Children with disabilities and special health care needs present unique challenges for dental care. They often experience poorer oral health than others due to limited access to care, difficulties with home care, and disability-related factors. Providing care requires special preparation and modifications including protective stabilization, treatment plan alterations, desensitization to dental equipment, and management of anxiety. Common conditions discussed that impact oral health are intellectual disabilities, Down syndrome, autism, and fetal alcohol spectrum disorder.

1. Special children
Handicapping conditions
By Dr. Rena Ephraim

2. World Health Organization [WHO]
A handicapped person as 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.
Children with disabilities have poorer oral health than
their nondisabled counterparts.
Variable access to dental care, inadequate oral hygiene
and disability-related factors are the causes.

3. • Home dental care in general for physically
disabled child
• Diet and nutrition
• Fluoride exposure
• Preventive restorations
• Regular professional supervision

4. General considerations in the
management of a child with special
health care needs
• Protective stabilization
• Treatment plan modification
• Mental retardation
• Hyperactivity
• Learning disabilities
• Down syndrome (trisomy 21)
• Fragile x syndrome
• Foetal alcohol spectrum disorder

5. • Children with special health care need-
present challenges that require special
preparation before the dentist and office staff
can provide acceptable care.
• Parental anxiety concerning the problems
associated with SHCN frequently delays dental
care until significant oral disease developed

6. • World Health Organization [WHO]
• A handicapped person as 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.
• Children with disabilities have poorer oral health than
their nondisabled counterparts.
• Variable access to dental care, inadequate oral hygiene
and disability-related factors are the causes.

7. Home dental care in general for
physically disabled child
• Should begin in infancy
• teach the parents to gently cleanse the incisors daily with a
soft cloth or an infant toothbrush.
• For older children the dentist should teach the parent or
guardian to clean teeth twice a day using correct tooth
brushing techniques, safely immobilizing the child when
necessary.
• Stabilization of the child’s head prevents unnecessary
trauma from sudden movements.
• Electric toothbrushes are effective in children with mental
and physical disability.
• Vibration and noise desensitize the patient for future
dental appointments.

8. • Body
• Papoose Board (Olympic Medical Corp., Seattle, Wash)
• Triangular sheet
• Pedi-Wrap (The Medi•Kid Co., Hemet, Calif)
• Beanbag dental chair insert
• Safety belt
• Extra assistant
• Extremities
• Posey straps (Posey Co., Arcadia, Calif)
• Velcro straps
• Towel and tape
• Extra assistant

9. Home care

29. Mental retardation
• If an individual's intellectual development is
significantly lower than average and whose
ability to adapt to their environment is
consequently limited

30. classification
• Mild-educable
• Moderate-trainable
• severe-self help skills

31. Oro- facial changes that accompany
mental retardation.
• Dental Problems
• Anomalies in the dento facial morphology and in the dental eruptive
pattern.
• Enamel hypoplasia.
• Delayed eruption.
• High palatal vault with a hypoplastic maxilla.
• Tendency for Class II malocclusion with an open bite.
• Over retained primary dentition.
• high prevalence of caries and periodontal diseases due to over indulgence
over cariogenic diet pattern and ignorance of oral hygiene.
• Abnormality in number of teeth.
• Poor tongue coordination with food pouching.
• Increased rate of oral trauma due to accident proneness and self inflicted
injuries.

34. etiology
• Oxygen lack to the brain
• Complications of labour
• Infections to the brain-meningitis
• Encephalitis
• Toxemia of pregnancy
• Congenital defects of the brain
• Kernicterus
• Heavy metal and drug poisoning
• Trauma to the head
• Premature birth with CNS abnormality

37. Dental problems
• Dental caries
• Periodontal disease
• Malocclusions
• Bruxism
• Trauma
• Excessive drooling and difficulty in swallowing
• Tongue thrust

41. Down’s Syndrome
Mongolism
Trisomy 21

46. Skeletal craniofacial features;
• Brachycephaly with a flattened occiput
• Decreased length and flattening of the cranial base.
• The facial mid-third is underdeveloped, producing a hypoplastic
maxilla with a high, short, and narrow palate.
• The frontal and paranasal sinuses are hypoplastic
• Ethmoid bone is retracted.
• Mandibular prognathism is mild or marked relative to the maxilla.
• Facial appearance is altered with short palpebral fissures,
hypertelorism, a wide nasal root, a narrow soft nose with a high
nasal tip, a high upper lip, and wide short low ears.
• muscles of mastication and facial expression are hypotonic
• laxity of the temporo mandibular joint ligaments

47. Oral findings
• mouth breathing,
• Open bite,
• Appearance of macroglossia due to relatively small size of the oral
cavity,
• Fissured lips and tongue,
• Angular cheilitis,
• Delayed eruption times,
• Missing and malformed teeth,
• Oligodontia, small roots,
• Microdontia,
• Taurodontia,
• Decreased root to crown ratio
• Decreased tooth size

48. • Altered crown shape
• Protrusion of the lower incisors
• Crowding
• Low level of caries.
• High incidence of rapid, destructive periodontal disease, - tooth
morphology, bruxism, malocclusion, and poor oral hygiene.
• The first primary teeth may not appear until 2 years of age, and the
dentition may not be complete until 5 years of age.
• There is poor or delayed suckling ability,
• Problems with mastication due to slow development of motor skills
• Drooling,
• A tendency to allow the mouth to hang open at rest
• A protruded tongue posture.
• Aspiration -liquid and semiliquid food reaching the bronchi.

49. FETAL ALCOHOL SPECTRUM DISORDER
• Maternal consumption of alcohol during pregnancy ; affects the
normal development of the neural crest cells.
• The physical findings
• Moderate to severe growth retardation with persistent
microcephaly.
• Weak muscles around the mouth that make it difficult to consume
food;
• Unusual taste preferences for salty or spicy food at an inappropriate
age;
• Gross caries at a young age;
• Prolonged and excessive drooling;
• Weak buccinators muscles that prevent the proper placement of
food for chewing.

50. Autism spectrum
• Autism spectrum disorder includes
conditions—
• autism
• Asperger's syndrome
• childhood disintegrative disorder
• an unspecified form of pervasive
developmental disorder

51. • Incapacitating disturbance of mental and emotional
development that causes problems in learning,
communicating, and relating to others.
• A developmental disability manifests itself during the
first 3 years of life
• Believed to be caused by a physical disorder of the
brain.
• Prevalence ;6 per 1000 people
• 4 times more common in boys as girls.
• Poor muscle tone, poor coordination, drooling, a
hyperactive knee jerk, and strabismus.

52. Clinical features
• Extreme loneness
• Language disturbance,
• Mutism
• Parrot like repetitions
• Speech difficulty
• Confusion
• obsessive desire for maintenance of sameness,
• Eating disturbance,
• Mobility such as intrigue with spinning objects,
• Hyperactivity,
• Self stimulatory behavior,
• Nystagmus,

53. • Early Symptoms of Autism in Infants
• baby who doesn't babble or gesture by the age of 12
months.
• baby who lacks eye contact with its mother by the age
of 12 months.
• baby who resists being held or cuddled by its mother.
• baby who doesn't respond when its mother says its
name.
• baby who appears to be deaf.
• An infant who doesn't say single words by the age if 16
months.

54. Dental findings
• Higher susceptibility to caries:
• Due to soft and sweetened food, pouching due to poor tongue
coordination and difficulties in brushing and teeth flossing
• Bruxism: one of the sleep disorders in autistic children
• Damaging oral habits: tongue thrusting, picking at the gingiva, lip
biting, and pica
• Traumatic injuries: Traumatic ulcerated lesions usually brought on
by self-injury from head banging, picking or face tapping
• Texture sensivities: Food texture sensitivities leads to the
consumption of refined and high-sugar diet
• Gingivitis and poor oral hygiene: Occur due to heavy plaque
accumulation and hormonal influences are the likely explanations
for the dental concerns.

55. management
• Speak slowly to allow information to be processed.
• Limit any background noises in the surgery
• use the same staff and a secluded dental surgery if possible.
• Positive re-enforcement of desired behaviour should be ‘celebrated’ so
that it is repeated.
• If child gets aggressive, maintain an unresponsive facial expression and
use a calm tone.
• Offer parents and children the opportunity to tour your dental office, so
that they may ask questions, touch equipment, and get used to the place.
• Allow autistic children to bring comfort items, such as a blanket or a
favorite toy.
• Children with autism need sameness and continuity in their environment.
• A gradual and slow exposure to the dental office and staff is therefore
recommended.

56. • Solicit suggestions from the parent or caregiver on how best to deal
with the child.
• Autistic children are easily overwhelmed by sensory overload. This
can cause "Stimming“ (flapping of arms, rocking, screaming. etc.)
• Autistic children are hypersensitive to loud noises, sudden
movement, and things that are felt.
• Make the first appointment short and positive.
• Approach the autistic child in a quiet, nonthreatening manner.
Don’t crowd the child.
• Use a “tell-show-do” approach to providing care.
• Explain the procedure before it occurs. Show the instruments that
you will use. Provide frequent praise for acceptable behavior.

57. REFERENCES
• Pediatric Dentistry :- Nikhil Marwah
• Textbook of Pedodontics:- Shobha Tandon