Management of Special Needs Pediatric Patients PDF

Management of the Special Needs Pediatric patient Special needs: A patient with special needs can be de ned as Di erent terms used in di erent part of the world: Special needs Disabled/handicapped Persons with disability Sensory Disabilitie...

Management of the Special Needs Pediatric patient Special needs: A patient with special needs can be de ned as Di erent terms used in di erent part of the world: Special needs Disabled/handicapped Persons with disability Sensory Disabilities—> Blindness, deafness, can’t feel, can’t speak Musculoskeletal & Mobility —> CP, Muscular dystrophy , Torrettes Intellectual & Developmental —> Down syndrome Autism Attention & Behaviour—> ADD, ADHD, Anxiety Medical Disabilities —> Diabetes, liver, kidney, cardiology, psychiatric disabilities Bedridden & Chronic Illnesses Congenital unsensing of pain. Where the child is unable to feel anything or pain. These patient require full mouth clearance under anasethesia, for those patient u still need too give them anesthesia to control bleeding Impaired Vision Blind are not deaf Use their other senses How? Touch→feel the prophy brush in hands and cheeks Hear→they still need reassurances and instructions Smell→they can smell the prophy and uoride before applying Taste→explain what they can taste Musculoskeletal & Mobility Impairment CP (cerebral palsy) Muscular dystrophy (Duchenne) How can musculoskeletal issues a ect your care? Swallowing re ex is lost. No gag re ex→Ensure airway isn’t blocked Patient often in wheelchair How can mobility issues a ect your care? Does the patient have access to your clinic Is it wheelchair accessible. Where are these patients seen (hospital care vs clinical care) Cerebral Palsy Most common congenital neuromuscular disability Three major types of motor disorders are encountered: 1. Spastic CP, which accounts for 70% to 80% of cases. Its predominant characteristic is increased muscle tone. 2. Dyskinetic CP, which is observed in 10% to 15% of cases. Motor characteristics include hypotonia, athetotic (slow, writhing) movements, abnormal postural control, and overall problems with coordination. 3. Ataxic CP, which accounts for only approximately 5% of cases. These individuals have problems with voluntary movement, balance, and depth perception. Many individuals exhibit mixed motor involvement and cannot be categorized exclusively in any one of these groups.( they might be of one type and a bit of another type) 1 of 9 fl ff ff ff ff fi fl fl  Cerebral Palsy Joint contractures, misalignment secondary to Gastroesophageal re ux muscle spasticity Dysphagia or aphagia Failure to thrive/malnutrition Hip dislocation Hearing loss Spinal disorders (scoliosis or kyphosis) Intellectual disability (seen in 30%–50% of Osteoporosis individuals) Seizures Oral features: - Similar dental caries experience between the CP and non-CP group Children with CP had more extracted, unrestored teeth, but fewer poorer quality restoration Oral hygiene and gingival health were worse Delayed eruption and higher levels of tooth wear. Signi cantly greater overjet and less crowding occurred in the study group than in the control group. - Traumatic dental injuries (mixed evidence) Due to seizures, motor disability and Class II malocclusion, supposedly more prone to dental trauma. Greatly increased incidence of dental trauma in a CP population when compared with reports in general populations Incidence of dental trauma in children who had CP was only slightly or not signi cantly higher General notes: Little research has been done that examines the e ectiveness of various behaviour management techniques. Assistive stabilization and postural maintenance Scoliosis can a ect a patient’s ventilatory capacity, gag re ex, which can put a patient at more risk for aspiration. A patient who has compromised communication ability may also be unable to express breathing di culties; Always try to have the care provider in the room to tell you if the patient unable to express pain or chocking. Oral hygiene Multiple reason for di culty in brushing dyskinetic movements presence of pathologic oral re exes (biting and vomiting) inability to manipulate a toothbrush. Extensive calculus deposits Oral hygiene habits may need to be preforms and/or supervised by caregivers. Preventive dental care, including parental counselling regarding diet, oral hygiene habits and use of uoride should begin as early as possible 2 of 9 ffi fl ff ffi fl fl ff fi fl fi Learning di culties - Down syndrome - Autistic Spectrum Disorder Down Syndrome Trisomy 21 Genetic disorder involving the chromosomal structure of chromosome 21 Caused by: Non-disjunction→a pair of 21st chromosomes in either the sperm or the egg fails to separate (this is the most common) Translocation→part of chromosome 21 becomes attached (to another chromosome during the formation of reproductive cells Mosaicism→some cells have 46 chromosomes and other cells have 47 Anomalies are mild with intelligence approaching normal It is the most common genetic intellectual disability among humans General Features (Distinguishing features) Short and broad stature Learning disability Brachycephalic skull Widely spaced eyes and epicanthic folds. Hands may appear to have a shortened 5th gure (clinodactyly) and a palmar crease Arms and legs may appear relatively short in relation to the body At birth, they will be below average weight and length. Systematic Features of Down syndrome: 1. Cardiovascular related anamolies (occurs from 40-50% of patients with Down Syndrome) - All corrected by surgery during infancy - Ventral septal defects A/V communications - Atrial Septal defects - Patent Ductus Arteriosis - Mitral valve prolapse occurs 5-15% more often in Down syndrome when comparing to those who do not su er from Down syndrome - Mitral valve prolapse can result in arrhythmias, embolisms and sudden death. Dental Considerations: NICE guidelines no longer recommends antibiotic cover, however patients with Down syndrome who have had valve replacements or a previous episode of endocarditis are considered HIGH RISK Any treatment require tissue manipulation or contacting the bone require an antibiotic. 3 of 9 ffi ff fi (Systemic features of Down syndrome continue) 2. Haematopoietic anomalies Immune-haematological anomalies At increased risk of infection due to defective and short lived neutrophil Cell-mediated immunity impaired Common infections include dermal, mucosal, GI, respiratory, recurrent middle ear, nasal and sinus infections Leukaemia: Greater risk of developing Acute Lymphoblastic Leukaemia. A ects 1:200 Can develop ACUTE MEGAKERYOBLASTIC LEUKAEMIA in children less than 4 years of Dental Consideration: Look for the signs. Persistent lesions, spontaneous gingival haemorrhaging. Consult with physician if symptoms appear. Bleeding risk as well The normal range for neutrophils is 2.5-7.5 x 109/L. As the neutrophil count falls, especially once neutrophils are Commonly involving upper laterals Microdontia in 30-50% of down syndrome patient →pegged lateral incisors or shovel central incisors. Hypocalci cation and Hypoplastic defects. Periodontal disease→greater incidence due to complex immunity issue * Amano and co-authors (2000)→no signi cant di erence between 2-13 yr olds with and without down syndrome Reasons for reduced caries rate (ORAL FEATURES) 1. Increase in salivary pH 5. Spacing 2. Increase in salivary bicarbonate 6. Delayed eruption 3. Microdontia 7. Shallow ssures 4. Hypodontia Dental Consideration: Concerning the palate, they may need to be evaluated for orthodontic or surgical correction. Is it feasible for your patient? Open mouth often lead to mouth breathing and xerostomia, which can worsen oral health and decreases cleansing ability of saliva. Periodontal health is a ected by decrease in immunity, decrease in manual dexterity, and poor oral hygiene. Early contact with the dentist is critical (before the age of 18 months). Although caries risk is low, children with Down syndrome are more often giving nursing bottles than children who do not have Down syndrome (50% vs 12%). Prevention should be realistic and achievable.. Multidisciplinary approach is needed to address the comprehensive dental need. 5 of 9 fi fi fi fi ff ff  Autistic Spectrum Disorder (ASD) De nition: The abnormal or impaired development in social interaction and communication coupled with a restricted repertoire of activity and interest. Manifestations of the disorder vary depending on the developmental level and chronological age of the individual. CDC: Autism spectrum disorders (ASDs) are a group of developmental disabilities that can cause signi cant social, communication and behavioral challenges. People with ASDs handle information in their brain di erently than other people. What does that mean? Can’t read/understand emotional cues Delayed/limited language development Repetitive/limited behaviours, following a routine Some may be aggressive, hyperactive Lifelong neuro-developmental disorder a ecting language, social interaction and creative and abstract thinking, and how a person communicates with, and relates to, people and the world around them Aetiology of ASD is unknown→associations with inheritance and other conditions : Birth trauma Tuberous sclerosis fragile X syndrome Autism a ects about 1 or 2 people in every hundred in the UK and is more common in boys than girls with a ratio of 3.5:1 Cause Brain function and structure abnormalities Hereditary/Genetics/Medical co- morbidities Concordance ratio 77% for identical twins 31% nonidentical twins 20% siblings Environmental→heavy metals may be potential risk factor Diagnosis Multiple screenings 9 months 18 months 24 or 30 months Refer to: Developmental Pediatricians Child Neurologists Child Psychologists or Psychiatrists Where to refer in kuwait (see bellow) 6 of 9 fi fi ff ff ff  Autistic Spectrum Disorder Continues….. May be extremely sensitive to sound, touch, sight or smell. May display a combination of lack of response to stimuli, including pain, with abnormal fearlessness. Situations which usually don’t bother other children such as a light touch, sound of a vacuum cleaner or even the wind may a ect them Barriers to accessing treatment Waiting in the waiting room, arranging transport, and behavioural changes (mainly due to loud noises) Dental Consideration: Most behavioural management techniques work by establishing a two way communication pathway to alleviate fear and anxiety. This may be ine ective with Autism The learning resource on autistic spectrum conditions for primary care advises practitioners to use clear, simple language with short sentences; avoid idioms, irony, metaphors and words with double meanings; use direct requests. Methods that may work include the following: Provide the caregiver photographs of the dental clinic and sta for the child to see before the appointment Use social story about dental visit and use symbol strip Allow the parents to take photographs of the child in the waiting room use later on Makaton Health Considerations - Epilepsy→over 30% have experienced seizures by adolescence - Depression/Anxiety - Attention De cit Hyperactivity Disorder (ADHD), Obsessive Compulsive Disorder (OCD), Schizophrenia - Developmental delay - Pica in 30% of a ected children (eating something that is abrasive) Oral ndings Bruxism (20-25%) Non-nutritive chewing Tongue thrusting Self-injury (picking at gingiva, self extractions, biting lips) creating ulcerations Erosion (many parents report regurgitation, medical consult may be indicated) Caries-similar to general population, however some children receive sweet foods as behavioural rewards (suggest sugar-free substitutes) Poor oral hygiene Limited dietary preferences (exclusively pureed foods, no fruits/vegetables, etc.) Attention and behaviour disorders (Refer to Almanara center In Kuwait) - Children with behavioural and attention related disorders can be referred ADD ADHD Anxiety 7 of 9 fi fi ff ff ff ff Medical Disorders Diabetes Haematological Cardiac Psychiatric Renal Bedridden patients and chronically ill Liver patients Immunological What are we worried about? A. Bleeding risk Haematological condition Liver pathologies B. Infection risk Immunological conditions (linked with lower neutrophil number and function) Immunosuppressed conditions (transplants, oncology) Infective endocarditis C. Contraindication to the dental treatment To what aspect of treatment? What medication are they taking? COPD and nitrous? Implants and immunological conditions? Dentist and dental environment Prepare yourself: How does the patient communicate? And with who? Is your clinic prepared to manage such patients? Child friendly Safe environment Trained sta /nurses Sit down and discuss child’s behaviour and health concerns with the parents.What is normal behaviour? Tantrums and Meltdowns and triggers Social stories/visual schedules Parents Medical History!!! Who is the primary carer?—> Who does the child listen to/take after? What management strategies work at home? Best time for the child? What are the parents expectations? Provide parents with support and training material→online resources Child Every child is di erent→no speci c protocol Ask the child what do they expect to happen in the visits? Its not good to lie to the child about treatment→can break trust Listen to the child→they are the patient not the parents Respect the parents wishes but never push the child past their point 8 of 9 ff ff fi Dental Visit The dentist should great the patient Dentist running on time? How does the child feel that day? Avoid bright lights and loud noises for ASD Remove any clutter→keep the clinic organised Tell-show-do (start with the basics) Clear and accurate information End each visit on a positive note→know your limits and the child limits LA vs GA vs RA Behaviour management approaches Basics: TSD Distraction Positive reinforcement Mixed Visual aids→(ASD) children may respond better with pictures than words Social stories→keep them short and speci c Descriptive, perspective, a rmative sentences Desensitisation→slow and steady Does child have a therapist? Other advanced approaches A. Nitrous oxide sedation Needs to be paired with non-pharmacological approaches Mixed level of success but can work Any medical contraindication? (folate metabolism COPD) Consult parents and physician B. Protective stabilisation Active vs passive Limit the time and treatment→least traumatic as possible Some evidence to suggest calming e ect May trigger defensive response→leads to injury Risk and bene ts C. Deep sedation (IV)→ For one quatrent In Kuwait its hospital based and often for older children (14+) often private sector Midazolam +/-nitrous Needs to be cleared medically D. General anaesthesia Available in the government and private sector After age of 12→admitted to adult wards —> (Refer to MGD/Adult special needs) Other options failed Hospital environment Visual aids can help 9 of 9 fi ffi ff fi