This document defines and classifies different types of handicapped children, including those who are physically, mentally, medically, emotionally, or socially handicapped. It discusses the importance of prevention for these children through dietary advice, oral hygiene instruction, fluoride treatment, fissure sealants, and regular checkups. It also emphasizes the need to carefully assess each child's medical history and abilities, consult their physician, and create a treatment plan tailored to the child and family's specific needs and capabilities. Behavioral management may require various techniques depending on the child's cooperation level, from mild sedation to general anesthesia in some cases.

1. HANDICAPPED CHILDREN

2. HANDICAPPED CHILDREN
Definition:
A disadvantage for a given individual resulting from an
impairment or a disability that limits or prevents the
fulfillment of a role that is normal (depending upon age, sex,
social and cultural factors) for that individual. WHO; 1980
OR
A handicapped child is defined as one who, over an
appreciable period of time, is prevented from full
participation in childhood activities of a social, recreational,
educational and vocational nature. WHO

3. Impairment & Disability
Impairment:
Any loss or abnormality of psychological,
physiological or anatomical structure or
function (WHO,1980).
Disability:
Any restriction or lack (resulting from an
impairment) of ability to perform an activity in a
manner or within the range considered normal for
a human being (WHO,1980).

4. The term ‘disabled’ is often preferred.
A person with any condition which do not
interfere with his job can’t be classified as
disabled or handicapped.

5. Classification
1. Physically handicapped.
2. Mentally handicapped.
3. Medically handicapped.
4. Emotionally handicapped.
5. Socially handicapped.

6. The problems range from those of children with something
organically wrong but who are not in an accepted sense ill (e.g.
deafness, cerebral palsy or mental handicap) to children who
suffer chronic disease lasting for long periods and with life-long
effects (e.g. asthma, cystic fibrosis and haemophilia).
These children with special needs deserve the highest standard
of dental care that can be provided for them.
To achieve this the dentist must be prepared to adapt and
modify his treatment techniques, to gain a wider knowledge of
the handicapping condition and to be sensitively aware of its
social and emotional effects on the child and its family.

7. Physically handicapped
• These are individuals in wheel chair.
• Other physical abnormalities due to trauma etc.
Example: Cerebral palsy.
• Someone who has physical disability may not be
mentally disable.

8. Mentally handicapped
• Also called educationally subnormal (ESN).
• A wide spectrum of cooperation can be expected, from
docile acceptance to aggressive resistance.
• Mentally unable to understand the dental treatment and so
may not co-operate.
Intelligence Quotient (IQ): Relates mental age to
chronological age.
90 – 120 Normal
50 – 70 Moderately educationally subnormal ESN (M).
0 - 50 Severely educationally subnormal ESN (S).

9. Medically handicapped
• These are children whose medical condition is such that
there is an increase in morbidity if they suffer from dental
disease or if they require routine dental treatment.
• Court report (1976): These children should be given highest
priority for comprehensive dental care from as early an age
as possible.
• Holzel report (1978).

10. Holzel report (1978)
This report identified six types of dental risks associated
with medical conditions and/or medical treatment which
might seriously affect a child’s general health.
These are:
1. Hemorrhage
2. Sepsis
3. Transient bacteraemia
4. GA
5. LA
6. Oral surgery
These risks were adopted as the criteria to qualify a
medical condition as “medically handicapping condition”.

11. Hemorrhage:
Coagulation disorders (haemophilia), thrombocytopenia / purpura,
leukaemias (due to thrombocytopenia), haemangiomas, hepatic disorders
(cirrhosis), nephrotic syndrome & ch. Renal failure.
Sepsis:
Cardiovascular disorders, Immunodeficiency, leukaemias, haemangiomas
nephrotic syndrome & ch. Renal failure, diabetes mellitus, cirrhosis.
Transient bacteraemia:
Cardiovascular disorders, immunodeficiency, leukaemias, nephrotic
syndrome& ch. Renal failure.
GA:
Cardiovascular disorders, Coagulation disorders, thrombocytopenia /
purpura, anaemia (resulting from haematological disorders), asthma, ch.
Bronchitis & bronchiectasis, cystic fibrosis, leukaemias, nephrotic
syndrome & ch. Renal failure, diabetes mellitus, cirrhosis.
LA:
Coagulation disorders, thrombocytopenia / purpura, (bleeding due to
cirrhosis & defects in clotting mechanism), leukaemias, haemangiomas,
nephrotic syndrome & ch. Renal failure.
Oral surgery:
Cardiovascular disorders, Coagulation disorders, thrombocytopenia /
purpura, immunodeficiency, leukaemias, haemangiomas, nephrotic
syndrome & ch. Renal failure, cirrhosis.

12. Emotionally handicapped
• Children who are very frightened would not
accept dental treatment.
• Would need inhalation sedation or GA.

13. Socially handicapped
Patients who has got many social problems, so
that they can’t co-operate, e.g., single parent
family, poor family having a lot of children.

14. Treatment
For all handicapped children, the rule of thumb:
1. Careful history (assessment).
2. Consult with child physician.
3. Vigorous prevention.
– Dietary advice
– OHI
– Fluorides
– Fissure sealants
– Regular check ups
4. Treatment plan consistent with abilities of parents
and prognosis of patient.

15. Careful history (assessment)
• Not only needed in handicapped children
but for all patients.
• Treating handicapped children without detailed
history can be very dangerous.

16. Consult with child physician
• Some precautions may be advised by the
physician treating the child.
• These precautions need to be strictly followed.

17. Vigorous prevention
As great problems are encountered in the dental treatment
of handicapped children, the concept of prevention comes to
the forefront of treatment planning.
It includes:
– Dietary advice
– OHI
– Fluorides
– Fissure sealants
– Regular check ups

18. Dietary advice
• Due to the reluctance of subnormal and some physically handicapped
children to chew and swallow solid food, they are retained on feeding
bottles for very prolonged periods of time. Parents should be warned of
the dangers from the prolonged use of feeding bottles and the harmful
effects of sweetened comforters. Even if necessary, the contents should
be unsweetened whenever possible.
• Medicinal syrups when used over long periods of time should be given
prior to meals.
• In older handicapped children, advice should be given to avoid excessive
consumption of confectionary and other snacks between meals. Can
take these foods at meal times and the meal should be finished with
some detergent food such as a hard apple, carrot or celery.
• Apart from verbal instructions on the diet, written notes may be given to
the parent to read and learn at home. A three-day diet sheet for the
child may be completed by parent to get proper dietary history.

19. Oral hygiene instructions
• The use of electric toothbrushes are suggested to be of more help in
handicapped children for maintaining and promoting oral health.
• Modification of the toothbrush handle may be made to make it easier
for the handicapped child to use it.
• Mugs with indented basis are available for use by spastics.
• Children who can rinse or spit out are recommended to use fluoridated
toothpaste but those who can’t should use a moistened brush without
paste.
• In handicapped children, the oral hygiene procedures are usually carried
out by parents. The mother should stand behind the child cradling the
head in her arm and maintaining support against her body. In severely
handicapped children, oral hygiene procedures may be carried out with
the child seated in a chair or lying supine on the couch or bed.
• The use of mouth props made from tongue spatulas and tape, disclosing
solutions and dental floss is also advocated for the home maintenance of
dental health in handicapped children.

21. Fluorides
• If the child is resident of an area with low fluoride in
drinking water, fluoride supplements should be considered.
However, this might be difficult with less intelligent parent.
• Topical applications of fluoride might be more useful in
handicapped children. Varnishes especially Duraphat (2%
Sod. fluoride) exceedingly useful in treatment of young and
handicapped children.
• Where the child is more co-operative and perhaps less
handicapped, the 4 – 6 minutes application of acid
phosphate fluoride solutions or gels 6 – monthly is
recommended.

22. Fissure sealants
• The presently available fissure sealants are less effective in
primary dentition as compared to permanent dentition.
Moreover, the meticulousness needed for the application of
these materials may not be possible in young handicapped
child’s mouth.
• However some of these materials are sufficiently effective to
be applied in suitable circumstances. Where the
handicapped child is sufficiently co-operative, the
application of sealants to the permanent dentition could be
a very useful caries preventive measure.

23. Regular check ups
Regular visits to the dentist are very important for all
handicapped children:
Firstly it helps in reinforcement and monitoring the effectiveness
of the preventive advice given.
Secondly diagnosis of disease can be established at the earliest
possible time when the least restorative treatment may be most
effective.
Bimolar extra-oral radiographs may be of help in the
diagnosis of early carious approximal lesions in many
handicapped children for whom intra-oral bitewing
radiographs would be impossible to obtain.

24. Treatment plan consistent with abilities
of parents and prognosis of patient
Treatment plan should be formulated keeping in mind:
o The socio-economic status of the parent.
o The attitude of the parent towards the dental treatment.
o The ability of the child to undergo the treatment successfully.
o The effectiveness of the procedures in the specific child.

25.  Behavioral management of the
handicapped child.
 Operative treatment.
 Maintenance.

26. Behavioral management of the
handicapped child
• Normal behaviour management techniques.
• Pharmacotherapeutic approaches ranging from mild
sedation to general anaesthesia.
• Physical restraints.

27. Management of physically and mentally handicapped
children in the dental chair
• Some of the younger cerebral palsied children are best managed by the
mother sitting in the dental chair with the arm nearer the operator being
lowered, the head of the child being cupped in the lap of the operator and
the mother holding the remainder of the child in her lap. The mother is
then able at the same time to control any abnormal movements of the
child’s body, hands and legs, with possible assistance from the dental
assistant. This gives sufficient oral access for restorative treatment.
• The use of mouth props may help in preventing damage to the child’s oral
soft tissues and to the operator’s fingers during cavity preparation. The
mother’s handling of the children during treatment contributes a sense of
protection and confidence to the child.
• With older children the use of the modern contoured chair tilted well back
can assist greatly in carrying out restorative treatment, the mother and
the dental nurse assisting with the control of abnormal movements.
• The use of steel unbreakable mirrors and finger guards are recommended
for the dental surgeon when treating such children but, with suitable skill,
these should rarely be required.

28. Operative treatment
• Restorative treatment should be carried out to the highest
standard possible.
• Treatment may be attempted by conventional means, but
sometimes the severity of the handicap or the urgency of
the treatment may require that dental treatment is
undertaken under general anaesthesia, preferably in a
specialized day-care centre associated with a hospital.
• The handicapped child will be certainly less upset if he is
treated under GA in a day-care centre rather than if he is
admitted in a general ward.

29. Maintenance
• Once the mouth has been fully restored to function, it is
then good policy to maintain the condition by regular follow-
up care, in many cases assisted by a dedicated oral hygienist.
• Handicapped children deserve the very best dental care that
can be provided for them so that dental problems does not
further affect their already reduced life style.

30. Three aspects
• The family
• The public
• The child

31. The family
• Severe physical or mental handicaps may be apparent at birth, may
become manifest later, or be acquired as a result of an accident or severe
illness. Have profound effects on the child parents and family.
• At first the parents are shocked and there is disbelief and denial followed
by vacillating acceptance or total rejection. Parents may feel ashamed or
may become angry. May indulge in fantasies about a magic cure.
• Parents may try to hide the handicapped child from outside world. This
is very damaging for the child’s future as in some cases early detection
and referral for specialist assessment and advice is of prime importance,
e.g. cleft lip and palate.
• Parents of child with grave handicaps need counselling and support.
They need to be in contact with the Handicap Team usually composed of
a paediatrician, general medical practitioner, social workers,
psychologist, community nurses, physiotherapist and in some cases the
dentist.
• Parents may need to be introduced to other parents or groups of parents
who themselves have suffered the same problem. In some cases, parents
may need to be given short-term relief (holidays) when other people will
look after their child. May also need advice about local special schools.

32. The public
• Public reaction to the appearance and disability of the
handicapped child may stigmatize him through curiosity,
fear, revulsion or pity. This can affect the child’s self
confidence and be very distressing.
• The ‘handicapped’ knows how ‘normals’ identify him but
may still have a sense of not knowing how others really
think about him. He may become shy, or attempt a hostile
bravado.

33. The child
• The handicapped child’s approach to life is complicated both
by the disability and the attitude of those caring for him. He
may have to endure long periods of sickness and
hospitalization.
• The handicap may block both approaches to him and his
own attempts to communicate with the outside world.
• In general the most important thing is to help him to accept
the inevitable and to make the most of what is left.

34. Antibiotic Prophylaxis for Infective
Endocarditis
FOR
• Dental extraction
• Scaling
• Periodontal surgery

35. Antibiotic Prophylaxis for Infective
Endocarditis
Under Local Anaesthesia or No Anaesthesia
A. Patient not allergic to penicillin
• Amoxicillin 3g, 1 hour before procedure
Under 10, half dose
Under 5, quarter dose
B. Patient allergic to penicillin
• Erythromycin 1.5g, 1-2 hours before procedure
500mg, 6 hours later
Under 10, half dose
Under 5, quarter dose

36. Antibiotic Prophylaxis for Infective
Endocarditis
Under General Anaesthesia
A. Patient not allergic to penicillin
• Amoxicillin IM, 1g just before induction
500mg orally 6 hours later
Under 10, half dose
B. Patient allergic to penicillin
• Vancomycin IV, 1g in infusion 1 hr before induction
• Gentamycin IV, 120mg just before induction
Under 10: Vancomycin 20mg/kg body wt
Gentamycin 2mg/kg body wt

37. Thank you