This document provides guidance on the dental management of handicapped children. It discusses the first dental visit, radiographic examination, preventive dentistry including home dental care, diet and nutrition, fluoride exposure, and professional supervision. It also covers management during treatment such as immobilization techniques, nitrous oxide analgesia, and general anesthesia. Finally, it discusses dental treatment considerations for specific conditions including mental disabilities, respiratory diseases, hearing loss, visual impairment, and heart disease.

1. 2019
Asmaa
abdelrahman
abdelhakeem
sayed
41020102
[MANAGEMENT OF
HANDI CAPPED
CHILDREN IN THE
DENTAL OFFICE]
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2. Ma
DentalManagement OfhandicappedChildren
MANAGEMENT OF THE HANDICAPPEDCHILDREN
I. FIRST DENTAL VISIT
a. Schedule patient at designated time (early in the day)
b. Allow sufficient time to talk with the parents and patient before initiating treatment
II. RADIOGRAPHIC EXAMINATION
a. assistance from the parent and dental auxiliaries and the use of immobilization
devices may be necessary to obtain the films.
b. Better cooperation may be elicited on second visit.
c. For patient with limited ability to control film position, intraoral films with bite-
wing tabs are used
d. Patient should be wear lead apron with thyroid shield.
III. PREVENTIVE DENTISTRY
A. HOME DENTAL CARE
a. The dentist is responsible for the consulting with the caregiver of the child with
disabilities
b. Home dental care should begin in infancy.
c. Some of the positions most commonly used for children requiring oral assistance
d. Electronic toothbrushes.
B. DIET AND NUTRITION
a. Influence caries by affecting the type and virulence of microorganism in dental plaque, the
resistance of teeth and supporting structures,and properties of saliva in the oral cavity.
b. Conditions with difficulty in swallowing (cerebralpalsy) – pureed diet Dental
Management Of Handicapped children.
c. Metabolic disturbance – diets restricting total caloric consumption
d. Discontinuation of nursing bottle – 12months.
e. Cessation of breastfeeding – after teeth begin to erupt.

3. C. FLUORIDE EXPOSURE
a. Patient with disabilities who has poor oral hygiene – daily rinsing of 0.05% NaF 0.4%
Stannous fluoride brush on gel at night
D. PREVENTIVE RESTORATION
a. Sealantsare appropriate forpatientwithdisabilities
b. Deep occlusal pits and fissures should be restored with long wearing composites to prevent
further breakdown and decay
c. Patient with bruxism and interproximal decay – restore with stainless steel crowns
E. REGULAR PROFESSIONAL SUPERVISION
a. Although most patient are seen semiannually for professional prophylaxis, examination
and topical fluoride application, certain patient can benefit from recall examinations every 2,
3 or 4 months
IV. MANAGEMENT OF A CHILD WITH DISABILITIES DURING DENTAL TREATMENT
A. TREATMENT IMMOBILIZATION
INDICATIONS:
 lack of maturity and Diagnosis is needed
 mental and physical disabilities and diagnosis is needed
 child does not cooperate after other behavior management techniques have failed
 The safety of the patient/practitioner would be at risk without the use of protective
immobilization
:CONTRAINDICATIONS
 Cooperative patient
 Patient who cannot be safely immobilized because of underlying medical or
systemic conditions
:PHYSICAL AIDS TO KEEP MOUTHOPEN
:  Wrapped tongue blades
 Open wide disposable mouth props
 Molt mouth props

4.  Rubber bite blocks
:HEAD&EXTEMETIES,BODY
 Papoose board
 Posey straps
 Forearm-body support
B. NITROUS OXIDE ANALGESIA
Safe and effective method of decreasing apprehension or resistance to dental
treatment. Except for children who have severe mental retardation or emotional
disturbance, there are few contraindications to its use.
C. GENERAL ANESTHESIA
:Indicationsforgeneralanesthesia
1. The uncooperative child who resists treatment after all conventional management
procedures have been tried.
. 2. The child with a hemostasis disorder who needs extensive dental service.
3. The mentally retarded child so severely handicapped that dentist-patient
communication is impossible.
4. The child suffering from central nervous disorders manifested by extreme
involuntary movements.
5. The child with severe CHD who is considered incapable of tolerating the
excitement and fatigue of extensive dental service.
I. MENTAL DISABILITY
when an individual’s intellectual development is significantly lower than average and
ability to adopt to the environment is consequently limited
o SEVERESUBNORMALITY(IDIOT) – IQ OF0– 19
oMODERATE SUBNORMALITY(IMBECILE) – IQOF20– 49
oMILDSUBNORMALITY(MORON) – IQOF50– 69.

5. :CLASSIFICATIONOFMENTALRETARDATION
DENTAL TREATMENT OF PERSON WITH MENTAL DISABILITY
.) Give family brief tour of the office before attempting treatment1
.2) Be repetitive; speak slowly and in simple terms
.3) Give only 1 instruction at a time. Reward the patient with compliments
.4) Actively listen to the patient
5) Invite the parent into operatory for assistance and to aid in communication
with patient
.6) Keep appointments short
nts’ visit early in the day.7) Schedule the patie
:A.DOWNSYNDROME

6.  Bestknownchromosomaldisorderandiscausedbypresenceof
threecopiesofchromosome21.
 Have underdevelopedmidfacecreatingaprognathicocclusal
relationship
 Medicalconditionsoccurringincludecardiacdefects,leukemia
andupperrespiratoryinfections.
 Oralfindingsincludemouthbreathing,openbite,macroglossia,
fissuredlipsandtongue,angularcheilitis,delayederuptiontimes,
missingandmalformedteeth,oligodontia,smallroots,
microdontia,crowdingandlowlevelofcaries.
 high incidenceofrapiddestructiveperiodontaldisease.
B.LEARNING DISABILITIES
 childrenwhoexhibit adisorderin oneormoreofthebasic
psychologicprocessesinvolved in understandingorusingspokenor
writtenlanguage.
 disordersoflistening,thinking,talking,reading,writing,spellingor
arithmeticIncludesconditionthathave beenreferredtoas
perceptualhandicaps,braininjury,minimalbraindysfunction,
dyslexia,anddevelopmentalaphasia .

7. :C.FRAGILEXSYNDROME
 Commoninheritedform ofmentaldisabilityandautism.
 The defect is an abnormal gene on the terminal portion ofthe long arm of an X
chromosome .
 A history of developmental delay and hyperactivity, and physical features
such as prominent ears,long face,prominent jaw, high arched palate,
flattened nasal bridge, hyper tensile joints, flat feet, cardiac murmur, simian
creases of the palms, post adolescent macroorchidism in males.
 Behavior features such as hand slapping, hand biting and poor eye contact.
 Dental treatment depends on level of developmental delay , cognitive ability
and, degree of hyperactivity.
 Mild cases may be treated by scheduling shortappointments and using
immobilization/ conscious sedation.
 Severely affected(generalizedanesthesia).
:D.FETALALCOHOLIC SYNDROME

8.  Consumption of 1-3 drinks a day during the first 2 months of pregnancy.
 Physicalfindingsinclude microcephaly,bilateral ptosis, short depressed midface,
flat nasal bridge, short philtrum and thin upper lip
 Most ofthe dentalproblemsassociatedwithfetalalcoholsyndrome in children are
related to high incidence of dental and skeletal malocclusions.

:E.AUTISM

9.  An incapacitatingdisturbance ofmentalandemotionaldevelopmentthat causes
problemsinlearning,communicatingandrelatingtoothers
 Manifest duringthefirst 3yearsoflife .
 Have poormuscle tone,poorcoordination, drooling,hyperactiveknee jerk,
strabismusandepilepsy.
 Childrenprefersoft andsweetenedfoods Because oftheirtendency toadhere to
routines, childrenwithautismmay requireseveraldentalvisitsto acclimateto the
dentalenvironment.
 Use papoose boardorpedi-wrapandpreappointmentconscioussedation.
F.CEREBRALPALSY
One of the primary handicapping conditions of childhood; most severely handicapping
problem affecting newborn
1) SPASTIC
a. Hyperirritability of involved muscles
b. Tense,contracted muscles
c. Limited control of neck muscles
d. Lack of control of muscles supporting the trunk e. Lack of coordination of intraoral,
perioral and masticatory muscles
2) DYSKENETIC
a. Constant and uncontrolled motion of involved muscle
b. Athetosis and choreoathetosis
c. Frequent involvement of neck muscles (excessive movement of head)

10. d. Possibility of frequent uncontrolled jaw movement
e. Frequent hypotonicity of perioral musculature
f. Facial grimacing
g. Speechproblems
3) ATAXIC
Combination
4) MIXED
Muscle are flaccid
5) RIGIDITY
Muscle are in a constant state of contraction
Neonatal reflexes may persist long after the age at which they normally disappear.
Three ofthe most commonreactionswhich a dentistshouldrecognizeare :
1) Asymmetric tonic neck reflex
2) Tonic labyrinthine reflex
3) Startle reflex
ManifestationsofCerebralPalsy
1) Mental retardation
2) Seizures disorders
3) Sensory deficits/dysfunction (strabismus : most common visual defects)
4) Speech disorders
5) Joint contracture
 Intraoralanomaliesmore commoninpatientswithcerebralpalsy
1) Periodontal diseases
2) Dentalcaries
3) Malocclusion
4) Bruxism
5) Trauma

11. II. RESPIRATORY DISEASES
:A.ASTHMA (ReactiveAirwayDisease)
 Very commonchildhooddiseases
 Chronicairway diseasecharacterizedby inflammationandbronchialconstriction
 Diffuse obstructive disease oftheairwaycausedby edemaofthe mucous
membranes, increasemucoussecretionsandspasm ofsmoothmuscle .
Symptoms:
coughing,wheezing,chesttightness,anddyspnea
 Patient with taking systemic corticosteroids and those who were hospitalized or in
emergency dept.
 in the last year should be treated with caution because they are at higher risk of
mobility and mortality
 Patient who use bronchodilators should take a dose before their appointment, and
they should bring their inhalers/nebulizers
 Hydroxyzine HCl and diazepam may be used to alleviate anxiety
Contraindications:
 barbiturates,narcotics, aspirinandNSAID’s
 Positionthe childwithmildasthmaticsymptomsinanupright/semi – upright
position

12. :Emergency treatment
 discontinuing dental procedure, reassuring patient and opening airway
 Administer 100% oxygen while placing patient in upright/ comfortable
position
 Keep the airway open, administer patient B2 agonist with inhaler/nebulizer
 If no improvement, administer subcutaneous epinephrine
B.BRONCHOPULMONARY DYSPLASIA
 Chroniclungdisease usuallyresultingfrom occurrence duringinfancy of
respiratory distresssyndrome thatrequiresprolongedventilationwitha high
concentrationofinspiredoxygen More likely inthepremature infant .
 Some childrendevelopright ventricularhypertrophy (corpulmonale) .
 Majorcausesofdeathinclude corpulmonale,respiratory infections, andsudden
death.
 If the patientistakingO2 continuouslyvia a nasalcannula, short appointment with
frequent breaksare necessaryto preventpulmonary vasoconstriction.
:C.CYSTIC FIBROSIS

13.  Autosomalrecessivedisorder.
 Most commonlethalgeneticdisorderaffectingwhites
 The defective gene productscauseabnormalH2Oandelectrolyte transport across
epithelialcells, whichresultsina chronicdiseaseofthe respiratory andGIsystem,
elevatedlevelsofelectrolytesinsweat, andimpairedreproductionfunction.
 Inthe lungs, retentionofmucousoccurswhichcausesobstructivelungdiseaseand
increasedfrequency ofinfections .
andease chest diameter,clubbing fingers and toes, decrease exercise toleranceincr:Symptoms
chronic productive cough
Children with cystic fibrosis have a high incidence of tooth discoloration, mouth breathing,
and open bite malocclusion.
Incidence of dental caries is low.
They prefer to be treated in a upright position and avoid sedative agents.
III. HEARING LOSS

14. The following should be considered when treating a hearing impaired patient:
 Prepare the parent andthepatient before thevisit a welcomeletter
 Let the patient andparentdetermine howthe patientdesirestocommunicate
 Assessspeech, longabilityanddegreeofimpairment
 Enhance visibility forcommunication
 Reassure the patientwithphysicalcontact
 Employ the tell-show-do approach
 Display confidence
 Avoidblockingthe patientvisualfield
 Adjust the hearingaid
 Make sure the parent/patientunderstandsexplanationsofdiagnosistreatment
IV. VISUAL IMPAIRMENT
Dentists should realize that congenitally visually impaired children need a greater display of
affection and love early in life and that they differ intellectually from children who are not
congenitally visually impaired
Explanation is accomplished through touching and hearing, smelling and tasting
Hypoplastic teeth and trauma to ant. Teeth are common also gingival inflammation.
TREATMENT
 Determine the degreeofvisualimpairment
 Findout ifcompanionisaninterpreter
 Establishrapport
 Inguidingthe patient totheoperatory, askifthe patientdesiresassistance
 Paint a picture inthe mindofvisually impairedchild
 Introducedotheroffice personnelvery informally
 Whenmakingphysicalcontact, doso reassuringly
 Allow patient toaskquestionsaboutthecourse oftreatmentandanswerthem

15.  Allow a patient whowearglassestokeepthemon
 Invite the patientto touch,taste,orsmellratherthantell-show-feel-do
 Describe indetailinstrumentsandobjectstobe placedinthe patientmouth
 Because strongtaste may berejected, usesmallerquantities
 Some patient may bephotophobic
 Explainthe proceduresoforalhygieneandthenplace thepatient’shandoveryours
15.Use audio cassette tapesandBraille dentalpamphlets
 Announce exitsandentrance tothe dentaloperatory cheerfully
 Limit providersofthe patients’ dentalcare to one dentistwheneverpossible
 Maintaina relaxedatmosphere
V. HEART DISEASE
A. CONGENITAL HEART DISEASE
Dividedintotwogroups:
IC CHD1. ACYANOT
Characterized by minimal or no cyanosis, and has 2 major groups:
a. (Ventricular and atrial septaldefect) Left to right shunting of blood within the heart – CM:
CHF, pulmonary congestion, heart murmur, labored breathing and cardiomegaly
b. (Aortic stenosis and coarction of aorta) obstruction.
Characterized by right to left shunting of blood within the hear.
2. CYANOTIC
Characterized by right to left shunting of blood within the heart
Cyanosis is often observed even during minor exertion ( tetralogy of fallot, transposition of
the great vessels,pulmonary stensis and tricuspid atresia)
Cyanosis is often observed even during minor exertion ( tetralogy of fallot, transposition of
the great vessels,pulmonary stensis and tricuspid atresia).
B. ACQUIRED HEART DISEASE
1. RHEUMATIC FEVER
A seriousinflammatorydiseasethatoccursas a delayedsequel topharyngealinfectionwith
groupA streptococci.
Commonlydiagnosedcause of acquiredheartdisease inpatientunder40 yearsold
Appearsmostcommonlyin6-15 yearsold.
Cardiac involvementisthe mostsignificantpathologicsequelaof rheumaticfeverandcanbe
fatal or can leadtochronic RHD as a resultof scarringand deformityof heartvalves.

16. 2. INFECTIVE BACTERIAL ENDOCARDITIS
One of the most seriousinfectionsof humans
Characterizedbymicrobial infectionof the heartvalvesorendocardiuminproximityto
congenital oracquiredheartdefects
a) ACUTE
Fulminatingdiseasethatusuallyoccurswhenmicroorganismsof highpathogenicityattacka
normal heart,causingerosive destructionof valves
Causedby staphylococcus,grp.A streptococcusandPneumococcus.
b) SUBACUTE (SBE)
 Usually developsinpersonswithpre existingcongenitalcardiacdiseaseor
rheumaticvalvularlesions
 Also causedby surgicalplacement ofprostheticheart valves
Commonly causedby viridiansstreptococci, microorganismcommonto theoralflora
Embolizationisa characteristicfeature ofinfective endocarditis
:Symptoms
low irregular fever( afternoon or evening peaks) with sweating, malaise, anorexia, weight
loss and arthralgia, painful fingers and toes and skin lesions.
MANAGEMENTDENTAL
a. Behavior management techniques are useful and conscious sedation and
nitrous oxide – oxygen analgesia have been proven beneficial in reducing
anxiety in such patient
b. Cardiopulmonary resuscitation equipment should be readily available during
the appointment
c. If gen. anesthesia is indicated, the dental procedures should be completed in a
hospital setting