management of children with special health care needs SEM.pptx

MANAGEMENT

1. Every child is a different kind of flower and all together they make this world a beautiful garden . 1

2. Differently abled patients: are we treating them in a different way???? DR. PREETIKA GOYAL DEPARTMENT OF PAEDODONTICS AND PREVENTIVE DENTISTRY 2

3. CONTENTS Taboo Definition Census 2011 classification Risk factors General consideration Intellectual disability Down syndrome Cerebral palsy Cerebral palsy Hearing loss Visual impairment Learning disability Autism Cardiac disease Haemophilia Respiratory disease 3

4. Many families are reluctant to report disability in view of the prevailing negative attitudes in most communities. Religious beliefs attributes disability as punishment for last deeds. In some villages, people with disabilities are shunned, abused, or abandoned at birth. 4

5. Special health care needs include “any physical, developmental, mental, sensory, behavioral, cognitive, or emotional impairment or limiting condition that requires medical management, health care intervention, and/or use of specialized services or programs. A person is dentally disabled :- if there is pain, infection or lack of function that effects the following : Restrict the consumption of a diet adequate to support growth and energy needs. Delays or otherwise affects growth and development. Inhibits the performance of any major life activity including work, learning, communication and recreation AAPD,2009 5

6. Legal protection in India The Mental Health Act, 1987 The Persons with Disabilities Act, 1995 The Rehabilitation Council of India Act, 1992 The National Trust for Welfare of Persons with Autism, Cerebral Palsy, Mental Retardation, and Multiple Disabilities Act of 1999 6

7. 7

8. 8

9. 9

10. 10

11. 11

12. Classification 12

13. By Nowak (1976) Physically handicapped Mentally handicapped Congenital defects Convulsive disorders Communicative disorders Systemic disorder Metabolic disorders Osseous disorders Malignant disorder 13

14. According to treatment modalities 14

15. Perception towards the special child Children as young as kindergartners demonstrate reluctance to interact with children with mental retardation. Parents of children with disability describe stress associated with social attitudes of other children and adult. Bozkurt FY, Fentoglu O, Yetkin Z. The comparison of various oral hygiene strategies in neuromuscularly disabled individuals. J Contemp Dent Pract. 2004 Nov;5(4):1-9. 15

16. Nagarkar et al conducted a study on the prevalence of depression in mothers of the mentally retarded children. Prevalence of depression in mothers of mentally retarded children in India seems to be much greater than those reported from studies around the world. Nagarkar A, Sharma JP, Tandon SK, Goutam P. The clinical profile of mentally retarded children in India and prevalence of depression in mothers of the mentally retarded. Indian J Psychiatry. 2014 Apr - Jun; 56(2):165–170. 16

17. Factors Affecting Dental Treatment Special children lack the ability to maintain oral hygiene. Inability to cooperate sufficiently to allow comprehensive treatment. Parental anxiety may delay treatment Dentist may be uncomfortable/lack sufficient knowledge to provide care to special patients. Gupta P, Hegde A. Understanding and Management of Special child in Paediatric Dentistry. 1 st Ed. Jaypee Brothers Medical Publishers;2012 17

18. Risk factors 18

19. General considerations Dental office access First dental visit Preventive dentistry protocol Home dental care Radiographic examination 19

20. DENTAL ACCESS 20

21. 21 8 10

22. 22 1:12 max slope 1:50 max slope WALKWAY PARKING SPACE 20 FEET PASSENGER LOADING ZONE

23. 23 5-feet 32-36 inches BRAILLE 3 feet 1:20 max slope RAMP DOOR TELEPHONE

24. 24 48 inches 32-36 inches FLOORING RESTROOM

25. FIRST DENTAL VISIT 25

26. The first dental appointment is very important and can set the stage for subsequent appointments. Special attention should be given for obtaining thorough medical and dental history. Name and address of medical and dental personnel who have previously visited the patient are necessary for consultation purpose. 26

27. 27

28. PREVENTIVE DENTISTRY 28

29. Fluoride exposure – topical fluoride should be applied after a regular professional prophylaxis. Daily regimen of rinsing with 0.05% NaF is suggested for patient with SHCN who have poor oral hygiene and high decay rates. 29

30. Preventive restoration - pit and fissure sealants reduce occlusal caries effectively. Stainless steel crown to be used in patient with severe bruxism and interproximal decay. Regular professional supervision – close observation of caries-susceptible patients and regular dental examination are important in the treatment of patient with SHCN. 30

31. Bozkurt FY, Fentoglu O, Yetkin Z. The comparison of various oral hygiene strategies in neuromuscularly disabled individuals. J Contemp Dent Pract. 2004 Nov;5(4):1-9. Bozkurt et al conducted a study to compare various oral hygiene strategies in neuromuscularly disabled individuals. They concluded that the electric powered tooth brushes are more recommended in such people. 31

32. HOME DENTAL CARE 32

33. Home dental care should begin in infancy. Dentist should teach the parents to gently cleanse the incisors daily with a soft cloth or an infant toothbrush. For older children who are physically unable to cooperate the dentist should teach the parent or guardian to clean teeth twice daily, safely immobilizing the child if necessary. 33

34. Oral care assistance positions 34

35. 35

36. RADIOGRAPHIC EXAMINATION 36

37. Radiography is delayed until the second visit, till the patients are familiar with the dental office. Intraoral films with bite-wing tabs are used for all bite wing and periapical radiograph. An 18-inch (46-cm) length of floss is attached through a hole made in the tab. 37

38. MANAGEMENT OF CHILDREN WITH SHCN DURING DENTAL TREATMENT

39. Additional time must be spent with the parent and the child to establish rapport . 39

40. If patient cooperation cannot be obtained, dentist must consider alternatives such as:- Protective stabilization Conscious sedation or general anesthesia 40

41. Protective Stabilization 41

42. Physical aids to keep patient’s mouth open Padded and wrapped tongue blade Open wide mouth prop Molt mouth prop Mckesson bite blocks 42

43. B O D Y 43

44. B O D Y 44

45. EXTREMITIES 45

46. H E A D 46

47. Machado GDCM, Mundim AP, Prado MMD, Campos CC, COSTA LR. Does Protective Stabilization of Children During Dental Treatment BreakEthical Boundaries? OHDM. 2015 August;14(4):188-193. To discuss the bioethical aspects involved in the use of protective stabilization The use of protective stabilization breaks ethical boundaries if the dentist is not trained in the application, does not analyze the risks, benefits, insists on its use for non-emergency procedures, does not respect the child’s autonomy and does not consider local law. 47

48. Hospital based management which include GA is an integral part for children with mental disability 48

49. Wheel chair transfer 49 U.S. Department of Health and Human Services. Wheelchair transfer, a health care provider’s guide Contents;2009.

50. 50

51. I N T E L L E C T U A L D I S A B I L I T Y 51

52. It is a term applied to persons whose intellectual development is significantly lower than that of normal persons and whose ability to adapt to their environment is consequently limited . Idiot ( if IQ < 25) Imbecile ( IQ 25-50) Moron (IQ 50-70) 52

53. Classification of Intellectual disability Degree of mental disability WISC III SB-IV Communication Special requirements for dental care Mild 69-55 67-52 Should be able to speak well for most communication Treat as normal children ; mild sedation or nitrous oxide-oxygen may be beneficial Moderate 54- 40 51-36 Has vocabulary and language skills such that the child can communicate at a basic level with others Mild to moderate sedation may be beneficial, use physical restraints and positive reinforcement, G.A may be indicated . Severe 39 and below 35 and below Mute or communication in grunts ; Little or no communication skills same Current WELSCHER INTELLIGECE SCALE FOR CHILDREN (WAIS–III, WISC–III, WPPSI–III) 3 rd ed 53

54. Dental treatment A brief tour of the office before treatment. Introduce the patient and family to the office staff. Allow the patient to bring favorite items to hold for the visit. Be repetitive; speak slowly and in simple term. 54

55. Reward the patient with compliments after successful completion of the procedure. Keep short and early morning appointment Invite parent to the operatory for assistance and to aid in communication. Give only 1 instruction at a time. 55

56. Actively listen to the patient. The dentist should be sensitive to gestures and verbal requests. Start from simple procedures and gradually progress to more difficult procedures. 56

57. Zaid 15 yrs/M C/C – Pain in right and left lower back tooth. Poor eye contact He shows temper tantrums if any change is introduced Communication problems Echolalia. Disturbed sleep Fussy eating. Case report 57

58. Down syndrome 58

59. 59

60. Extra copy of chromosome 21 (trisomy 21) Cardiac defects, leukaemia, and upper respiratory infections. Have 10- to 20- fold greater incidence of leukemia during infancy compared with the general populations 60

61. Dental management Children with Down syndrome are affectionate and cooperative Emphasis should be made on preventive dental care with frequent follow up visits Light sedation and immobilization may be indicated in children who are moderately apprehensive. Severely resistant patient require general anaesthesia 61

62. 62

63. 63

64. 64

65. 65

66. Learning disability Learning disabilities 66

67. Term is applied to children who exhibit a disorder in one or more of the basic psychological processes, involved in understanding or using spoken or written language. More common in boys than girls Etiology – physiologic factors such as minimum brain injury or damage to CNS Genetic predisposition 67

68. Dental management Most patient with learning disability accept the treatment and cause no unusual management problem to the dentist. In resistant patient – behavior management and conscious sedation can be used with success. 68

69. Mogasale V, Patil VD, Patil NM, Mogasale V. Prevalence of Specific Learning Disabilities Among Primary School Children in a South Indian City. Indian J Paediatr. March 2012;79(3):342-347. Mogasale et al conducted a study to measure prevalence of Specific Learning Disabilities Among Primary School Children in a South Indian City. The prevalence of specific learning disabilities was 15.17% in sampled children, whereas 12.5%, 11.2% and 10.5% had dysgraphia, dyslexia and dyscalculia respectively. 69

70. Cerebral palsy 70

71. Types 71

72. BASED ON NEUROMUSCULAR INVOLVEMENT 72

73. Santos MT, Masiero D, Novo NF, Simionato MRL. Oral Conditions in Children with Cerebral Palsy. J Dent Child. 2003;70:40-46. Maria et al in the year 2003 conducted a study to find oral condition in patient with cerebral palsy and concluded that earlier preventive measures for CP patients are required because they are a high-risk group for dental caries. 73

74. Dental management 1.Consider treating a patient who uses a wheelchair in the wheelchair itself. 2.Patient’s head should be stabilized throughout the dental treatment 3.Patient’s back should be kept slightly elevated to minimize difficulties in swallowing. 4. Mouth props should be used to control involuntary jaw movement. 74

75. Dental management 5.Allow frequent time-outs for patient to regroup, relax and breath normally. 6. To minimize startle reflex reactions, avoid stimuli such as abrupt movements, noises, and light. 7. Introduce intraoral stimuli slowly to avoid eliciting a gag reflex. 8. Sedation or general anaesthesia may be an option for more complex patients. 75

76. Patient name – Gulshan Age – 4 years Chief complain – pain in lower front tooth region CASE REPORT 76

77. Hearing loss 77

78. Management Let the patient and parent determine how the patient want to communicate. Reassure the patient with physical contact. Adjust the hearing aid before the handpiece is in operation. 78

79. Tell-show-do 79 Tell-show-feel-do

80. Visual impairment 80

81. Management If the patient is accompanied by a companion, find out if the companion is an interpreter Do not grab, move, or stop the patient without verbal warning. Paint a picture in the mind of the visually impaired children about the office setting and treatment 81

82. 82 TELL-SHOW-DO TOUCH, TASTE, OR SMELL

83. Some patients may be photophobic. Allow these patients to wear sunglasses. Place the patient’s hand over yours as you slowly but deliberately guide the toothbrush. Use audiocassette tapes and braille dental pamphlets explaining dental procedures 83

84. Patient name – Nishant AGE – 8 years Chief complain – decayed tooth in upper and lower right back tooth region CASE REPORT 84

85. Reddy K et al in the year 2011 conducted a study to know prevalence of oral health status in visually impaired children and concluded that there was a greater prevalence of dental caries, poor oral hygiene, and trauma in visually impaired children. Reddy K, Sharma A. Prevalence of oral health status in visually impaired children. J Indian Soc Pedod Prev Dent. 2011 Jan-Mar;29 (1):25-7. 85

86. To assess the dental caries and oral hygiene among visually impaired children and to compare these parameters with that of a group of deaf children. Blind children had more caries prevalence than deaf children in both permanent and primary teeth. Blind lack the vision to understand and master the technique of oral hygiene practices. Singh A, Kumar A, Berwal V, Kaur M. Comparative Study of Oral Hygiene status in Blind and Deaf Children of Rajasthan. J Adv Med Dent Science. 2014;2(1):26-31. 86

87. Autism 87

88. It is an incapacitating disturbance of mental and emotional development that causes problems in learning, communicating, and relating to others. This disability manifests itself during the first 3 years of life, is difficult to diagnose, and has no cure. 88

89. Dental Management Children with ASD may require several dental visits to acclimate to the dental environment. Use of a Papoose Board or Pedi-Wrap Preappointment conscious sedation. 89

90. Dental health burden in India Age group Dental problem /max incidence Primary dentition Dental caries (24%), Mixed dentition Gingivitis (50%) Permanent dentition Gingivitis (48.96%) and malocclusion (71.15%) Vishnu RC, Arangannal P, Shahed H. Oral health status of children with autistic disorder in Chennai. Eur Arch Pediatric Dent. 2012 Jun;13(3):126-31. Oral health status was assessed for 483 children with autism, solicited from special education schools, autistic child centers and therapy centers 90

91. Cardiac diseases Cardiac diseases 91

92. Dental considerations 92 Wilson W, Gewitz M. Prevention of infective endocarditis : Guidelines from the American Heart Association. JADA. 2008 January;139:3-24.

93. Wilson W, Gewitz M. Prevention of infective endocarditis : Guidelines from the American Heart Association. JADA. 2008 January;139:3-24. 93

94. Respiratory disease 94

95. Asthma It is a Chronic airway disease characterized by inflammation and bronchial constriction. Etiology - involves biochemical, immunologic, infectious, endocrine, and psychological factors. Triggered by allergens such as dust, cold air etc. 95

96. 96

97. Dental management Before treatment, dentist should record frequency, severity, triggers of the attack, last hospitalization, medications the patient takes and the activity limited. Child should be seated in upright or semi upright position. 97

98. Inhalers or nebulizers should be brought into the dental office . Behavior management and Nitrous oxide oxygen can be used to reduce anxiety. Non steroidal anti-inflammatory agents are contraindicated. 98

99. Emergency management- discontinue dental treatment, 100% oxygen administered, β₂ agonist delivered with an inhaler or nebulizer If there is no improvement, subcutaneous epinephrine (0.01 mg/kg of 1:1000 solution) is administered and medical assistance is obtained immediately. 99

100. Hemophilia 100

101. 101

102. Medical Management The mainstay of therapy is replacement of the deficient coagulation. DDAVP (1-deamino-8-D-arginine vasopressin) Used for minor hemorrhagic episodes due to factor VIII deficiency. Given intravenously, subcutaneously or intranasally causes a rise in factor VIII activity and VW. 102

103. Dental Management Dentist should consult with PHYSICIAN AND HAEMATOLOGIST about type of bleeding disorder, the severity of the disorder, the frequency and treatment of bleeding episodes. Drug therapy – ANTIFIBRINOLYTIC AGENTS DRUG CHILDREN ADULT 1. Aminocaproic acid 100 to 200 mg/kg (orally), 50-100mg/kg for 5-7 days 3 g (orally) four times daily 2. Tranexamic acid 25 mg/kg 25 mg/kg 103

104. 104 3. ANALGESIA

105. 4. LOCAL ANAESTHESIA Periodontal ligament (PDL) injections may be used along the four axial surfaces of the tooth. 40% factor concentrate is mandatory with block anesthesia in severe cases.. Aspiration is mandatory. If there is bloody aspirate, further factor replacement is required in severe cases of hemophilia . 105

106. 5. RESTORATIVE PROCEDURES 6. ENDODONTIC THERAPY 106

107. The normal exfoliation of primary teeth does not require factor replacement. For erupted teeth extraction, 30-40% factor replacement is required in severe cases. 7. ORAL SURGICAL PROCEDURE 107

108. Antifibrinolytic therapy started immediately before of after the procedure and continued for 5-10 days. Patient should be placed on a clear liquid diet for the first 72 hours. Resorbable sutures recommended 7. ORAL SURGICAL PROCEDURE 108

109. 109 KNOWN HAEMOPHILIC PATIENT SHOULD BE TREATED UNDER HOSPITAL BASED MANAGEMENT

110. The aim of this study was to examine if patients with hemophilia were at increased risk for dental decay. Better dental health was observed in children with hemophilia as compared to children without it. Zaliuniene R, Aleksejuniene J, Brukiene V, Peciuliene V. Do Hemophiliacs have a higher risk for dental caries than the general population? Medicina (Kaunas). 2015;51(1):46-56. 110

111. CONCLUSION 111

112. Children with SHCN are those who are chronically ill, homebound, developmentally disabled, and emotionally impaired. Receipt of timely dental services is of particular importance to children with SHCN because of high prevalence of structural irregularities, infections, and diseases among these children 112

113. Successful management of such children requires multi-disciplinary co-operation and expertise. Role of paediatric dentist is the co-ordination of the treatment plan, guidance and support of the family as well as a careful follow up. 113

114. 114 Points to remember

115. 115 Preventive strategies should be given maximum importance. APF is preferred over other topical fluoride GIC is preferred over composite Extraction must be kept for last and as far as possible one extraction per appointment should be done Physical restraints should be avoided. Pit and fissure sealant which are less moisture sensitive should be used Airotor should be avoided– mechanical and chemo mechanical excavation is preferred.

116. RECOMMENDATIONS Every dental college should include a special clinic for treating patient with SHCN. Number of wheel chair should be increased. One day in the month should be fixed for treating such patients. Dental camps should be regularly organized in school and centers for special children. As there should be no accessibility barrier a slope should be included in college infrastructure. 116

117. AKNOWLEDGEMENT Dr. Nikhil Srivastava (Guide) Principal & Head Dr. Vivek Rana Professor Dr. Vivek K. Adlakha Reader Dr. Preetika Chandna (Co-Guide) Reader Dr. Noopur Kaushik Reader Dr. Himanshu Kapoor Reader 117

118. Dr. Neha Dr. Ashutosh Dr.Vrinda Dr. Priya Dr. Sabika Dr. Madan Dr. Nakul Dr. Parul 118 AKNOWLEDGEMENT

119. Heaven’s very special child A meeting was held quite far from Earth: “it’s time again for another birth.” Said the angel to the Lord above, “This special child will need much love.” Her progress may seem very slow, Accomplishments she may not show And she’ll require extra care From folks she meet way down there. 119

120. She may not run or laugh or play Her thoughts may seem quite far away: In many ways she isn’t adapt And she’ll be known as handicapped. So lets be careful where she’s sent We want her life to be content. Please, Oh Lord, find the parents who Will do a special job for you 120

121. They will not realize right away The leading role they’re asked to play But with this child sent from above Comes a stronger faith and richer love. And soon they’ll know the privilege given In caring for the gift from heaven. Their precious charge, So meek and mild Is Heaven’s Very Special Child 121 - Edna Massimila

122. Dean JA, Avery DR, McDonald RE. Dentistry for the Child and Adolescent.9 th Ed. Elsevier;2011. Nagarkar A, Sharma JP, Tandon SK, Goutam P. The clinical profile of mentally retarded children in India and prevalence of depression in mothers of the mentally retarded. Indian J Psychiatry. 2014 Apr - Jun; 56(2):165–170. Bozkurt FY, Fentoglu O, Yetkin Z. The comparison of various oral hygiene strategies in neuromuscularly disabled individuals. J Contemp Dent Pract . 2004 Nov;5(4):1-9. Gupta P, Hegde A. Understanding and Management of Special child in Paediatric Dentistry. 1 st Ed. Jaypee Brothers Medical Publishers;2012. Kava MP, Tullu MS, Muranjan MN, Girisha KM. Down syndrome: Clinical profile from India. Arch Med Res . March 2004;36(2):183. Mogasale V, Patil VD, Patil NM, Mogasale V. Prevalence of Specific Learning Disabilities Among Primary School Children in a South Indian City. Indian J Paediatr. March 2012;79(3):342-347. Santos MT, Masiero D, Novo NF, Simionato MRL. Oral Conditions in Children with Cerebral Palsy. J Dent Child. 2003;70:40-46. Singh A, Kumar A, Berwal V, Kaur M. Comparative Study of Oral Hygiene status in Blind and Deaf Children of Rajasthan. J Adv Med Dent Science. 2014;2(1):26-31. Reddy K, Sharma A. Prevalence of oral health status in visually impaired children. J Indian Soc Pedod Prev Dent. 2011 Jan-Mar; 29 (1):25-7. Murthy G, John N, Gupta SK, Vashist P, Rao GV. Status of paediatric eye care in India. Indian J Ophthalmol. 2008 Nov-Dec;56(6):48-18. Vishnu RC, Arangannal P, Shahed H. Oral health status of children with autistic disorder in Chennai. Eur Arch Pediatric Dent. 2012 Jun;13(3):126-31. Blackman JA, Gurka MJ. Developmental and behavioral comorbidities of asthma in children. J Dev Behav Pediatr. 2007 Apr;28(2):929. Zaliuniene R, Aleksejuniene J, Brukiene V, Peciuliene V. Do Hemophiliacs have a higher risk for dental caries than the general population? Medicina (Kaunas). 2015;51(1):46-56. Salles PS, Tannure PN, Gomes CA, Ribeiro IP, Portela MB. Dental Needs and Management of Children With Special Health Care Needs According to Type of Disability. J Dent Child. 2012;79(3):165-9. 122

123. We do not want to change them for the world, but we want to change the world for them…….. Thank you…... 123