This document discusses the management of children with disabilities in dentistry. It begins by defining various disabilities like physical, mental, medical, and social disabilities that may interfere with normal functioning. It emphasizes that children with disabilities should be managed by a multidisciplinary team. The dentist's role is to evaluate oral findings, establish a diagnosis, and identify the child's strengths and weaknesses for future care. Special preparation may be needed to provide acceptable dental care for these children. The document then discusses various disabilities like cerebral palsy and autism in more detail and provides guidance on managing these pediatric patients in a dental setting.

1. Dr. Prasannakumari
Pedodontics & preventive

2. • The term disability includes all handicapping conditions
or combinations a health professional might encounter

3. Children
with
disabilities
Mental
Physical
Medical
Social
Interfere with normal functioning

4. Management

5. • Should be best managed by multidisciplinary team
• Dentist should be able to evaluate extra-oral and intra-oral
findings of the child
• Diagnosis should be established
• Child’s strength and weaknesses should be identified for future
care
• Present challenges that require special preparation before we
provide acceptable care
Children with disabilities

6. • WHO(1980)
Handicapped person- One who over an appreciable period is
prevented by physical or mental conditions from full participation
in the normal activities of their age groups including those of a
social, recreational, educational and vocational nature.
• AAPD(1996)
A person should be considered dentally handicapped if there is
pain infection or lack of functional dentition that affects him or
her as follows:
• Restricts consumption of a diet adequate to support growth
and energy needs
• Delays or otherwise alters growth and development
• Inhibits performance of any major life activity

7. • Blind or partially sighted
• Deaf or partially deaf
• Educationally subnormal
• Epileptic
• Maladjusted
• Physically handicapped
• Defective in speech
• Senile

8. • Physically handicapped
• Mentally handicapped
• Congenital defects
• Convulsive disorders
• Communication disorders
• Systemic disorders
• Metabolic disorders
• Osseous disorders
• Malignant disorders

9. This is very important and this sets a stage for subsequent appointments
Schedule the patient at a designated time and allowing sufficient time to talk
with the parents and the patient before initiating any dental care, a practitioner
can establish an excellent relationship with them
Sending a letter or call before the appointment, explaining the first visit to the
family
Often proves advantageous and saves time
through-out the entire treatment process

10. Adequate radiographic records are often
necessary in planning dental treatment
Through appropriate behavior management of a
child, a dentist can usually perform a complete
radiographic examination of the teeth when
indicated
Assistance from the parents and dental auxiliaries
and the use of immobilization device may be
necessary to obtain films
Delay radiography until second visit for better co-
operation of the child
For patient with limited ability to control film
position intra-oral films with bite-wing tabs are
used for all bitewing and peri-apical radiographs

11. • 18 inch length of floss is attached through a hole made in
the tab to retrieve the film if it falls toward the pharynx

12. • Lead apron with thyroid shield are mandatory for the
patient and operators

13. • Home dental care should begin in infancy; Dentist should
teach the parents to gently cleanse the teeth daily with a
soft cloth or an infant tooth brush
• For older children who are unwilling or physically unable
to cooperate the dentist should teach the parent or
guardian correct tooth brushing techniques

17. • Wrapped tongue blades- helps the child to keep the
mouth open
• Stabilization of the child’s head is necessary
• Horizontal scrub technique is easy to perform and can
yield good results
• Soft multi- tufted nylon brush should be used
• Electric tooth brushes can be used

19. • A topical application of fluoride is necessary for reducing
the decay rates
• Pit & fissure sealants can be used to reduce occlusal
caries effectively
• Deep occlusal pits & fissures should be restored with
amalgam or long wearing composites

20. • Patients with severe bruxism and interproximal decay,
stainless steel crowns are required

21. • Effective way to deliver dental care for patients with
neuro-muscular disorders and resistant patients
• Informed consent is necessary and should be
documented
• Should not be used as punishment

22. Indications:
• A patient requires diagnosis or treatment and cannot co-
operate
- because of lack of maturity
- Mental or physical disabilities
- If other behavior techniques have failed
• The safety of the patient or practitioner would be at risk
without the use of protective immobilization
Contra-indications:
• Co-operative patients
• Underlying medical systemic conditions

23. • Padded or wrapped tongue blades
- Easy to use
- Disposable
- Very inexpensive

24. • Open wide mouth prop
- Has durable mouth foam core on the end of a
tongue
depressor
- Easy to use
- Disposable
- Slightly more expensive than wrapped tongue blade

25. • The molt mouth prop
- Use for prolonged treatment duration
- Available in both adult and child sizes
- Allow accessibility to opposite side of the mouth
- Operates on reverse scissor action
Disadvantage
- Possibility of lip and palatal lacerations
- Luxation of teeth if not use properly

26. • Rubber bite blocks (McKesson)
- Available in various sizes
- Fits on occlusal surfaces of the teeth
- Stabilizes the mouth in open position
- Should be attached for easy retrieval if they
dislodges

27. • The following are commonly used immobilization
Body
• Papoose
board
• Triangular
sheet
• Pedi-wrap
• Beanbag
dental chair
insert
• Safety belt
• Extra
assistant
Extremities
• Posey
straps
• Velcro
straps
• Towel &
tapes
• Extra
assistant
Head
• Fore-arm-
body
support
• Head
postitioner
• Plastic bowl
• Extra
assistant

31. • Simple to store and use
• Available in size
• Has attached head stabilizers and is reusable
• Does not always fits the contours of dental chair
• Sometimes supporting pillow is required
• It cover patient diaphragm, a pre-tracheal stethoscope is
necessary to monitor respiration if it used in combination
with sedation
• Requires constant attention and supervision
• Patient may develop hyperthermia if immobilized for too
long

32. • Bed sheet technique
• Used in extremely resistant child
• Allows the patient to sit upright during radiographic
examinations
• Disadvantage:
Frequent need of straps to maintain the patient’s position
in the chair
Difficult to use with small children
Possibility of airway obstruction
Hyperthermia on long periods of immobilization
Need for constant supervision

33. • Available with or without backboard
• Available in various sizes
• Allows the movement while still confining the patient
• Mesh fabric permits better ventilation
• Loosing the chance of developing hyperthermia
• Requires straps to maintain body positions in the dental
chair
• Constant supervision to prevent the patient from rolling
out of chair

34. • To accommodate hypotonic and severely spastic persons
who needs more support and less immobilization in a
dental environment
• Reusable
• Washable
• One size fits most people
• Child’s arms can be immobilized with help from the
parents or dental assistant with Posey straps or with a
towel and adhesive tape

35. • Immobilization actually
encourages relaxation and
prevents undesired reflexes by
keeping the patient’s arms in
midline of the body
• Patient’s head position-
maintained through the use of
forearm-body by the dentist
• Presence of additional assistant to
stabilize the child’s head or use of
a papoose board head positioner
or a plastic bowl ( doggie bowl) to
provide position guidance

37. • It is caused due to permanent damage to brain in the
prenatal or perinatal period during which the central
nervous system is still developing
• This disability might involve muscle weakness, stiffness,
paralysis poor balance or irregular gait and
uncoordinated or involuntary movements

38. Etiological factors:
Decreased oxygenation of the developing brain can be
responsible for brain damage
Complications of delivery
Infections of brain such as: meningitis, Encephalitis,
Toxemias of pregnancy
Congenital defects of the brain
Kernicterus
Poisoning with certain drugs and heavy metals
Accident resulting in trauma to head

39. Classification based on the involved
areas of the body:

40. • Spastic (70%)
• Dyskinetic (15%)
• Ataxia (5%)
• Mixed (10%)

41. Spastic (70%)
Hyperirritability of involved muscles
Tense contracted muscles
Limited control of neck muscles which results in head roll
Lack of control of the muscles supporting the trunk
Lack of co-ordination of intraoral, perioral and
masticatory musculature, possibility of impaired chewing
and swallowing, excessive drooling, persistent spastic
tongue thrust and speech impairment

42. Dyskinetic (15%)
Constant and uncontrolled motion of involved muscles
Succession of slow twisting or writhing involuntary
movements (athetosis) or quick jerky movements
(choreoathetosis)
Frequent involvement of neck musculature which results
in excessive movement of the head
Possibility of frequent uncontrolled jaw movements
causing abrupt closure of the jaws or severe bruxism
Frequent hypo tonicity of perioral musculature with mouth
breathing tongue protrusion and excessive drooling
Facial grimacing
Chewing and swallowing difficulties
Speech problems

43. Ataxia (5%)
Inability of involved muscles to contract completely so
that voluntary movements can be partially performed
Poor sense of balance and uncoordinated voluntary
movements
Possibility of tremors and an uncontrollable trembling on
voluntary tasks

44. Mixed (10%)
Combination of characteristics of more than one type of
cerebral palsy

45. Neonatal reflexes
• Asymmetric tonic neck reflex

46. • Tonic labyrinthine reflex

47. • Startle reflex

48. Common manifestations
Mental retardation
Seizures disorders
Sensory deficit or dysfunctions
Speech disorders
Joint contractures

49. Oral manifestations
Periodontal diseases
Dental caries
Malocclusions
Bruxism
Trauma

50. Management
• Patient who uses wheel chair consider the treatment in
wheel chair
• Ask for the mode of transfer
• Stabilize the patient’s head throughout all phase of dental
treatment
• Try to place and maintain the patient in the midline of the
dental chair with arms and legs close to the body as
feasible
• Keep the patient back slightly elevated to minimize
difficulties in swallowing

51. • Always determine the degree of comfort and assess the
position of the extremities
• Consider the use of pillows, towels for support
• Use mouth props and finger splints
• Avoid abrupt movements, noises and lights to minimize
startle reflex reactions
• Introduce intra oral stimuli slowly to avoid eliciting a gag
reflex
• Consider use of rubber dam
• Work efficiently and minimize patient time in the chair to
decrease fatigue of the involved muscles

52. DR. PRASANNAKUMARI
DEPT OF PEDODONTICS

53. Kanner’s syndrome
Early infantile autism
Infantile psychosis
Childhood schizophrenia
Autism is derived from Greek word- ‘autos’ meaning ‘self’
1st described in 1943 by Leo Kanner
Child With Autism
Autistic Child

54. “ Autism is severely incapacitating disturbance of mental and
emotional development that causes problems in learning,
communication and relating to others”
Social
interaction
Communication
Repetitive
behaviours or
restricted
Interests
DIAGNOSTIC & STASTICAL MANUAL OF MENTAL DISORDER
Mean age noted for these deviations is 17 months, for final
diagnosis is 44 months
pediatric dentistry, 1998

55. • The condition manifests in 3 years of life, difficult to diagnose, with
no known cure
• Is a neurologic disorder (DIAGNOSTIC & STASTICAL MANUAL OF MENTAL
DISORDER,APA)
“ Believed to occur due to physical disorder of the brain(the
limbic system, the cerebellum)”
• Look like normal children and have normal life span
• Incidence- approx 2-5 in 10,000 births
4 times more common in boys(1st born male)
females are more likely to have severe mental retardation
- Kopel, 1977
- pediatric dentistry, 1988, 20(5)

56. • Etiology
- Abnormality in brain structure& functions
- Lack of environment stimulation of psychological factors
- Defective metabolic processes
“Lotter postulates that the personalities, attitudes, behavior of the
child's parent contribute to the psychodynamics of autism”
Autism may be early manifestation of childhood schizophrenia

57. Nongenetic causes includes
• Prenatal rubella infection,
• Untreated metabolic disorder
such as phenylketonuria,
• Anticonvulsants taken
during pregnancy,
• 17-58% Tuberous sclerosis
complex
0.4-3% vice versa
• Post natal infection such as
encephalitis
• Fragile X syndrome in 2-5%
patient
Genetic factors
• There is high concordance
rate in monozygotic twins. A
three to five time’s higher
prevalence in males suggests
an X-linked mode of
inheritance.
• 2q, 7q, 16p and 19p.

58. • IQ score:
Approx 60% - <50
Approx 20% - between 50-70
Approx 20% - >70
Pediatric dentistry, 1998, 20(5)

59. • Extreme loneliness
• Language disturbance
• Mutism
• Parrot like repetitious speech
• Difficulty with concept of ‘yes’
• confusion in the use of personal pronouns
• Obsessive desire
• Eating disturbance
• Prefer soft foods, Sweetened food
• Mobility such as intrigue with spinning objects
• Hyperactivity

60. Poor muscle tone
Poor co-ordination
Hyperactive knee jerk
Drooling
Epilepsy(30% cases)
Strabismus
Poor tongue co-ordination
Delay in motor milestone(50%)
Exhibit an extreme resistance to being held and show tantrums,
aggressive or destructive behaviors to fearful situations

61. • Interpersonal weaknesses are evident during infancy, when the
baby does not seek the attention of the caregiver and fails to
cuddle, make direct eye contact, raise arms in anticipations of
being picked up, engage in games, Point to or show an object
such as a toy to the parent or respond to smiles or a mother's
voice
• Do not seem to recognize that other people have intentions,
desires, feelings and beliefs

62. • Mental retardation- evident in one half – two thirds of autistic
children
• Seizure disorders- manifested as they grow older
• Some common oral problems the dentist may encounter are:
- Bruxism
- Non-nutritive chewing
- Tongue thrusting
- Self-injury
- Erosion
- Xerostomia (dry mouth)
- Hypergag reflex

63. • Seen in 4-5% individuals
• A change in in daily routine may initiate or increase it
• Range from self pinching or scratching to severe self biting or
head banging
Pediatric dentistry,1998

64. • Positive reinforcement
• Special education programs
• Psychotherapy
• Family counseling
• Rewarding
• Distracting from an undesired action
• Inserting a prefabricated oral screen as a temporay physical
distraction
• Desensitisation

65. • Phenytoin therapy may lead to gingival sequel
• A patient and slow approach to approach oral cavity
• Tell show do & use of positive reinforcement & rewards –beneficial
• Immediate verbal praise after each accomplished step of a procedure & a prize at
the end of a dental session
• The oral commands should be clear, short and simple sentences
• Preoperative sedation with muscle relaxants and nitrous oxide analgesia can also
be used for treatment
• Use of papoose board or pedi wrap may be necessary
• GA in case of extensive treatment
• Long term care: increasing oral hygiene frequency & efficiency with the help of
the parents, using a topical fluoride gel or rinse daily, limiting cariogenic food,
having frequent preventive recall appointments

66. • Methylphenidate, thioridazine, diphenhydramine, phenytoin,
haloperidone, carbamazepine
• Megadoses of vitamin B
• Serotonin uptake inhibitor fluvoxamine

67. • Patients may require several visits to the dental office prior to the treatment
so as to familiarize with facility & to establish routine
• Gradual & slow exposure to dental environment with non threatening
contacts
• Before hospitalization , preadmission visits should be scheduled, with a
parent
• Surrounding setting should have soothing effect on the patient
• Well organized appointment, waiting time not to exceed10-15 min
• Light background music-beneficial
• Any participating person in procedure should reduce movements
• Discussion of any aspect of the actual work should be avoided

69. • Trisomy(95%)
• Translocation(3%)
• Mosaicism (2%)

70. Brachycephalic skull- flattened face
and occiput
Presence of 3rd fontanelle- anterior
to posterior fontanelle
Flat nasal bridges with a small
maxilla

72. Brushfield spots
Scanty eyelashes
Cataract
Squint
nystagmus

73. Dyspalstic ears
Abnormal pinna

74. Short and broad neck with excess skin
posteriorly

75. Broad and short (clinodactyly) with single
transverse palmar crease(simian crease)
Short incurved little finger
Multiple loops on finger tips

76. Hypotonicity and hyperextensibility

77. Other associated problems
• Congenital heart disease- ASD and VSD
• Duodenal atresia
• Atlanto-axial instability
• Umbilical hernia
• Multiple immunological defects
• ALL
• Hypothyroidism
• Alzheimer's disease

78. Oral manifestations
Small mouth
Open mouth
Tongue protrusive, fissured
Circumvallate papillae enlarged
Filliform absent
macroglossia

79. Lips- thick, dry, fissured

80. Anterior open bite and
cross bite
Class III tendency
Small maxilla

81. High palatal shelves
Bifid uvula
Cleft lip & palate

82. Retarded eruption
Early shedding of deciduous teeth
Hypodontia
Microdontia
Hypo-calcification, hypoplastic defects
Low incidence of caries
Severe, early onset periododntal disease

85. • Mc donald, 1983- intellectual development is significantly
lower than that of normal people and whose ability to
adapt to their environment is consequently limited.
• American academy of mental deficiency- significantly
sub-average intellectual functioning, existing concurrently
with deficit in adaptive behavior and manifested during
developmental period.

86. Mental
age
Chronological
age
100
IQ range Grade
Above 140
120-139
110-119
90-109
80-89
70-79
<69
Very superior
Superior
High average
Average
Low average
Borderline impaired
Mentally retarded

87. Prenatal influences Natal influences Postnatal influences
Maternal and fetal
infections
Kernicterus
Cretinism
Fetal alcohol syndrome
Genetic diseases
Infection
Cerebral trauma
Birth injuries
Hemorrhage
Hypoxia
Anoxia
hypoglycemia
Cerebral infections
Cerebral trauma
Poisoning
Cerebral vascular
accident
Post immunization
encephalopathy
malnutrition

88. Dental problems
• Multiple anamalies of facial structures
• Eruption time
• Sequence
• Numbers
• Malocclusion
• Enamel hypoplasia
• Higher incidence of caries and periodontal disease

89. Treatment consideration
• Familiarize the patient to dental office
• Speech- slow & simple
• Only instruction at a time
• TSD & TLC approach
• Short appointment and early (in the morning)