1. Estimation of Dental Treatment
Need inSpecialCare Patients
Pediatric Dentistry: R2 Mohammad Alkeshan

2. PresentationOutlines
 Introduction.
 Background.
 Barriers to Dental Care for Children with Special Needs.
 Access to Dental Services For (CSHCN).
 Responsibility ofTreatment.
 FirstVisit And Radiographic Examination.
 Management And Preventive Dentistry.
 Management of A Child (SHCN) During DentalTreatment.
 DentalTreatment of A Person With Intellectual Disability.
 DentalTreatment of Down Syndrome.
 Conclusion

3. Introduction
Definition of (CSHCN);
People with disabilities that affect daily life activities and
influence the delivery of health care, including Dental care.
 It include a wide variety of physical, developmental, mental,
sensory, behavioral, cognitive, and emotional impairments
that require medical management.
 10% of the world's population live with disabilities
 The patient’s age, the severity of the impairment and the
living conditions may influence oral health

4. Background
 Many children with CSHCN are best managed initially by a
multidisciplinary team to evaluate extraoral and intraoral
findings of the child.
 Pediatric Dentistry has automatically become the dental
assistance reference for children as well as adults with special
health needs.
 Pediatric Dentists tend to provide more preventive
procedures such as restorative, oral hygiene, scaling, fluoride,
sealants and orthodontics.

5. BarrierstoDentalCareforChildrenwithSpecial
Needs.

6. AccessToDentalServicesFor(CSHCN)
 These children often have complex medical conditions
requiring a range of services provided by multiple health care
providers, typically inTertiary Care Center.
 Medical and Dental care should deliver by personal who had
the skills and disposition to treat the children.
 Money barrier?
 alleviate some of the financial barriers for families
(transportation fees)
 General Dentists should provide early referral to tertiary-
level care for medically or behaviorally complex CSHCN .

7. GeneralRequirementsNeededtoGainAccess.

8. RequirementsNeededtoGainAccess.
Hospital Outpatient Dental Programs
 Major advantage of an outpatient program within a community
hospital is the ready availability of medical consultation and
evaluation, and general anesthesia.
 Patients are screened by physicians knowledgeable about the
special problems common to people with disabilities, who can
provide behavior management assistance, e.g., IV sedation or
general anesthesia.

9. RequirementsNeededtoGainAccess.
University Professional Dental training programs
 For pre-Doctoral dental students these programs provide an
adequate number and geographical distribution of dental
professionals with the skills and willingness to treat severely
disabled people.

10. RequirementsNeededtoGainAccess.
Innovations in dental education: Developmental dentistry
fellowships interested in special care patients
 (AADMD) focuses on establishing a several of University-
Based Developmental Medicine and Dentistry Programs
(UDMDPs) in medical and dental schools which can help
Dentists to :
I. Improve the access.
II. Address critical education gaps.
III. Promote patient-centered research .
IV. Encourage partnerships.

11. RequirementsNeededtoGainAccess
Mobile Dental programs
 The chief advantage of this type of program is that it serves a
large geographical area, thereby increasing access to
residents in rural and urban areas.
 Only basic dental care.

12. AccessToTheDentalChair
• A break-leg chair• A reclining wheelchair
 As a general rule
it is always prudent to ask the patient how much or little help they require
and not to assume that they need help

13. AccessToTheDentalChair
 Chair design should eliminates the risk of accidents during
the transfer of patients from wheelchairs to dental units.
 There are a number of designs now available utilizing manual
and electronic controls, they eliminate transfer risks to both
staff and patients.
• wheelchair recliner

14. AccessToTheMouth
 The patient’s body should be well
supported and joints and muscles
should be in the rest position.
 If the patient has uncontrolled limb
movements then safeguards will need
to be put in place to prevent them
from knocking against equipment's.
 Where there is a risk that the patient
may suddenly bite, this can be
managed by the use of a bite support
or rubber spatula.

15. First Visit And Radiographic Examination
 The first dental appointment is very important .
 Scheduling the patient at (early in the day) and allowing
sufficient time to talk with the parents and patient.
 Complete radiographic examination when indicated Better
cooperation (2nd visit).
 An 18-inch (46-cm) length of floss is attached through a hole
made in the tab to facilitate retrieval of the film if it pass
toward the pharynx.

16. ManagementAndPreventiveDentistry
 An effective preventive dentistry program is important for a
child with SHCN
 Dental diagnosis and treatment planning will necessitate an
accurate, up-to-date medical history at each visit.
 Dry mouth , the oral cavity should be moistened with a saliva
substitute or other lubricants.

17. ManagementAndPreventiveDentistry
Home Dental Care
 Parental assistance is required to remove all plaque.
 Brushes of the appropriate size and contour (Various
toothbrush handle modifications) should be selected to meet
the child’s needs.

18. ManagementAndPreventiveDentistry
Home Dental Care
 Parents can be helpful in assisting the
child.
 Positions most commonly used for
children requiring oral care assistance
are as follows; A, Standing. B, Upright
wheelchair. C, Reclining on couch. D,
Reclining in bed. E, “Leg-lock”
position. F, Reclining on floor.

19. ManagementAndPreventiveDentistry
Fluoride.
 Fluoride varnish is a particularly useful form of topical
fluoride in patients with impairments and intellectual
disabilities.
Duraphat (2.26% fluoride)Varnish has been shown to be
effective when applied bi-annually.
 Caution is required (patients with an allergy to sticking
plaster) may exhibit hypersensitivity to colophony.
 Toothpastes containing high fluoride concentration (5,000
ppm) are available commercially for daily use.

20. ManagementAndPreventiveDentistry
Chlorhexidine.
 Indicated to control gingivitis , or compensate for
the brushing of teeth.
 Many patients may be incapable of rinsing due to
cognitive problems, dysphagia, or poor
neuromuscular co-ordination.
 swabbing the gingivae with 0.2% solution is an
effective way of modifying application .

21. ManagementAndPreventiveDentistry
Diet And Nutrition
Cerebral palsy and Parkinson’s disease:
 Feeding difficulties and fail to gain weight.
 Energy-rich food supplements prescribed to ensure adequate
nutritional intake have a high carbohydrate and sugar content
which will affect on oral health.
 Management strategies include recommending sipping water
at regular intervals during the day and chewing sugar-free
gum.
 A proper non-cariogenic diet, is essential to a good
preventive program .

22. PreventiveRestoration
 Pit and fissure sealants have been shown to reduce occlusal
caries effectively.
 Deep occlusal pits and fissures should be restored with
amalgam or long-wearing composites to prevent further
breakdown and decay.
 Patients with severe bruxism and interproximal decay may
need their teeth restored with stainless steel crowns.
 Close observation of caries-susceptible patients and regular
dental examinations .

23. Management OfAChildWithSpecial Health
CareNeedsDuringDentalTreatment
 Physical support or protective stabilization is used
 The ADA Policy Statement on the use of Sedation and
General Anesthesia by Dentists summarizes the education
that dentists should receive to use these modalities.
(1). Protective stabilization (PS)
 The parents must be informed and must give consent before
protective stabilization is used
 Partial/complete PS necessary and effective way to diagnose
and treat patients who need help to controlling their
extremities.

24. Management OfAChildWithSpecial Health
CareNeedsDuringDentalTreatment
Indication of PS :
1) patient requires limited treatment and cannot cooperate
because of lack of maturity, mental or physical disability.
2) when behavior management techniques have failed.
3) The safety of the patient, staff, parent or practitioner would
be at risk without the use of PS.
Contraindications of PS:
1) A cooperative non-sedated patient.
2) Patients who cannot be safely stabilized due to medical
conditions.
3) patients with non-emergent treatment requiring.

25. ProtectiveStabilization

26. Management OfAChildWithSpecial Health
CareNeedsDuringDentalTreatment.
Nitrous Oxide
 A useful alternative to general anesthesia.
 The use of conscious sedation with nitrous oxide resulted in
successful completion of dental treatment in 83% of cases.
 Considered safe , practical , and effective for pediatric very
young ,fearful patients and for patients with intellectual
disability.
LIMITATION : If disabled patient can not be able to breathe
adequately through a nasal mask the use of general anesthesia
be justified.

27. Management OfAChildWithSpecial Health
CareNeedsDuringDentalTreatment.
General Anesthesia and Sedation
 Healy et al. Examined the use of local anesthetic and
intravenous diazepam, as an alternative to general
anesthesia, and found the operating conditions acceptable in
80% of cases
 Manford and Roberts. showed the successful use of relative
analgesia as an alternative to the use of general anaesthesia
in the treatment of young handicapped patients.
 Silver et al . showed the effective use of oral midazolam in 31
patients aged 3–18 years.

28. DentalTreatmentOfAPersonWithIntellectual
Disability
 Providing dental treatment for a person with intellectual
disability requires adjusting to social, intellectual, and
emotional delays. ID patients represent approximately 2% of
the populations.
 ID Patients have High mortality rates due to cardiovascular
diseases, intestinal obstruction, pneumonia, trauma, and
proplem in vision and hearing reported.
 They have a higher incidence of (poor oral hygiene, gingivitis,
malocclusion, and missing /untreated caries).
 Proved beneficial in establishing Dentist-Patient-Parent-Staff
rapport and reducing the patient’s anxiety about dental care.
 Dentists should Be repetitive; speak slowly and in simple
terms, give only one instruction at a time.

29. DentalTreatmentOfDownSyndrome
 High susceptibility to periodontal
disease, knowledge of a heart
condition is essential for dental
treatment.
 Children with Down syndrome have a
10- to 20-fold greater incidence of
leukemia during infancy compared
with the general population.
 Many patients with Down syndrome
are affectionate and cooperative, and
dental procedures can be provided
without compromise if the dentist
works at a slightly slower pace.

30. DentalTreatmentOfDownSyndrome
A recent study documented periodontal healing responses in a
patients with Down syndrome using Nonsurgical periodontal
therapy + Chlorhexidine Rinse twice a day and chlorhexidine gel
and monthly recalls.
• Caries: incidence is
reduced in children
• Bruxism : regular
review program
needed

31. DentalTreatmentOfAutismSpectrumDisorder
 Have multiple Medical and behavioral problems that make
dental treatment difficult.
 Male : female ratio is 3:1
 Have poor muscle tone, poor coordination, drooling, a
hyperactive knee jerk, and 30% develop epilepsy.
Dental treatment of patients with autism
 The use of a Papoose Board or Pedi-Wrap and pre-
appointment conscious sedation may be necessary and in
some instances has a calming effect on the child.
 Use of a dental Mouth prop.
 Use of “hand over mouth” andTell-show-do technique.
 Positive and negative verbal reinforcement

32. DentalTreatmentOfAutismSpectrumDisorder
Dental treatment of patients with autism
 Long and involved treatment procedures under general
anesthesia and avoid oral sedative medications .
 Administration of intravenous sedative agents consedr safe
too.

33. Conclusion
 The majority of people with a mild or moderate disability or
medical condition can and should be treated in general dental
practice.
 Recent legislation, particularly the Disability Equality Duty,
impacts on the responsibility of the dental team to ensure
that disabled people are treated equally.
 There are many practical ways of facilitating access for the
special care patient.
 Preventive care is considered a major factor in minimizing
the need for further treatment under GA.