special needs pedo 2 2022.docx special edition jan 2023.pdf

DENTAL MANAGEMENT OF CHILDREN WITH SPECIAL HEALTH CARE NEEDS PRESENTED BY :DR. YOUSRA MOHAMED 2022 2023 Pedo 2 1|Page According to the American Academy of Pediatric Dentistry ‘Special healthcare needs (SHCN)’, included ‘any physical, developmental, mental,sensory,...

DENTAL MANAGEMENT OF CHILDREN WITH SPECIAL HEALTH CARE NEEDS PRESENTED BY :DR. YOUSRA MOHAMED 2022 2023 Pedo 2 1|Page According to the American Academy of Pediatric Dentistry ‘Special healthcare needs (SHCN)’, included ‘any physical, developmental, mental,sensory, behavioral, cognitive, or emotional impairment or limiting condition that requires medical management, healthcare intervention, and/or use of specialized services or programs. Special needs dentistry is defined as “a method of oral health management that is specially designed for patients with special needs who have a variety of medical conditions or disabilities that require more time or altered delivery methods than the routine delivery of dental care for the general population. Conventional Classification of Children with Impairments Modified from Welbury’s Pediatric Dentistry 2016 2|Page 3|Page Physically impaired Cerebral palsy Definition ▪ Cerebral Palsy International Sports and Recreation Association and American Academy of Pediatric defined cerebral palsy as, a group of permanent disorders affecting the development of movement and causing a limitation of activity. Non-progressive disturbances that manifest in the developing fetal or infant brain lead to cerebral palsy. ▪ It is not a specific disease entity but rather a collection of motor disabling disordered by permanent damage to the brain in the prenatal perinatal periods during which the CNS is still maturing. It is the most common cause of childhood disability. The degree and type of motor impairment and functional capabilities vary depending on the etiology. Cerebral palsy may have several associated comorbidities, including: ▪ Epilepsy ▪ Musculoskeletal problems ▪ Intellectual disability ▪ Feeding difficulties ▪ Visual abnormalities ▪ Hearing abnormalities 4|Page ▪ Communication difficulties. ▪ Advanced Classifications(2018) Gross Motor Function Classification System Expanded and Revised The gross motor function of children and young people with CP can be categorized into five different levels using a tool: LEVEL I :Walks without Limitations LEVEL II :Walks with Limitations LEVEL III :Walks Using a Hand-Held Mobility Device LEVEL IV Self-Mobility with Limitations; May Use Powered Mobility LEVEL V: Transported in a Manual Wheelchair 5|Page Etiology I.PRENATAL 1.Acute maternal infections (as Rubella) 2.Chronic maternal infection (as Syphilis) 3.Toxemias of pregnancy 4.Poisonning with drugs &heavy metals 5.Premature birth 6.Exposure to radiation II.NEONATAL CAUSES 1.Hypoxia 2.Apnea 3.Birth injury 4.Prolonged or difficult labor III.POSTNATAL CAUSES 1.Meningitis&Encephalitis 2.Accidents resulting in trauma to the head 3.Congenital brain defects 4.Brain tumors 1. Spastic (≈ 80% of cases) 1.lesion of the cortical motor area 2. Scissor gait and toe walking 3. Limited control of neck muscles 4.Lack of control of the muscles supporting the trunk 5.Lack of coordination of intraoral, perioral and masticatory musculature, Possibility of impaired chewing and swallowing, 6.Excessive drooling ,ersistent spastic tongue thrust, and speech impairments 6|Page 2.Dyskinetic (athetosis and choreoathetosis) (≈7-15% of cases) Lesion of basal ganglia Constant and uncontrolled motion of involved muscles Succession of slow, twisting, involuntary movements (athetosis) or Quick ,jerky movements (choreoathetosis) Possibility of frequent, uncontrolled jaw movements, causing abrupt closure of the jaws or severe bruxism Frequent hypotonicity of perioral musculature with mouth breathing, tongue protrusion, and excessive drooling Facial grimcing Chewing and swallowing difficulties Speech problems 3. Ataxic (≈ 5% of cases) Poor sense of balance and uncoordinated voluntary movements Stumbling gait Difficulty in grasping objects 4. Mixed (≈ 10% of cases) General Clinical Manifestations Intellectual disability: Approximately 60% of persons with cerebral palsy demonstrate some degree of intellectual disability. 2.Seizure disorders(30-50 %) 3.Sensory deficits 4.Speech disorders 5.Joint contractures Oral manifestations 1.Dental caries: Many factors contribute to the development of dental caries including biological, economic, cultural, environmental and social factors. Poor oral hygiene,poor chewing ,enamel hypoplasia 7|Page 2. Periodontal disease: Several studies have shown that gingival hyperplasia and associated bleeding occurs with higher frequency in children with CP. 1.Difficulties in conducting daily oral hygiene, intraoral sensitivity, and 2. oro-facial motor dysfunction are the main contributing factors. 3. Use of antiepileptic drugs, particularly phenytoin. 4. Malocclusions: Malocclusion has been reported with increasing frequency in children with CP. Protrusion of maxillary centrals Increase overbite &overjet Open bite Unilateral crossbite Causes: A primary cause may be a disharmonious relationship between intraoral and perioral muscles. (Uncoordinated and uncontrolled movements of jaws,lips,and tongue) Dental erosion and wear: High susceptibility to trauma due to: a)Flaring of maxillary anterior teeth b)Increased tendency to fall c)Diminished reflex to cushion such falls Traumatized anterior teeth: Bruxism Enamel defects Parotid gland composition & secretion Sialorrhea Temporomandibular joint (TMJ) disorders 8|Page Preventive measures:(Dental home care) Tooth brushing &flossing: By the pt. himself under parent supervision or by the parent or the caregiver b) Stabilization of the head during tooth brushing c) Using acrylic custom handle tooth brush or electric tooth brush d) Using floss holders with long handles e) Brushing after each dose of sweetened medication ad motivation f) Tongue brushing is important to prevent halitosis General considerations during dental appointments Appointments should be kept short and people with CP may need sedation, General Anaesthesia (GA), or hospitalization if extensive dental treatment is required. The chief concern of the dentist is to adjust his procedures to the physical & mental condition of the patient as this patient is considered uncooperative &unmanageable due to: 1.Involuntary limbs &head movements 2.Unintelligible speech 3.Spastic tongue 4.Being intellectually delayed Dental treatment in dental office: 1-Evaluation for the child & both medical & dental history should be taken 2-Consultation with the physician if any drug therapy is needed for premedication purpose to reduce the anxiety &muscle spasm or use nitrous oxide. 3-Early short appointments to decrease muscle fatigue 4-Consider wheel chair operation (either on dental unit or wheel chair &the preferred method of lifting). 5.No contraindication for the use of local anesthesia 9|Page Delayed cough reflex increases chances of aspiration Use rubber dam Dental floss attached to files & clamps Dental treatment in dental office: 1-Evaluation for the child & both medical & dental history should be taken 2-Consultation with the physician if any drug therapy is needed for premedication purpose to reduce the anxiety &muscle spasm or use nitrous oxide. 3-Early short appointments why? 4-Consider wheel chair operation 5.No contraindication for the use of local anesthesia Delayed cough reflex increases chances of aspiration Use rubber dam Dental floss attached to files & clamps What is intellectual disability? The term intellectual disability was primarily known as mental retardation. Someone with intellectual disability has significant limitations in two areas. These areas are: 1.Intellectual functioning: Also known as IQ, this refers to a person’s ability to learn, reason, make decisions, and solve problems. IQ (intelligence quotient) is measured by an IQ test. The average IQ is 100, with the majority of people scoring between 85 and 115. A person is considered intellectually disabled if he or she has an IQ of less than 70 to 75 2.Adaptive behaviors In children with severe or profound intellectual disability, there may be other health problems as well. These problems may include : Seizures Mood disorders (anxiety, autism, etc.) 10 | P a g e Motor skills impairment Vision problems Hearing problems Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) Classification which is published by the American Psychiatric Association. Both of these systems classify severity of ID according to the levels of support needed to achieve an individual's optimal personal functioning Recent IQ TESTS A frequently used IQ measure for children in the United States is the Wechsler Intelligence Scale for Children (WISC-V). Diseases associated with Mental impairments Down Syndrome Cerebral Palsy Autism Down syndrome (DS or DNS), also known as trisomy 21, is the best-known chromosomal disorder caused by the presence of all, or part of a third copy of chromosome 21. It is typically associated with physical 11 | P a g e growth delays, characteristic facial features, and mild to moderate intellectual disability. Down's syndrome is the most common cause of intellectual disability, accounting for around 15-20% of the intellectually disabled population. Oral findings Under-developed maxilla leads to open mouth Palate with “v” shaped high vault Macroglossia as a result of small oral cavity and tongue thrust Fissured lips and tongue Angular cheilitis Mouth breathing High incidence of gingival and periodontal diseases Teeth Microdontia Conical teeth Oligodontia Small roots Delayed shedding and eruption Frequent malocclusion Bruxism Medical conditions that occur more frequently in infants and children with Down syndrome Hearing defects Vision defects Seizure disorders Obstructive sleep apnea: a condition where the person’s breathing temporarily stops while asleep 50-70% of cases. Cardiac defects: The incidence of congenital cardiac defects is about 40%. Leukemia: Upper respiratory infections. Thyroid disorder ---hypothyrodism Poor immune system Obstructed gastrointestinal tract. Dental management 12 | P a g e ▪ Premedication ▪ First dental visit: introductory treatment ▪ Radiographs are difficult (gagging reflex) so film holder is used ▪ Prophylactic antibiotic ▪ Strong and durable restorations ▪ Resorbable sutures after surgery ▪ Attach dental floss to instrument ▪ A. Behavior management 1.Talk to the caregiver or physician about techniques they have found to be effective in managing the patient's behavior 2. Schedule the patient’s visit early in the day. 3. Give the patient and family a brief tour of the office before attempting treatment. This will familiarize the patient with the personnel and facility and reduce the patient’s fear of the unknown. 4. Allow the patient to bring a favorite item (toy) to hold for the visit. 5. Be repetitive; speak slowly and in simple terms. 6. Minimize distractions, such as sights and sounds, which may make it difficult for the patient to cooperate. 7. Give only one instruction at a time. 8. Reward the patient with compliments after the successful completion of each procedure. B.Considerations due to associated medical conditions: Compromised immune system: lead to more frequent oral and systemic infections. Chronic respiratory infections contribute to mouth breathing, xerostomia, and fissured lips and tongue. Treat acute oral infections Preventing oral infections with regular dental appointments and daily oral care. 13 | P a g e Stress the importance of using fluoride to prevent dental caries associated with xerostomia. Use lip balm during treatment to ease the strain on patient's lips. Dental caries Children and young adults with Down syndrome have fewer caries than people without this developmental disability. Recommend preventive measures such as topical fluoride and sealants. Suggest fluoride toothpaste, gel, or rinse, depending on patient's needs and abilities. Emphasize non cariogenic foods and beverages as snacks. Advise caregivers to avoid using sweets as rewards. Advice taking sugar-free medicines if available and rinsing with water after dosing. Autism spectrum disorder (ASD Autism spectrum disorder (ASD) refers to a group of neurodevelopmental disabilities with a core set of defining criteria\; 1. Impaired social interaction 2. Compromised communication 3. Restricted or repetitive behavioral stereotypes. Clinical Features of Autism: ASD initiates before the third year of age and generally undergoes a steady course without remission through ageing. Early detection is necessary for early introduction of learning and behavioral guidance, which will give abiding benefits for these children and their families. Early signs and symptoms:like ???? 1.Caries 2.Tooth eruption: Most of the times, tooth eruption might be delayed due to gingival hypertrophy which is caused by phenytoin. 14 | P a g e 3.Trauma: Dental injuries were also common in autistic patients owing to the need of skills. 4.Malocclusion: These patients exhibit higher tendency to certain malocclusions, like ogival palate, crowding, and open bite. Harmful oral habits like nocturnal bruxism, tongue thrusting, and lip biting and gingival pricking were common. Dental management They may need several dental visits to get acquainted with the dental environment. Require great patience and positive reinforcement to promote desirable behavior. Desensitization, tell show do ,voice control It may be feasible to treat the patient in a calm, secured sole operatory with reduced decoration and dimmed lights &rhythmic music The use of Pedi-Wrap or pre-appointment conscious sedation may be necessary. Convulsive disorders Epilepsy Epilepsy is a common neurological condition that is characterized by seizures occurring due to abnormal or excessive neuronal activity in the brain. It is a disease characterized by a chronic or recurrent form of seizures where consciousness is lost either for an instant or for a period of minutes. This loss of consciousness may or may not be accompanied by muscular contractions. Etiology : There is still some argument about the exact cause ( genetic, injury, disease or brain anomaly). Types : Grand mal : prolonged loss of consciousness generalized convulsion , tonic and clonic phases of muscle spasm that cause: Slipping of child from dental chair 15 | P a g e Tongue biting & sudden closure of mouth Pt. may be cyanotic during tonic phase, pt. wake up with headache & confusion Petit mal : more common ,momentary loss of consciousness, no evidence of muscle spasm Dental implications The major oro-dental concerns with epileptic children are gingival enlargement and the precipitation of a seizure in the dental surgery. Main Problems 1)Injuries caused by the seizure: Laceration of the tongue or buccal mucosa. Injuries to the face from falling. Looseness of teeth. Sublaxation of TMJ 2.Complications of treatment Drugs Side effects Phenytoin Gingival hyperplasia Increased incidence of cleft lip/ palate in children of mothers Carbamazepine Xerostomia (Tegratol) Glossitis 16 | P a g e Stomatitis Dental management.Management of gingival hypertrophy is dependent on oral hygiene and dental development at diagnosis. a. In the permanent dentition, full mouth gingivectomy may be required, but gingival overgrowth will recur if oral hygiene is not optimal. b. Maintenance of adequate oral hygiene may be especially difficult in children with additional intellectual disability and is highly dependent on the motivation and skill of the parents and caregivers. d. The use of daily chlorhexidine-containing gels is effective in reducing the inflammatory component of the gingival overgrowth. 3.The following management protocol is recommended for prevention and control of seizures in the dental surgery: a. Reduce stress to the child by behavioural management and conscious sedation techniques and premedication if needed. b.Reduce direct overhead lighting, particularly for the photosensitive form of epilepsy. c. Avoid seizure-promoting medications, such as CNS stimulants and local anesthetics containing adrenaline (epinephrine). d. Emergency drugs such as oxygen, intravenous or rectal diazepam (Valium) andintravenous phenobarbital sodium should be readily available. 4.General anaesthesia is preferable in children with poor seizure control as the abnormal neural activity is completely ablated during the procedure. 17 | P a g e 5.Removable appliances are contraindicated in an epileptic child due to potential airway obstruction. 6. In case an episode occurs: Stop all dental procedure Lower dental chair in a supine position Turn the patient’s head to the side, to prevent aspiration of oral fluids Use suction to prevent aspiration Use wrapped tongue blades floss small objects in mouth Maintain the mouth prop in place Loosen the patient’s clothing After the seizure, it is better to discontinue the therapy. If a cavity is already prepared, either temporize or complete the final restoration