental procedure, it is required the presence of an auxiliary on oral health and / or another dentist. The room should be wide and equipped in order to deal with cardiopulmonary emergencies and must contain at least: 1) stethoscope to auscutate the breathing (check every five minutes); 2) oximeter to monitorate peripheral perfusion; 3) non-invasive monitor to check the blood pressure (sphygmomanometer or automatic cuff device); 4) supply and administering of 100% oxygen source; 5) supply for intravenous medication(must be performed by a qualified professional). Special patients in dentistry Guidelines of Service 37  Guidelines of Service Step 4 - Patient Monitoring: Oxygenation: Coloration of mucosal, skin or blood should be evaluated continuously; oxygen saturation by peripheral oximetry may be considered clinically useful. Ventilation: The dentist and / or the qualified profesional should observe elevations of the chest and check breathing continuously. Maintain airway permeability. Circulation: Blood pressure and heart rate should be evaluated preoperatively and monitored intra and postoperatively. Special patients in dentistry Guidelines of Service 38  Guidelines of Service Step 5 – Dental Treatment: The most favorable cases are those in which the dental needs are small and easily resolved with short appointments. Preventive, restorative and surgical treatment can be performed and concluded in different approaches. Step 6 - Documentation: All the procedures should be documented, reporting the sedative drugs and the local anesthetics administered, as well as the doses and the pre / postoperative medications. The description of the dental procedure performed is also part of this description. Step 7 - Patient Discharge: It is necessary that the patient is capable to walk with minimal assistance. Postoperative pain and bleeding should be minimal or absent. The patient should be accompanied by a responsable person who will receive verbally and written postoperative orientations. Special patients in dentistry Guidelines of Service 39  Guidelines of Service General Anesthesia The assistance sequence proposed takes as reference the guidelines of the American Dental Association and the Australian and New Zealand College of Anesthetists. Step 1 - Initial Assessment of the Patient: Completion of a health questionnaire, including medical history, physician reports, hospital treatments, medications in use, health problems, alimentary habits and level of cooperation. Patients included in categories 1 and 2 (Tables 1 and 2) are potential for intervention. Special patients in dentistry Guidelines of Service 40  Guidelines of Service Step 2 - Preoperative Evaluation: Medical assessment by the team which manage the patient; request of laboratory exams (urea, creatinine, complete blood count, complete coagulation exams, X-ray of the chest, electrocardiogram for patients older than 50 years or for patients who have pre-existing cardiac abnormalities); verbal and written instructions to the patient and / or the responsible person about the procedures before, during and after surgery; informed consent form of the patient / guardian; dietary orientations (absolute fasting of 10 hours). Step 3 - Professionals and Equipment: Among professionals, it is necessary an anesthesiologist, the nursing team and the dental team. Among the equipment, a complete surgical center is requested. Special patients in dentistry Guidelines of Service 41  Guidelines of Service Step 4 - Patient Monitoring: Responsibility of the anesthesiologist team. Step 5 – Dental Treatment: The use of general anesthesia is indicated for cases of more complex dental problems, which involve extensive dental treatment. Preventive, restorative and surgical treatment can be performed and concluded in a single appointment. Special patients in dentistry Guidelines of Service 42  Guidelines of Service Step 6 - Documentation: The whole procedure must be documented, reporting the name of the administered inducing drugs and anesthetics (local and general), the doses and the pre and postoperative medications. Step 7 - Recovery Room: Postoperative care related to the type of the dental procedure performed. Drug prescription must be maintained as used in the operating room. The patient care is responsability of the hospital nursing team. Step 8 - Hospital Liberation: For dental procedures without complications, patient will be released between 1-2 days. Anesthetic liberation is liability of the responsable anesthesiologist. Special patients in dentistry Guidelines of Service 43  Guidelines of Service Home Care The sequence of assistance for home care is based on the guideline proposed by the British Society for Disability and Oral Health. Step 1 - Initial Assessment of the Patient: Completion of a health questionnaire, including medical history, physician reports, hospital treatments, medications in use, health problems, alimentary habits and level of cooperation. Patients included in categories 3 and 4 (Tables 1 and 2) are potential for intervention. Special patients in dentistry Guidelines of Service 44  Guidelines of Service Step 2 - Preoperative Evaluation: Medical assessment by the team which manage the patient; request of laboratory exams linked to the clinical state; verbal and written instructions to the patient and / or guardian about the pre, intra and postoperative procedures; informed consent form of the patient and / or guardian; dietary restrictions according to the underlying disease. Step 3 - Professionals and Equipment: It is requested two dentists. The necessary equipments are presented in Table 5. Step 4 - Patient Monitoring: Constant cardiac and respiratory monitoringalong the dental appointment is only necessary in cases of bedridden patients previously monitored by the medical team. Blood pressure, oxygen and random blood glucose monitoring will be performed routinely according to the underlying disease of the patient. In these situations, the behavior will be the same done in the dental office. Special patients in dentistry Guidelines of Service 45  Guidelines of Service Special patients in dentistry Guidelines of Service 46  Guidelines of Service Step 5 – Dental Treatment: The most favorable cases are those in which the dental needs are small and easily resolved with short appointments. Preventive, restorative and surgical treatment can be performed and concluded in different approaches. Step 6 - Documentation: Every procedure should be documented, reporting each drug used (ie. Administered local anesthetics and pre / postoperative medications). Special patients in dentistry Guidelines of Service 47  Summary CLASSIFICATION OF PATIENTS TYPES FACTORS REDUCING RISK IN THE CONSULTATION – ASA I: Healthy individual 1. Clinical assessment prior to treatment – ASA II: Mild disease 2. Consultation with a specialist – ASA III: No incapacitating systemic disease 3. Monitoring (Supplementary tests..) – ASA IV: Incapacitating serious illness 4. Little aggressive treatments (risk-benefit) – ASA V: Dying 5. Opting for short treatment 6. Postoperative Control Special patients in dentistry Summary 48  Summary CARDIOVASCULAR PATIENT BREATHING PATIENT 1. Cardiac Pathology 1. Respiratory diseases a. Heart failure COPD chronic obstructive pulmonary disease b. Congenital heart Disease c. Arrhythmias 2. Clinical management 2. Oral Complications a. Physical limitations a. Avoid oral foci b. They require special handling b. Limited treatments c. Avoid prolonged visits. c. Stress affects their state d. Attention anticoagulant drugs Special patients in dentistry Summary 49  Summary DIGESTIVE PATIENTS RENAL PATIENT 1. Gastrointestinal disorders 1. Renal Pathology a. Esophageal stricture a. IRC chronic kidney failure b. Reflux disease 2. General complications: hypertension, anemia, receive c. Ulcerative colitis corticosteroid therapy (have osteoporosis, tendency to d. Pernicious anemia infections) e. Crohn's disease 3. Oral Complications: disgeusias, mucosal disorders, sensory disturbances, xerostomy (feeling lack saliva), hypoplasia 2. Oral Complications (mineralization defects teeth) a. Attention bleeding b. Avoid infections Special patients in dentistry Summary 50  Summary ENDOCRINE PATIENT. a. Pancreatic diseases b. Adrenal diseases MELLITUS DIABETES c. Thyroid disease 1. General manifestations: kidney, cardiovascular, ophthalmologic, neurologic disorders. d. Parathyroid diseases 2. Oral manifestations: periodontal infection, frequent infections, abnormal oral mucosa, sensory disturbances, tooth decay. I Special patients in dentistry Summary 51  Summary LIVER PATIENTS CANCER PATIENT 1. Liver. The most common pathology: 1. - Oral Complications a. Swellings a. Resulting from their illness: infections b. Hepatitis b. Secondary treatment: immunodeficiencies.. c. Cirrhosis 2. - Clinical Management 2. Clinical Management: a. To prevent a. Bleeding tendency b. Knowing their current status c. Apply specific protocol according to case b. Medication intake limited c. Some are potentially contagious Special patients in dentistry Summary 52  Summary IMMUNOSUPPRESSED PATIENT ANTICOAGULATED PATIENT 1. - Immunity pathology. 1. Coagulation pathology a. Congenital primary immunodeficiencies a. Congenital disorders (Haemophilia, Von b. Acquired (virus, HIV) Willebrand disease) c. Secondary treatment (ie transplanted) b. Secondary (cardiovascular patients) 2. - Clinical Management 2. Clinical Management a. Knowing current state a. Identify and classify risk b. Remove oral foci b. Assess treatment needs c. Assess and classify outpatient risks c. Contact specialists Special patients in dentistry Summary 53  Summary NEUROLOGICAL PATIENT PSYCHIATRIC PATIENT 1. Neurological diseases Psychiatric Pathology: a. Alzheimer disease – Depressant b. Parkinson disease – Anxious (bruxism, nitrous oxide) 2. Clinical Management – Neurotic a. Communication sometimes difficult – Hyperkinetic Assess each case and the degree – Psychotic of involvement b. Xerostomising they take drugs – Autistic Contact specialists c. Technical difficulties – Anorexia nervosa Apply specific protocol – Drug Addiction Ask premedication if necessary Special patients in dentistry Summary 54  Summary DISABLED PATIENT CERBRAL PALSY. Oral manifestations: 1. PSYCHIC DISABILITY – Higher prevalence of: 2. AUTISTIC DOWN SYNDROME. Oral Features: Malocclusion. 3. DOWN'S SYNDROME – Arched palate. Hypoplasia. 4. CEREBRAL PALSY – Alterations in the eruption. – Caries and gingivitis. (Medication) – Microdontia. – Alteration oral musculature – Hypoplasia. Chewing Swallowing Phonation Special patients in dentistry Summary 55