DENTAL MANAGEMENT

OF PATIENTS WITH SPECIAL

NEEDS
 SPECIAL CARE
DENTISTRY
• 1.MEDICALLY COMPROMISED
PATIENT
• 2.PATIENT WITH SPECIAL NEEDS
SPECIAL CARE NEEDS PATIENT

-SOME KIND OF MEDICAL RISK

-SOME KIND OF SPECIAL MANAGEMENT REQUIEREMENT
- behavioural
- due to the tecnique need
-EXISTENCE OF A CONDITION THAT INCREASES THE
PATIENT´S RISK FOR ORAL PATHOLOGY
-INTERACTION OF MEDICAL PROBLEMS AND ORAL
TREATMENTS
1.MEDICALLY COMPROMISED PATIENT

• 1.oncologyical patient
• 2.neurological patient
• 3.cardiovascular patient
• 4.respiratory patient
• 5.endocrine patient
• 6. patient with immunodeficiencies
• 7.patient with coagulation problems
• 8.the pregnant patient
• 9.gastronitestinal patient
• 10.renal patient
It is important for the Dentist to study Special Care Dentistry:

-Dental treatment is risky

-The practicioner must recognize the potential medical
problems before they appear
-It is important to have a fluent cooperation with the current
phisicians that treat them
-The dentist must follow certain guidelines and prothocols to
prevent emergency situations in these patients
 ASA I ASA II
Healthy patients Patient with mild controlled disease
No treatment modifications Medical advice may be helpful

ASA III
Patient with severe systemic disease
limiting activity but not incapacitating
ASA IV
Medical advice is helpul
Patient with incapacitating disease that is
a constant threat to life

ASA V
Moribund patient
• ASA I: Healthy patient
• ASA II: controlled diabetes, anticoagulation, asthma,
hypertension, epilepsy, pregnacy, anxiety
• ASA III: chronic renal failure, epilepsy with frequent
seizures, uncontrolled hypertension, recent myocardial
infarct, uncontrolled diabetes
• ASA IV: Severe asthma, stroke, cancer, unstable angina or
recent infarct
• ASA V: moribund patient not expected to survive 24h without
treatment
• ANESTHESIOLOGY AMERICAN SOCIETY
• CORRECT PROCEDURE TO AVOID EMERGENCY SITUATIONS

• 1. Determine what the patient requieres and wants

• 2.Obtain an accurate medical(including medication), family,
social , developmental history
• 3.Perform a risk-benefit analysis related to pre-treatment
intents
• 4.Obtain informed consent to any procedures that may be
needed from the patient or their legally responsible
2. SPECIAL CARE NEEDS.CONCEPT
People are considered to have special care needs if they have
physical, developmental, mental, sensory, behavioural, cognitive or
emotional impairment or a condition that requires medical
management, healthcare intervention or use of specialized
services or programs
The AAPD(American Academy of Pediatric Dentistry) defines special
care needs as any physical, developmental, mental, sensory,
behavioral, cognitive, or emotional impairment or limiting condition
that requires medical management, healthcare intervention or use
of specialized services or programs. The condition may be
developmental or acquired or may cause limitations in performing
daily self-maintenance activities or substantial limitations in a major
life activity
 Poorer oral hygiene
Worse periodontal
status More untreated
caries Fewer remaining
teeth

Great limitations in oral

hygiene
(motor, intelectual,
sensory disabilities)
Less responsibility for
preventive
oral practices
 Those with severe
impairments, are dependent
on parents or caregivers for
oral hygiene

Most of them have medical

complications and lack of
cooperation regarding dental
treatments
Health care for individuals with SCHN (special care health
needs) requires:
-specialized knowledge
-increased awareness
-attention
-adaptation
-accomodative measures
Caregiver Don´t value the importance of
s diet

Patient Have difficulties in oral

s hygiene

-
THE DENTAL TEAM FACES A GREAT
CHALLENGE.
THE CONSISTENT FOCUS SHOULD BE PROVIDE THESE
INDIVIDUALS AND THEIR CAREGIVERS A COMPLETE RANGE OF
PREVENTIVE SERVICES WITH RELEVANT INFORMATION AND
SUPPORT

-
SPECIAL CARE DENTISTRY is the field of dental practice
that addresses the needs of patients who require
treatment accommodation to their:
-physical
-mental
-medical problems
-with neglected dental health
-with dificulties in finding a proper dentist
For millions of people with special care needs, dental care is
often not a top priority and takes a back seat to more pressing
issues.

However, maintaining good oral health should be a priority for

everyone through preventive measures because it is well said
that
«prevention is better than cure»
DEFINITIONS AND TERMINOLOGY (WHO-ICIDH 1980)

IMPAIRMENT
Any loss or abnormality of physiological or anatomical structure
or function.
DISABILITY
Any restriction or lack (resulting from an impairment) of ability to
perform an activity in the manner or within the range considered
normal for a human being
DEFINITIONS AND TERMINOLOGY (WHO-ICIDH 1980)

HANDICAP

This is a disadvantage for a given individual resulting from an

impairment or a disabitity, that limits or prevents the
fullfillment of a «survival» role that is normal (depending
on age, sex, and social and cultural factors)
DEFINITIONS AND TERMINOLOGY (BRITISH DISABILITY

DISCRIMINATION ACT BDDA 1995)

DISABILITY

Physical or mental impairment which has a substantial and long

term adverse effect on his/her ability to carry out normal day-to

day activities
DEFINITIONS AND TERMINOLOGY (AMERICAN
ACADEMY OF PEDIATRIC DENTISTRY 2008)

SPECIAL HEALTH CARE NEEDS (SCHN) Children and

adolescents who have or are at an increased risk for
chronic physical, developmental, behavioural, or emotional
condition and who require health and related services of a
type or amount beyond that required by children
generally
ORAL HEALTH
STATUS
About 500 million people worldwide are disabled.

According to a recent study, out of 21.9 million disabled people in

India:

1.03% of population are visually

impaired 0.16% are speech impaired

0.12% are hearing impaired

0.59% are movement

impaired
0.22% are mentally impaired
Shah N, Mathur V, Logani A. Guidelines for oral health promotion and intervention for disabled population.Whoindia.org August
2012
 Learning
Communicati
ng Self-steem
Nutrition
 Cardiovascular
disease Bacterial
endocarditis
Higher risk for
Pulmonary
infection
 Puree
d
diets
Abnormal Sweetened
developmen
ts of
maxilars medicatio
n

Motor
problems Traumas
, poor in the
hygiene face
 Lack of
responsibili
ty
Depende
nce
Oral Periodontitis
problems due to
due to medical
medication conditions

Disorders Abnorm
that causes al
maloclusions
postures
MAIN ORAL PROBLEMS IN
SCHN

1.Tooth eruption
2.Tooth
abnormalities
3.Developmental
defects
4.Trauma
5.Tooth wear
(bruxism)
6.Dental caries
MAIN ORAL PROBLEMS IN
SCHN

7. Periodontal disease
8. Gingival overgrowth
9. Drooling
10. Dry mouth
11.Mucosa ulceration
12.Biting (self mutilation)
MAIN ORAL PROBLEMS IN SCHN

13. Bruxism
14. Maloclusions
15. Oral cancer
16. Bad habits
(coaching,rumiation)
Provision of oral health care for individuals with special needs
involves not only the delivery of safe and appropriate dental
care but also focuses on the need to improve the oral health
status of these populations.

But this population have barriers which might affect the provision
of effective care to such people
Type of barriers (Classification
1)

1.Information

al 2.Physical

3.Behavioral
Type of barriers related to the role of the dental profession and
its
interaction with individuals and society

1.Barriers related to the individual

-lack of perceived need
-anxiety or fear
-financial considerations
-lack of access
Type of barriers related to the role of the dental profession and
its
interaction with individuals and society

2.Barriers related to the dental profession

-inappropiate manpower resources
-training inappropriate to needs and demands
-insufficient sensitivity to patients attitudes and needs
-Uneven distribution of dental professionals
Type of barriers related to the role of the dental profession and
its
interaction with individuals and society

3.Barriers related to society

-insufficient public support
-inadequate oral health care facilities
-inadequate oral health manpower planning
-insufficient support for research
Type of barriers related to the role of the dental profession and
its
interaction with individuals and society

4.Barriers to related to government

-lack of political will
-inadequate resources
-low prority
1.Barriers related to the individual

a) Dependency

Persons with SCHN who are dependent on caregivers for daily

oral care characteristically have poor oral hygiene and greater
prevalence of periodontal disease.

Most of the caregivers are not motivated to provide oral health

care.
1.Barriers with reference to the individual

b) Fear and anxiety

Several studies indicate a high level of fear and anxiety in

persons
with disabilities.

The high proportions may reflect a lack of regular dental care

and poor past dental experiences.
1.Barriers with reference to the individual

c) Institutionalization

Institutionalized adults with disabilities comprise primarily

two groups:

1. persons with developmental disabilties

2. persons with psychiatric disorders

Poor oral hygiene and severe periodontal disease are

characteristic of institutionalized persons with disabilities
and compromising medical conditions
1.Barriers with reference to the individual

d) Homebound status

Although the majority of persons who are homebound are

geriatric, this population also includes younger persons with
disability, and they have the following barriers:

-difficulties in getting to a dentist

-paying for dental care

-poor health
1.Barriers with reference to the individual

e) Financial barriers

Persons with disabilities, particularly those with severe disabilities,

are deprived with respect to income and dental insurance, factors
that are major determinants in the rate of utilizing dental
services.

-inability to pay for the cost of care

-lack of dental insurance

-limited dental coverage by public services

1.Barriers with reference to the individual

f) Difficulty in Physical Access

Quite often patients with disabilities have to travel great distances

in adapted public or private vehicles placing an added burden
on family members or caregivers who accompany them.
1.Barriers with reference to the individual

g) Lack of effective patient self care or caregiver

assistance with oral care

Self care in general and oral care in particular can be

adversely affected by some chronic conditions like visual,
manual or shoulder and arm impairments, which can make
effective cleansing of the teeth and mouth difficult.
1.Barriers with reference to the individual

h) Communication difficulties

Difficulties in understanding and obtaining information from the

patient and explaining the treatments to him are major problems
for dentists.

Poor comprehension is a major barrier for deliverance of

effective oral care.
2.Barriers with reference to Dental/Health professional
workforce

Barriers related to health professional workforce are manifold

and include issues of

- number of distribution

- diversity and competency of dentists, hygienists and primary

care health professionals.

Education in special patient oral health is crucial to treat them.

2.Barriers with reference to Dental/Health
professional workforce

a)Lack of dental professionals with advanced

training The numbers of practicioners willing to treat

patients with SCHN are less. Practicioners are
selective regarding whom they accept and indicate a
greater reluctance to treat persons with
developmental or psychiatric disabilities than with
physical problems
2.Barriers with reference to Dental/Health professional
workforce

b) Lack of trained caregivers

Many persons with severe disabilities are completly

dependent on caregivers for maintaining an
adequate oral hygiene level.

For some of them, this is an unpleasant task. The ratio of

caregivers per patient in institutions, along with daily
difficulties are other major problems in
providing proper oral health to them.
2.Barriers with reference to Dental/Health professional
workforce

c) Uneven distribution of dental proffesionals

The geographic distribution of dental providers

is increasingly problematic in meeting the needs
of underserved populations.
2.Barriers with reference to Dental/Health professional
workforce

d) Unwillingness by dentist

Private practicioners do not feel the need to treat

the patient with mental impairment or some other

disabilities as it requires more time and effort.

They tend to avoid these patients or react with

frustration or apathy.
 Special
program
s

Special Adapte
instruments d
clinics

Trained Trained
hygienists clinician
s
2.Barriers with reference to
society
a) By SCHN individuals and their
caregivers
Lack of knowledge and low expectations about oral
health and its value influence care-seeking
behavior can result in care being deferred or neglected
entirely.
Little difference in rate of acceptance was based
found on resident age. Family and caregiver´s may
be
attitudes even more powerful in limiting access

to care.
2.Barriers with reference to society

b)Inadequate facilities and equipment

Unadapted clinics, nursing homes, etc., create a

dental access barrier.

Some of the residents in nursing homes can´t be

placed
in dental clinics even if they are located inside the
nursing
homes.
2.Barriers with reference to society

c) Lack of special equipment for special patients

Some patients are a potential risk to themselves during

the dental treatments, because they need some special
instruments.

Some of these patients can´t be treated without these

special instruments.
3.Barriers with reference to Government

a) By authorities

A general lack of awareness of the relationship of the

mouth to rest of the body is pervasive across the health
disciplines, social service agencies, and public policy-makers
concerned with services for persons with disabilities.
PROPOSED
MEASURES
1.Health education
and promotion
2.Creating behavioural changes
in patients
3. On-sites delivery systems

4.Integrated health care

delivery
5. Expanding workforce
6. Interdisciplinary
training
7. Providing physical
access
8. Financial support
9. Establishing
communication with
patient