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Dental management of children with special health care needs
- 1. Dental management ofchildren with Special Health Care Needs Dr. Aravindhan A JR-2 Dept. of Paediatric & Preventive Dentistry 1dr.aravindhan
- 2. Introduction • Individuals withspecial health care needs (SHCN) as those with “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.” American academy of pediatric dentistry. Definition of Special Health Care Needs. 2016;40(6):18-19. 2dr.aravindhan
- 3. • Every childis unique • Totally dependent on caregivers • Some children require more attention and care- children with special care needs • WHO describes a child with special health care as who, over an appreciable period of time, 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. 3dr.aravindhan
- 4. Classification • Frank alwinters, 1974. ( 8 stages) Blind or partially sighted Deaf- (total/ partially) Educably subnormal epileptic maladjusted Physically handicapped Speech abnormality senile 4dr.aravindhan
- 5. • Agerholm’s classificationof handicap conditions: ( 1975) Intrinsic category Handicapping conditions of the child cannot be eradicated/ eliminated Cerebral palsy, mental retardation, down’s syndrome Extrinsic category Handicapping conditions can be improved with meticulous care Social deprivation 5dr.aravindhan
- 6. • Nowak classificationof special children (1976)- 9 categories: Category Example Physically handicapped Kyphosis, scoliosis, poliomyelitis Mentally handicapped Down’s syndrome, cerebral palsy, mental retardation Congenital defects Cardiac anomaly, cleft palate Convulsive disorder Epilepsy Communication disorder Sensory handicap ( deafness, blindness) Systemic disorders Hemophilia, hyperthyroidism Metabolic disorders Juvenile diabetes Osseous disorders Ricketts , osteogenesis imperfecta Malignant disorders Rhabdomyosarcoma 6dr.aravindhan
- 7. accessibility First dental visit Radiographic examination Preventive dentistry Diet and nutrition Homedental care Fluoride exposure 7dr.aravindhan Factors considered in management of children with SHCN
- 8. • Improving accessto oral health care for those deprived of needed services should be of great concern to the dental profession. • Children with SHCN, such as those who are chronically ill, homebound, and have developmental disabilities and emotional impairments, fall into large segments of the population who do not have access to dental care. Accessibility 8dr.aravindhan
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- 11. Accessible dental operatorydesign 11dr.aravindhan
- 12.
- 13. First dental visit •Establishment of “ dental home ” • Role of the dental auxillaries. • Initial examination. • Management of parental anxieties. • Informed consent 13dr.aravindhan
- 14. AAPD recognizes adental home should provide • Comprehensive, continuous, accessible, family- centered, coordinated, compassionate, and culturally- effective care for children. • Comprehensive evidence-based oral health care including acute care and preventive services . • Comprehensive assessment for oral diseases and conditions. • Individualized preventive dental health program based upon a caries risk assessment and a periodontal disease risk assessment. • Anticipatory guidance regarding growth and development. 14dr.aravindhan
- 15. • Information aboutproper care of the child’s teeth and gingiva, and other oral structures. • This would include the prevention, diagnosis, and treatment of disease of the supporting and surrounding tissues and the maintenance of health, function, and esthetics of those structures and tissues. • Dietary counselling. • Referral, at an age determined by patient, parent, and pediatric dentist, to a dentist knowledgeable and comfortable with managing adult oral health care needs. 15dr.aravindhan
- 16. Initial examination • Mayrequire physical restraints • Proper history taking is needed. • Early morning appointment should be given for special children. • Informed consent should be obtained from caregivers. 16dr.aravindhan
- 17. Radiographic examination • Assistancefrom the parent and dental auxiliaries. • The use of immobilization devices may be necessary to obtain the films. • Better cooperation may be elicited from some children by delaying radiographs until the second visit. 17dr.aravindhan
- 18. • If radiographsof diagnostic quality are unobtainable, the dentist should confer with the parent to determine appropriate management techniques (e.g., preventive/restorative interventions, advanced behaviour guidance modalities, deferral, referral), • Giving consideration to the relative risks and benefits of the various treatment options for the patient. 18dr.aravindhan
- 19. • For patientswith limited ability to control film position, intraoral films with bitewing tabs are used for all bitewing and periapical radiographs. • 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 falls toward the pharynx. American Academy Pediatric Dentistry. Oral health policy on dental radiographs in children including those with SHCN . Pediatr Dent 2017;40(6):18. 19dr.aravindhan
- 20. • Hardwired digitalsensors have reduced this risk, although they may be difficult to tolerate by the patient. • The patient should wear a lead apron with a thyroid shield • Operator who helps hold the patient and the film or sensor steady should wear a lead-lined apron and gloves. 20dr.aravindhan
- 21. Preventive dentistry • Pitand fissure sealant application • Mouth guard fabrication • Oral prophylaxis • Interim restoration • Fluoride releasing restoration • Anticipatory guidance about trauma 21dr.aravindhan
- 22. Home dental care •Home dental care should begin in infancy; the dentist should teach the parents to gently cleanse the incisors daily with a soft cloth or an infant toothbrush. • The dentist should teach the parent or guardian to clean teeth twice a day using correct tooth brushing techniques. 22dr.aravindhan
- 23. • Dental educationof parents/ guardians/ caregivers is important to ensure that children with SHCN do not jeopardize their overall health by neglecting their oral health. • Horizontal scrub method of brushing is ideal for children with special health care needs23dr.aravindhan
- 24. Electronic tooth brush/ suction tooth brush Suction toothbrush Useful in children with mental retardation and cerebral palsy 24dr.aravindhan
- 25. Tooth brushing position •1. The standing or sitting child is placed in front of the adult so that the adult can cradle the child’s head with one hand while using the other hand to brush the teeth. • 2. The child reclines on a sofa or bed with the head angled backward on the parent’s lap. Again, the child’s head is stabilized with one hand while the teeth are brushed with the other hand. The parents face each other with their knees touching. 25dr.aravindhan
- 26. • 3. Theextremely difficult patient is isolated in an open area and reclined in the brusher’s lap. The patient is then immobilized by an extra attendant while the brusher institutes proper oral care. • 4. The standing and resistive child is placed in front of the caregiver so that the adult can wrap his or her legs around the child to support the torso while using the hands to support the head and brush the teeth. 26dr.aravindhan
- 27. Diet and nutrition •Proper assessment of the diet. • Dietary modifications are made. • Proper consultation with the patient’s primary physician or dietician. • Non cariogenic diet is emphasized. • Caries risk assessment • Early intervention and aggressive preventive care based on the child’s caries risk. 27dr.aravindhan
- 28. condition diet Difficulty inswallowing Eg. Cerebral palsy Pureed diet Autism Feingold diet Epileptic patients Ketogenic diet Metabolic disturbances Eg. Phenyl ketonuria Juvenile diabetes Restriction of specific foods. 28dr.aravindhan
- 29. Fluoride exposure • Topicalfluoride therapy • Fluoridated tooth paste • Mouth rinse with fluoride 29dr.aravindhan
- 30. Recommendations • Whether thepatient lives in an area with a fluoridated or non-fluoridated water supply, a topical fluoride should be applied after a regularly scheduled professional prophylaxis. • Dentifrice containing a therapeutic fluoride compound should also be used daily. • chronically poor oral hygiene and high decay rates a daily regimen of rinsing with 0.05% sodium fluoride solution is recommended. 30dr.aravindhan
- 31. • Nightly applicationof a 0.4% stannous fluoride or 1.1% sodium fluoride brush-on gel has also been successfully used to decrease caries in children. • SDF application in severe caries risk patients 31dr.aravindhan
- 32. Recall of SHCNchildren • Close observation of caries-susceptible patients and regular dental examinations are important in the treatment of patients with SHCN • Although most patients are seen semi- annually for professional prophylaxis, examination, and topical fluoride application, certain patients can benefit from recall examinations every 3, or 4 months. 32dr.aravindhan
- 33. Physical restraints • Neededfor the patient with extreme motion of extremities who is not a candidate for GA 1. Molt mouth prop 2. Rubber bite blocks ( McKesson mouth prop) 3. Finger guard/ inter occlusal thimble 4. Body : papoose board, pedi wrap triangular sheet ( mink’s) 5. Extremities: posey straps velcro straps 6. Head : head positioner plastic bowl 33dr.aravindhan
- 34. Cerebral palsy headsupport 34dr.aravindhan
- 35. Children with SHCN (for the description purpose) • Paediatric dentistry for special child - priya verma gupta Intellectually challenged Learning disabilities Genetically challenged Medically challenged Physically challenged Emotionally challenged 1.Mental retardation 2.Cerebral palsy 3.Epilepsy 4.Autism 1.Hearing impairments 2.Visual impairments 3.Speech impairments 1.Cardiovascular disorders 2.Respiratory disorders 3.Liver disorders 4.Hematological disorders 5.Endocrine/ metabolic disorders 6.Pediatric HIV infection 1.Cleft lip and palate 2. Down syndrome 3. Klinefelter syndrome 4. Treacher collins syndrome 5.Apert syndrome 6. Crouzon syndrome 1.Child abuse and neglect 1.ADHD 2.Dyslexia 7. Ectodermal dysplasia 35dr.aravindhan
- 36. Mental retardation • Canbe defined by a collection of symptoms, traits or characteristics. • Sheerenberger (1983) classifies that disability of brain and mind occurs due to brain damage. • Difficult to differentiate between developmental delay if there is no brain injury. Three levels of impairment: 1 .idiot : development arrested at 2 yrs of age 2. imbecile: development equal to 2-7 yrs old 3. moron : development equal to 7-12 yrs old. 36dr.aravindhan
- 37. Classification • Educable category •IQ: 55-70 • 85% of mental retardation individuals mild • Trainable category • IQ: 40- 55 • 10 % of individuals moderate • Lower functioning level • IQ: 25- 40 • Fully dependent on caretakers for basic needs severe 37dr.aravindhan
- 38. • IQ :less than 25 • Mental age: below 2 yrs • 1- 2% of individuals profound • Some children it is difficult to classify the MR • Due to very young age and un cooperation • Developmental delay is considered than MR Unspecified severity According to origin Syndromic Non syndromic 38dr.aravindhan
- 39. Clinical consideration- general •MR with downs syndrome patients have OSA • Aspiration and subsequent lung disease • Difficulty in swallowing which may lead to malnutrition and poor hydration • Seizures ( more prone) • Poor pain responders • Neuromuscular scoliosis 39dr.aravindhan
- 40. Oral manifestations- MR •Early childhood caries as the medication is given in syrup form for those patients. ( multifactorial- drug side effects like xerostomia, tooth cleaning neglect) • Trauma which may lead to fractured upper front tooth, non vital tooth • Early loss of tooth and subsequent malocclusion • Poor oral hygiene- periodontal diseases • Self inflicted habits. 40dr.aravindhan
- 41. Dental management General consideration • Mentalage • Need of Antibiotic prophylaxis • Accessibility issues • Drug interactions • consent Patient assessment • Mental competency • Co operation level • Possible use of anaesthesia Behaviour management • Desensitisation • Restraints • Oral sedation • GA 41dr.aravindhan
- 42. • Periodontal: 1. oralprophylaxis in every 3 months 2.proper oral hygiene instructions to caregivers 3. may need gingivectomy ( drug induced enlargement)- electrosurgery/ laser preferred. 4. mouthrinse is not advisable. Sprays can be prescribed. 5. electronic tooth brushes usage • Restoration and endodontic management: 1. orthopantomogram is ideal for baseline diagnosis 2. single visit pulp therapy is advisable 3. GIC restoration for caries than composite 4. SS crown for multisurface caries mangement 5. apex locators than radiographs 42dr.aravindhan
- 43. Traumatic injuries: • 1.managed as usual • 2. sedation is needed in some situations • 3. child abuse should be kept in mind during diagnosis. 43dr.aravindhan
- 44. Cerebral palsy • Cerebralpalsy is non progressive disorder of the development of movement and posture, causing activity limitations that are attributed to non progressive disturbances that occurred in the developing fetal or infant brains. ( American academy of cerbral palsy and developmental medicine) Epidemiology: 2- 2.5 cases/ 1000 live births Etiology: prenatal perinatal post natal prematurity 44dr.aravindhan
- 45. Classification Degree of affected areas •mild • Moderate • Severe • No CP Topography • Monoplegia • Diplegia • Hemiplegia • Triplegia • Quadriplegia • Tetraplegia • paraplegia Modified swedish classification • Spastic -hemiplegia -quadriplegia -diplegia • Ataxic -diplegia -simple (congenital) • Dyskinetic -choreoathetotic -dystonic 45dr.aravindhan
- 46.
- 47. Clinical considerations- general •Oral aversion • Drooling • GERD • Constipation • Dysphagia ( in some patients) • Urinary tract infections ( highly frequent) 47dr.aravindhan
- 48. Oral manifestations • SpasticCP: hypertonicity of tongue, tongue thrusting, cigar shaped tongue, flared anteriors, hypotonic upper lip • Athetoid CP: hyperactive tongue showing wave like motions, TMJ dislocation is more common. • Hypotonic CP: Tensely reclined head, flat large protruded tongue, weak facial musculature, inactive upper lip 48dr.aravindhan
- 49. Other findings: 1. rumination( rechewing already ingested food) 2. pica ( crave for non edible items) 3. pouching ( placing food in between cheek and teeth- increases caries risk) Dental management: • Similar to MR patients • Management of self inflicted habits • Bruxism – soft splint/ mouth guard fabrication 49dr.aravindhan
- 50. Epilepsy • Epilambanein- greekword • Definition: ( international league against epilepsy) - “neurological disease and only applied in case of 2 unprovoked seizure more than 24 hours apart or one unprovoked seizure along with probability of another one after 2 unprovoked seizures over a period of next 10 years”. Non epileptic: - no seizure for 10 years - No medication for 5 years 50dr.aravindhan
- 51. Etiology • 1. idiopathic •2. traumatic • 3. infections • 4. progressive ( underlying cranial abnormalities) Classification: 1. localised 2. generalised Based on seizure type: 1. generalised (absence, myoclonic, clonic, tonic, atonic, tonic-clonic) 2. focal 3. unknown ( epileptic spasm) 51dr.aravindhan
- 52. Generalised seizure-Clinical presentation •4-14 yrs of age •Lasts over 10- 25 seconds •May occur many times a day Absence seizure •Brief contraction of muscles occur due to cortical discharge •Without loss of consciousness •More common is juvenile myoclonic epilepsy Myoclonic seizure •Seen in patients with neurological disease •Seizure triggered when there postural loss •Less severe ( simple twitch, head nodding) Atonic seizure • Bilateral clonic jerking will be there Clonic seizure • Muscle contraction of large parts with loss of consciousness • Lasts for less than a minute with apnoea • Tonic- clonic seizure is referred as grand mal epilepsy • Post ictal phase is present and marked Tonic seizures 52dr.aravindhan
- 53. Pediatric variants ofgen. seizures • 6 months – 5 yrs of age • Accompanied With fever ( no cranial abnormalities) • Viral fever, Chicken pox, neonatal ICU patients (> 28 days) Febrile seizures (AAP,2008) • Present in neonatal period • May be occur up to 44 weeks of age • LBW / preterm babies. ( possible cranial damage) Neonatal seizures 53dr.aravindhan
- 54. Oral manifestations • Selfinjury to jaw / tooth structures due to seizure • Erythematous gingiva • Gingival overgrowth ( drug induced) • Mal occlusion • Poor oral hygiene 54dr.aravindhan
- 55. Dental management Factors toBe Taken into Consideration While Administering Treatment : • The frequency of seizures; • The date of the patient’s last seizure; • The consciousness and respiratory state of the patient during seizures; • The physical condition of the patient after a seizure; • Whether there is any aura before seizures; • Whether experiencing an aura always leads to a seizure; • The factors provoking seizures • The existence of status epilepticus. 55dr.aravindhan
- 56. General considerations • Morningappointment • Proper behaviour management as the stress may provoke seizure • Extreme noise, bright light should be avoided • Treatment must be postponed if last seizure attack occurred within one month (even if they are under medication) • During dental treatment, it has been suggested that seizure development can be controlled by sedation through nitrous oxide inhalation or intravenous benzodiazepine sedation. • GA is the ideal option for treating epileptic patients 56dr.aravindhan
- 57. • Mouth guardfor prevention of seizure induced trauma. • gingival hyperplasia caused by phenytoin should be controlled by preventing the formation of plaque . • plaque removal would be ineffective unless hyperplastic tissue is properly removed during gingivectomy. • Change the medication if gum hyperplasia recur • protective methods such as the use of chlorohexidine and fluoride, education regarding oral hygiene, regular dental checkups, and educating children to avoid sugary foods and drinks are crucially important. 57dr.aravindhan
- 58. • Restorative precedureshould be done under rubber dam (with floss secured files/ rubber dam clamp) • Removable prosthetic/ orthodontic appliance is contraindicated. Management of epileptic attack in dental clinic: • Treatment should be stopped • Remove if any object is in mouth • Place the patient supine position and turn to one side. • Lift the chin • Any tight clothing the patient is wearing should be loosened • If the seizure lasts more than 3 minutes and recurs, drug administration is required. • Buccal/ Intranasal midazolam (0.3 mg/kg) or intravenous diazepam (0.5 mg/kg) / midazolam (0.25 mg/kg) • Call for medical help 58dr.aravindhan
- 59. Autism • Leo kanner“ a neurological disease that occurs in first 3 years of life” “ a developmental disorder causing disturbance of behavioral development due to multiple reasons and differernt levels of severity” • ASD ( Autism Spectrum Disorder) Aspergers syndrome Rett’s disorder Autistic disorder Pervasive developmental disoder Childhood disintegrated disorder 59dr.aravindhan
- 60. Theories Pathological parenting Withdrawl of child from environment Developmentof autism Emotionless mother Parental rejection when active development of child behaviour Development of autism Deficiency state of mind Failure to read what others think Social deficiency and autism Psycho dynamic theory Refridgerator mother theory Theory of mind 60dr.aravindhan
- 61. Complicated cognitive behaviour Executive function( organised motor co ordination) Any interruption leads to dysfunction of executive function Inability to contest in sequential manner/ cannot think wider Poor understanding capacity Poor context processing Theory of executive dysfunction Weak central coherence theory Kanner’s theory: biologically based defects are responsible for autism Cognitive complexities and control theory: combination of all the above said theories 61dr.aravindhan
- 62. • Incidence: 1in 1000 • Male -female ratio . 3.5 : 1 • Etiology: 1. genetic 2. prenatal 3. postnatal 4. environmental Repititive and sterotype behavior Communi cation and language deficits Diagnostic alogarithm Social deficits 62dr.aravindhan
- 63. Clinical features • Socialdeficits • Failure to respond properly • Lack of eye contact • Delayed speech • Preference of isolation • Unable to empathize with other • Repetitive speech • Mood fluctuations • Abnormal motor behaviour • Self injurious behaviour • Mental retardation in 70% autistic child • Positive qualities: Truthful, kind, straight forward, high pain threshold 63dr.aravindhan
- 64. Oral manifestations • Dentalcaries • Poor oral hygiene • Bruxism • Erosion due to regurgitation • Tongue thrusting, non nutritive chewing • Self injurious behaviour • Prevalence of anterior open bite • Delayed Tooth eruptions 64dr.aravindhan
- 65. Dental management Preventive protocol: •Diet counselling • Fluoridated tooth paste twice daily • Frequent intake of water • Usage of mouthguard Management: - Behavioural assessment and make the child familiar with dental clinic - Use behavioral shaping techniques - Use of physical restraints - Go for GA in very un co operative patients 65dr.aravindhan
- 66. Physically challenged • Hearingimpairment •Visual impairment •Speech impairment 66dr.aravindhan
- 67. Hearing impairment • Hearingimpairment is clinical condition in which individual is unable to detect or perceive the sound frequencies in full/ partial capacity that can be otherwise heard by people in surrounding. Classification: According to type: 1.conductive ( obstruction to the flow of sound from the environment to the inner ear) 2.sensorineural ( reduced auditory threshold sensitivity/dysfunction located in inner ear/ auditory nerve/ CNS auditory systems) 3.mixed ( combination) 67dr.aravindhan
- 68. • According tothe age of onset: 1. prelingual hearing loss 2. post lingual hearing loss • According to severity ( WHO) impairment Audible dB level No impairment 25 dB or less Slight impairment 26 – 40 dB Moderate impairment 41 -60 dB Severe impairment 61- 80 dB Profound impairment 81 dB or more 68dr.aravindhan
- 69. Etiology • Genetic :usher syndrome, pendred syndrome • Age: • Disease: measles, mumps, adenoids, chlamydia infection ( common in children), congenital syphilis, fetal alcohol syndrome • Drug induced: aminoglycoside, macrolide antibiotics. Diuretics , chemotherapeutic agents. • Noise induced • Trauma • Oto-toxic chemicals: heavy metal toxicity, pesticides. 69dr.aravindhan
- 70. Clinical features (general) Oral manifestations Hearing with or without speech impairment Mouth breathing Lack of social and emotional development xerostomia Lack of learning Increased prevalence of dental caries Low self esteem Increased risk of periodontal infection Communication methods: 1. hand signs 2. lip reading Dental considerations: 1. Gain trust with the child through commuunication 2. do all the behavioral modification technique 3. Early morning appointment 4. Avoid long appointments 5. Emphasize on preventive strategies 6. Avoid aspirin/ macrolide antibiotics 70dr.aravindhan
- 71. Visual impairment • Defn: “ the functional limitation of the eye due to disorder or disease resulting in visual handicap”. • Classification: (WHO) 1. low vision: a. moderate visual impairment b. severe visual impairment 2. blindness: a. profound visual impairment b. near total visual impairment c. total visual impairment 71dr.aravindhan
- 72. • Etiology : -albinism- moebius syndrome -cataract - retinoblastoma -CMV retinitis - traumatic brain injury -glaucoma - diabetic retinopathy Oral manifestations: -no direct influence in oral cavity -poor self care leads to poor oral hygiene and related diseases - xerostomia 72dr.aravindhan
- 73. Management • Establishing communication: -Know the prefered way of communication of patient - Instruct slowly - Braille method is useful - Avoid strong lighting - Do all the behavior shaping methods once the communication is gained - Use audio analgesIa 73dr.aravindhan
- 74. Speech impairments • Definition: “an impairment of speech or sound production , fluency, voice or language which significantly affects a child’s educational performance or social , emotional or vocational development”. 74dr.aravindhan
- 75. Etiology: • Functional : -environment - psychological development - habit • Organic ( structural variance): a. primary organic voice disorder - asymmetry of vocal fold -neuromotor disorders -trauma / pathologies of vocal fold b. secondary organic voice disorder -mucosal irritation - recurrent laryngitis -chronic hyperplastic laryngitis Determinants of speech: 1. Vocal folds 2. Velum and the tongue 3. Tongue and palate 4. Lips and teeth 75dr.aravindhan
- 76. Dental associated speechdefects: 1. Cleft lip and palate 2. Rampant caries 3. Ankyloglossia 4. Open bite 5. Severe proclination of upper anteriors 6. Class 3 malocclusion 7. Abnormal oral habits 76dr.aravindhan
- 77. Management • Assess thelevel of impairment and analyse whether it is impairment or delayed milestone • Consult with speech therpaist • Make use of non verbal communication • pen, pencil, notebook should be handy for the child to convey the doubts • Do necessary behaviour shaping methods • Treatment of potential malocclusion • Release of ankyloglossia (if present) 77dr.aravindhan
- 78. Medically challenged • Thereare many medical conditions that can directly affect the provision of dental care and some where the consequences of dental disease, or even dental treatment, can be life threatening. • The definition of a “medically compromised” patient is not precise and in this context, it is interpreted as the presence of a medical factor which may have implications for the provision of dental care. 78dr.aravindhan
- 79. Cardiovascular diseases • Types –Congenital •ventricular septal defects, atrial septal defects, pulmonary stenosis, patent ductus arteriosus, tetralogy of Fallot, –Acquired • Rheumatic fever, diseases of the myocardium and pericardium, secondary hypertension 79dr.aravindhan
- 80. Dental management ofcardiovascular disorders • Prevent dental disease: OHI, diet counselling, fluoride therapy, fissure sealants • Any active dental disease must be treated before cardiac surgery. • Never give N2O inhalation sedation to the patients with cyanotic congenital heart disease 80dr.aravindhan
- 81. • Antibiotic prophylaxisgiven before invasive operative procedures • Ideally short appointments in children for maximal cooperation • Check patient’s platelet count and prothrombin time before tooth extraction. • No child with symptomatic cardiac problems should have any routine dental procedures until details of the condition have been obtained and the patient’s physician consulted. 81dr.aravindhan
- 82. • Prefer Endodontictreatment only for teeth with high probability of success like: –Permanent incisors –Straight canals –Closed apices –Single visit • Antibiotic prophylaxis for indicated children. 82dr.aravindhan
- 83.
- 84. Dental procedures needIE prophylaxis 84dr.aravindhan
- 85.
- 86.
- 87. Blood disorders 1.Bleeding disorders a.Hemophilia b.Von Willebrand’s disease c.Thrombocytopenia 2.Blood dyscrasias a. RBC disorders Anemia -Iron deficiency anemia, Glucose 6- Phosphate dehydrogenase deficiency, Sickle cell anemia,Thalassemia b. WBC disorders Leukemia ( AML, ALL, CML, CLL) 87dr.aravindhan
- 88.
- 89. Dental management ofbleeding disorders • Communicate with haematologist • Find out the diagnosis/aetiology • NSAIDS alter platelet function and should not be used. • Acceptable analgesics For acute pain – Acetaminophen, Propoxyphene hydrochloride For severe pain – Narcotics – heroin, morphine, hydroxycodone 89dr.aravindhan
- 90. • Care takenwhile placing intraoral xrays • Local anaesthesia infiltrations or intraligamentous injections unlikely to cause problems if given carefully • Regional anaesthesia (mandibular block) contraindicated as bleeding in pterygomandibular region may cause asphyxia • Rubber band extraction 90dr.aravindhan
- 91. Pre op (Rootstumps) After exfoliation by rubber band Immediate post op • Mean time of exfoliation after rubber band application is 5.8 weeks 91dr.aravindhan
- 92. • Pulp therapypreferred to extractions • Dental extractions or surgery best managed in hospital setting (use resorbable sutures if needed) • Antifibrinolytics – (e-aminocaproic acid, tranexamic acid) • Used as adjuvant to the factor concentrate replacement to prevent or control oral bleeding. 92dr.aravindhan
- 93. • High speedvacuum and saliva ejectors used with caution so that sublingual hematomas don’t occur. • Periphery wax used on impression tray • Orthodontic treatment possible- be careful wires don’t lacerate mucosa Hygoformic suction tip93dr.aravindhan
- 94.
- 95. Dental management ofleukemia • Tendency to bleed after invasive dental procedures • Tests to be taken- Hb, Hematocrit, WBC, Platelet cell count • Prevent dental caries as these children at high risk because of difficulty in taking care of oral health due to mucositis. • Preventive measures: –Oral surveillance –Topical fluoride therapy, toothbrushing information –Chlorhexidine mouthwash 0.12% –Nystatin 500,000units ‘swish and swallow –Diet control –Relieve mucositis 95dr.aravindhan
- 96. • All activedental foci of infection should be eliminated before chemotherapy • Unless dental emergency, no operative dental treatment carried out until child in remission 96dr.aravindhan
- 97. • Once theleukemia is in remission, and after consulting child’s physician, routine dental care can be undertaken with following protocol: 1. Hematological information required to assess bleeding risks 2. Prophylactic antibiotics incase of depressed neutrophil count. 3. Fungal infections treated with amphotericin B, nystatin, or fluconazole and herpetic infections with topical and/or systemic acyclovir 4. Regional block anaesthesia contraindicated 97dr.aravindhan
- 98. Respiratory disorders • Asthma •Cystic fibrosis 98dr.aravindhan
- 99. Dental management ofasthma • Dental treatment can cause emotional stress and subsequent asthmatic attack • Child may take puff of their inhaler before starting dental treatment • Use analgesics and sedatives with caution; opioids and sedatives decrease respiratory drive. • Recently a study has been published linking dental erosion with asthma. - Could be due to GERD in asthmatics - Or acidic long term medication - Or to increased consumption of erosive beverages due to ‘drying’ of oral mucosa by inhalers 99dr.aravindhan
- 100.
- 101. Dental management ofcystic fibrosis • These children suffer from delayed dental development, more commonly have enamel opacities and are more prone to calculus • They need to have higher caloric intake and may have frequent refined carbohydrate snacks – important priority group for dental health education and care 101dr.aravindhan
- 102. • May alsohave cirrhosis of liver -> clotting defects -> haemorrhaging , following surgical procedures • May be prescribed tetracycline to prevent chest infections -> intrinsic dental staining • General anaesthesia should be avoided. (Decreased respiratory minute volume) 102dr.aravindhan
- 103. Endocrine and metabolic disorders •Diabetes mellitus • Adrenal insufficiency • Thyroid disease 103dr.aravindhan
- 104.
- 105. Dental management ofdiabetes • Preventive care • Uncontrolled -> Increased glucose concentrations in saliva, decreased salivary flow -> dental caries • Periodontal problems and susceptibility to infections (Candida sp) • Dental appointments arranged at times when blood sugar levels well controlled; morning immediately after their insulin injection and a normal breakfast 105dr.aravindhan
- 106. • Very unco-operative children may need GA/ sedation. And those patients face problem of hypoglycemia due to NPO guidelines. • So glucose level and insulin is managed via I/V line before treatment under GA. 106dr.aravindhan
- 107.
- 108. Dental management ofadrenal insufficiency • In children, the risks of taking corticosteroids are greater than in adults and should only be used when specifically indicated, in minimal dosage and for the shortest time possible. • If child has adrenal insufficiency or on steroids, any infection or stress may lead to adrenal crisis. That time the oral steroid dose should be increased. • GA should be given under utmost caution as there is tendency to develop hypotension. 108dr.aravindhan
- 109.
- 110. Dental management ofliver disorders • Preventive measures • Strict cross-infection control • Consult patient’s physician to establish a safe and adequate treatment plan • If invasive procedures to be done then prior coagulation, antibiotic prophylaxis and hemostasis tests required • Be cautious when administering drugs. • Do not administer general anaesthesia 110dr.aravindhan
- 111. Renal disorders • Chronickidney failure is common in children due to developmental abnormalities. • Other disorders: nephrotic syndrome, acute glomerular nephritis, drug induced renal tubular injury. • Dental features: 1. pale oral mucosa 2. salivary composition alteration 3. xerostomaia and dental caries 4. increased calculus formation dr.aravindhan 111
- 112. Dental consideration • Cautionwith prescribing drugs as may worsen kidney disease. • LA should be given cautiously • Avoid NSAID ( specifically ibuprofen, diclofenac, indomethacin, naproxen, aspirin), unless patient is under dialysis • INR should be assessed for patient under dialysis as they are under anticoagulants. • Prefer paracetamol and opioids . dr.aravindhan 112
- 113. • Alfentanil isideal opioid drug for renal failure patients. • Don’t prescribe opioids ,if the GFR < 30 ml/ min • Midazolam accumulate in renal tubules. Should be avoided in sedation procedures. • N20 is given with caution. (may cause homocysteinemia and endothelial injury at prolonged usage) • Dose reduction is needed (20% atleast ) and dose interval should be increased for antibiotics. • Benzyl penicillin found safe. And Cefepime is strictly contra indicated. ( American kidney foundation, 2015) dr.aravindhan 113
- 114. Paediatric HIV infection •Most commonly due to vertical transmission T and B cell appears in the developing fetus at 10 weeks I.U HIV can be acquired at earlier stage Immature immune system leads to severe infection and usually child dies in first decade of life 114dr.aravindhan
- 115. Mode of transmissionto child Vertical transmission (20% - 35%) Pre natal Peri natal Post natal As early as 9- 11 weeks I.U •During delivery •Cervical secretions and ruptured membranes are source of infection •Through breast feeding.(21%) •HIV is present in high titer in colustrum 115dr.aravindhan
- 116. • Other modesof spread in children: 1. Needle sharing (iatrogenic) 2. Blood transfusion ( thalassemia, hemophiliac) 3. Sexual abuse • Risk factors: 1. Maternal viral load 2. Neutralising antibodies in mother 3. Mode of delivery ( duration of contact with maternal blood) 116dr.aravindhan
- 117. Clinical manifestations ofpediatric HIV infection General features Oral features Recurrent fever candidiasis Failure to thrive Oral hairy leukoplakia parotitis Herpes infection anorexia ANUG/ NUP cardiomyopathy Gingivitis (LGE), periodontitis Progressive encephalopathy Kaposi sarcoma Opportunistic fungal/ bacterial / viral infections. Recurrent apthous stomatitis Persistent lymphadenopathy Salivary gland dysfunction Saliva and HIV: less chance of transmission presence of SLPI ( salivary leukocyte proteinase inhibitor) infectious virions present less than 5% in saliva less transmission via aerosol. 117dr.aravindhan
- 118. Dental management • Properinfection control • Prior routine blood investigations and viral load titre in patient • Pre procedural mouth rinse (preferably hydrogen peroxide) • Conservative management of lesions. 118dr.aravindhan
- 119. • Routine preventive strategiesand oral hygiene instructions should be given as usual • Antibiotic prophylaxis for the patients with CD4+ count less than 400/mm3. • LA block should not be given • Scaling and periodontal therapy is indicated only when the CD4+ count is more than 500/ mm3 119dr.aravindhan
- 120. Learning disabilities ADHD (attentiondeficit hyperactivity disorder): Defn: “ a family of related chronic neurobiological disorders that interfere with an individual’s capacity to regulate activity level (hyperactivity), inhibit behaviour (impulsivity), attend to tasks ( inattention) in developmentally appropriate ways” 1918-1919: influenza pandemic left the survivors with similar kind of hyperactivity disorder and brain damage 1966: researchers changed the term from minimal brain damage to minimal brain dysfunction 120dr.aravindhan
- 121. Subtypes: ( AmericanPsychiatric Association-1994) 1. Predominantly hyperactive impulsive: 2. Predominanly inattentive 3. Combined hyperactive impulsive and inattentive ( most common). Prevalence: male : female= 3: 1 2- 20% prevalence in school children Etiology : • Still unknown • Some hypothesis on abnormal brain function of genetic origin is documented • “ADHD is due to brain’s inability of producing dopamine itself”- US Brookman national laboratory 121dr.aravindhan
- 122. Clinical features (general) Oral manifestations Inattention and restlessness High incidence Oro facial trauma Short attention span Dento alveolar fractures Social isolation Poor oral hygiene Poor memory power Less salivary secretion than normal Cognitive development is affected Caries in both primary and permanent dentition Be in constant motion, talk too much Dental management: •Early morning appointment •Discontinuing the dose of stimulant drug ( amphetamine/ bupropion) •First , try for behaviour modification and establish communication 122dr.aravindhan
- 123. • GA isbetter in extremely un co-operative children rather than conscious sedation. • Never use LA with levonordefrin in ADHD patients as they may be under treatment of TCA ( proper history is mandatory) • Maximum dose of adrenaline will be 40 mcg per child with ADHD. Excess adrenaline dosage may precipitate cardiac arrhythmia. • Salivary substitute can be prescribed. 123dr.aravindhan
- 124. Dyslexia • is aspecific reading disability that literally means inadequate of verbal language. • Definition: (2008) “ dyslexia is a spectrum of specific learning difficulties and is evident when accurate and/ or fluent reading and writing skills , particularly phonological awareness, develop incompletely or with great difficulty” Types: a. developmental dyslexia b. acquired dyslexia (stroke / neurological damage) - visual dyslexia - auditory dyslexia - mixed dyslexia 124dr.aravindhan
- 125. Clinical features • IQlevel is in normal range • Errors in reading • Reads slowly and loss of orientation • Unable to spell the word correctly • Poor memory retention • Distortion of text even when copying • Cannot write properly ( directional confusion) • Speech and language delay • Highly creative • Social isolation and stress Pathophysiology: •Distruptions in the left hemisphere posterior reading system mainly in the left temporoparietal occipital brain region •Along with increased action of frontal region125dr.aravindhan
- 126. • As dyslexiais a learning disability and therefore child is trainable for executing basic routine exercises. • Nail biting and notching in central incisor is common in dyslexic children. Dental management: • Children are more attentive , so not much behavioral modification is needed. • Oral hygiene instructions such as flossing and brushing should be taught regularly as they have poor memory retention 126dr.aravindhan
- 127.
- 128. References • Textbook ofPediatric dentistry- 4th edition. Nikhil marwah. • Pediatric dentistry for special child- 1st edition. priya verma gupta. • Illustrated Pediatric dentistry- 1st edition. chockalingam. • Paediatric Dentistry- 3rd Edition, by Richard Welbury and Monty Duggal. • Atraumatic Teeth Extraction in Bisphosphonate-Treated Patients- Eran Regev et al., JOMFS , 2008. • Management of Epileptic Patients in Dentistry- mehmet et al., JO Surgical Science, 2012. • Guidelines for the management of special children – AAPD, 2015. 128dr.aravindhan
- 129. Questions • 1. Nowakclassification of special children has how many categories? A. 8 B. 7 C. 9 D.10 • 2. which of the following diet is ideal for epileptic children A. feingold diet B. pureed diet C. ketogenic diet D. fatty diet 129dr.aravindhan
- 130. • 3. mostcommon seizure type in epileptic children A. Generalised tonic clonic seizure B. febrile seizure C. absence seizure D. myoclonic seizure • 4. NOIS or GA is contra indicated in which group of children A. cerebral palsy B. epileptic C. cystic fibrosis D. congenital heat disease 130dr.aravindhan
- 131. • 5. HIVcan be transmitted to developing fetus as early as ( IU life) A. 9- 11 weeks B. 16 weeks C. 27 weeks D. 32 weeks 131dr.aravindhan