16: Special Needs Patient Care

CHAPTER 16 Special Needs Patient Care

BASIC PRINCIPLES OF CARE FOR SPECIAL NEEDS PATIENTS

Disability is a permanent or long-term condition, including physical, medical, psychological, and/or mental limitations, that requires individual consideration in planning treatment. Risk factors for NOT achieving oral health are listed when involved.

image • See CD- ROM for Chapter Terms and WebLinks.
• See Chapters 6, General and Oral Pathology: common medical diseases and disorders; 10, Medical and Dental Emergencies: emergency protocol; 11, Clinical Treatment: modifications of dental treatment; 9, Pharmacology: drug therapies and antibiotic premedication, substance abuse.
A. Types of disabilities:

1. Developmental disabilities: may be present at birth (result of a genetic defect, brain damage, or nutritional or other deficiency during prenatal development) or may occur before adulthood; considered permanent conditions (e.g., chromosomal abnormalities, autism, cerebral palsy, fetal alcohol syndrome, postnatal infections, birth anoxia, epilepsy).
2. Acquired disabilities: obtained from external forces during adulthood, related to illness or injury (e.g., traumatic head injury, spinal cord injury, multiple sclerosis, arthritis).

B. Classifications:

1. Medical disabilities:

a. Medically compromised, associated with conditions that affect major organs of the body (discussed in other chapters).

2. Communication disabilities:

a. Related to neurological damage to parts of the brain responsible for language and speech development.
b. Include aphasia, apraxia, dysarthria.

3 Sensory disabilities:

a. Conditions associated with the senses.
b. Include varying degrees of blindness and hearing loss.

4. Cognitive disabilities:

a. Associated with reduced mental capabilities.
b. Include intellectual disability (mental retardation), Alzheimer’s disease, mental illness.

5. Orthopedic disabilities:

a. Conditions associated with use of the legs and arms.
b. Include loss of limbs, paralysis, arthritis, cerebrovascular accident (CVA, stroke), myasthenia gravis, Parkinson’s disease, multiple sclerosis.

Levels of Function

Assessment of functional level involves evaluation of ability to perform activities of daily living (ADLs) such as bathing, eating, dressing, speaking, walking. The higher the functional level, the greater the ability to take care of themselves. ADL assessments have different rating scales and four levels. First level (I) refers to highest level of function, and last refers to lowest level (IV). If guide dog is being used, do not pet or interfere with dog; ask how to handle the dog.

• See Chapter 18, Ethics and Jurisprudence: informed consents and those who have lower functioning levels.
A. High function category (levels I and II):

1. Able to attend to MOST of ADL needs with some supervision and encouragement.
2. Require daily reminder for oral care and encouragement to go slowly and thoroughly; may require assistance with transportation.
3. Capable of giving informed consent.

B. Moderate function category (level III):

1. Need supervision and assistance with some ADLs.
2. May require use of gestures, demonstration, or adaptive equipment for communication.
3. NOT able to give informed consent; power of attorney or guardianship documentation MUST be obtained to determine with whom to discuss treatment.

C. Low function category (level IV):

1. Little or NO ability to perform ADLs themselves.
2. Require second or third party to provide daily care; usually homebound.
3. NOT able to give informed consent; power of attorney or guardianship documentation must be obtained to determine with whom to discuss treatment.

Common Barriers to Healthcare

Americans with Disabilities Act (ADA) helped improve access to healthcare. Includes laws that govern wheelchair access to public buildings and restrooms, barrier-free public buildings, improved telecommunications for hearing- and vision-impaired individuals. Prohibits discrimination on basis of disability in employment, government, public accommodations, education, commercial facilities, telecommunications, and transportation. Dental offices are viewed as places of public accommodation. Special needs patients still face many barriers.

A. Communication barriers:

1. Include attitudes of healthcare workers about treating and communicating with disabled individuals, and patient and family attitudes toward dental care.
2. Forms that are readily understood by employees and patients; may include obligation to provide translators at no cost.
3. Involve hearing and visual losses and speaking difficulties:

a. Always talk directly to patient, even when caregiver is present, unless patient is NOT able to communicate.
b. Patient informed consent is required (when patient is cognizant) before patient care can be discussed with caregivers and others.

B. Physical barriers:

1. Include stairs, narrow doorways, heavy doors, distant parking, area rugs or other floor coverings that could cause tripping, lack of elevators, narrow restroom stalls, restricted access to drinking fountains, telephones, and restrooms.
2. Proper design of office spaces to accommodate needs of employees and patients in case of new offices and some remodeling projects (Box 16-1).

a. Remove access barriers, where such removal is “readily achievable.”
b. Defines readily achievable to mean easily accomplishable without much difficulty or expense.

C. Transport barriers:

1. MOST common; many prefer safety of the home to problems associated with public or private transportation.
2. Can influence ability to reach important destinations such as the dental office.

D. Economic barriers:

1. Greatest limitations to receiving necessary dental care:

a. Have only Social Security and other governmental programs as means of economic support.
b. Those who are employed typically earn low wages.

(1) Any money received is required for primary needs such as shelter and food.
(2) Medical and dental care is many times relegated to the bottom of list of needs.

c. Those on Medicaid and Medicare CANNOT find providers who are willing to accept less than customary fees for services.

2. Paying for dental services difficult because most are paid out of pocket and are not covered by insurance.

E. Motivational barriers:

1. MOST common for those who rely on others for partial care.
2. May be complicated by communication difficulties.

a. Although cognizant, may be NOT able to communicate needs to caregivers.
b. Some may also be forgetful; written instructions in addition to verbal instructions should be given to BOTH patient and caregiver.

F. Employment barriers: responsible practices that prohibit discrimination against those with physical or mental impairment coupled with reasonable accommodations for employees.

Box 16-1 American Dental Association Standards for Accessible Design

After handicapped parking space, route of travel must be free of obstruction and at LEAST 36 inches wide.
Minimum 32-inch door opening is needed with at least 18 inches of clear wall space on pull side of door next to the handle.
Door handle must be NO higher than 48 inches above floor and of lever type, able to be operated with closed fist.
Greeting desk may be required to be NO more than 36 inches high at some point to accommodate someone in wheelchair.
Hook for coats NO higher than 48 inches above the floor.
Circulation paths through public areas, all obstacles cane-detectable (located within 27 inches of floor or higher than 80 inches, or protruding less than 4 inches from wall).
A 5-foot circle for turning wheelchair completely.
Cabinets must be between 28 and 34 inches in height.

Patient with Communication Disorders

Patients with communication disorders are either NOT able to make speech sounds because of structural disease or damage, or NOT able to understand language or form thoughts into words. Related in discussion to disabilities in later sections.

A. Types:

1. Aphasia:

a. NOT able to put thoughts into words or to understand language.
b. Caused by neurological damage or organic brain disorder such as dementia.

2. Apraxia:

a. NOT able to form speech sounds properly.
b. Caused by central nervous system (CNS) lesion or organic brain disorder such as dementia.

3. Dysarthria:

a. NO clear speech pattern, slurring, as result of damage to the CNS or peripheral nervous system (PNS).
b. Motor speech disorder associated with cerebrovascular accident (CVA, stroke), cerebral palsy, Parkinson disease.

B. Oral signs:

1. Depend on severity of condition and loss of muscle control.
2. Difficulty in clearing food and inability to clean the teeth adequately may cause increased risk of caries and periodontal disease.
3. Difficulty swallowing and NOT being able to perform or understand need for good oral hygiene may also complicate oral health.

C. Risk factors: choking when swallowing is difficult; inadequate nutrition.
D. Barriers to care:

1. Economic cost if the disability affects employment.
2. Transportation if not able to drive.
3. Communication when speech production or comprehension is difficult.

E. Professional and homecare: maintenance of adequate homecare, with assistance as needed.
F. Patient or caregiver education: discussion about oral health and need for excellent oral care; caregivers who provide oral care SHOULD hear instructions.

CLINICAL STUDY

Age 17 YRS SCENARIO
Sex image Male image Female During an intraoral examination of a new patient, generalized moderate gingivitis is noted. The patient has not had dental radiographs taken for 2 years. He is unable to keep his mouth open, and communication with him is difficult.
Chief Complaint Unknown
Medical History
Developmentally disabled
Wheelchair bound
Spastic movements

Current Medications diazepam (Valium) 10 mg tid Social History
Lives with his family on weekends
Lives at special school during the week

1. What disability does the patient have?
2. What barriers or risks does the patient face in receiving adequate professional dental care? What radius for turning around a wheelchair does the dental office need to provide if it is being newly designed or remodeled?
3. Recommend homecare products and procedures for this patient.
4. What specific procedures should the dental office prepare to provide while treating him?

1. The patient has cerebral palsy (CP), developmental disability present since birth, possibly caused by exposure to virus prenatally or lack of adequate oxygen intake immediately after birth.
2. Physical barriers the patient may face include lack of wheelchair access. Communication barriers are also likely with spasticity because speech production is difficult. Risks associated with provision of professional oral care include accidental injury from involuntary movement. A 5-foot circle for turning a wheelchair completely around is needed in a new or remodeled dental office.
3. Recommendations for homecare should include as much emphasis on self-care as possible. If patient is not able to adequately clean his mouth or if brushing causes trauma because of spasticity, caregivers must perform toothbrushing procedures. Adaptive aids, such as lengthened toothbrush handle and fixed toothpaste cap, in addition to powered toothbrushes and oral irrigators, may be helpful.
4. Communication difficulties may be present and may affect interaction between clinician and patient. Parent or caregiver can provide useful link when communications are ineffective. Clinicians should be prepared to safely handle a wheelchair transfer to dental chair. Relaxed atmosphere and good rapport will help reduce spastic movements associated with emotional distress. Spastic movements can be risky for both patient and clinician, so solid instrumentation fulcrums are required. Mouth props, body wraps, and head restraints may be needed. Extra cushioning and/or frequent repositioning can reduce discomfort. Because of his age, panoramic radiograph may be indicated to check development of third molars and other oral structures. Bitewing radiographs can be taken by having parent or caregiver stabilize his head with one arm and hold film and holder in his mouth with the other hand.

Patient with Sensory Impairment

Patient with sensory impairment has loss of sight or hearing that makes communication and other daily living issues difficult. Sensory impairments often occur as result of infection, trauma, or disease, but some may be inherited.

A. Types:

1. Hearing impairment:

a. Severity can range from slight to total deafness.

(1) Conductive: outer or middle ear involvement of conduction pathways to inner ear.
(2) Sensorineural: damage to sensory hair cells of inner ear or its nerves.
(3) Mixed: combination of both.
(4) Central: damage to the CNS or pathways.

b. Can occur as result of infection, trauma, disease, drugs, or heredity.

(1) In adults: commonly noise induced or side effect of streptomycin as a child.
(2) In children: heredity, pregnancy, birth complications, meningitis.

c. May be indicated by inappropriate responses to questions or lack of interest in verbal communication.
d. Hearing aids may help restore some hearing acuity (in-the-ear or canal); may involve a cochlear implant.

2. Visual loss or blindness:

a. Many affected individuals are NOT able to read with correction.
b. FEW legally blind individuals are completely blind.
c. Blind individuals may exhibit sensitivity to light.

B. Oral signs NOT directly associated with visual or hearing impairment:

1. Poor oral hygiene and accompanying oral disease are common.
2. May occur because of inadequate presentation of oral hygiene instruction.

C. Factors that reduce effectiveness of oral care in the dental office:

1. For visually impaired, NOT able to see objects in path or to visualize instructions or procedures being done.
2. For hearing impaired:

a. NOT able to understand instructions; fear or shock in response to unexplained procedures.
b. May feel discomfort when hearing aids are on during noisy procedures.
c. SHOULD be asked to turn off or take off hearing aids or unhook implants when noisy powered devices such as high-speed handpiece or ultrasonic or sonic scaling instruments are being used.
d. Conduction of vibrations from dental equipment via teeth and bone can also be disturbing and such equipment should be used ONLY if necessary.
e. Moisture is a consideration for hearing aids and cochlear implants; moisture-proof surgical bonnet or small shower cap can be used to cover patient’s ears.

D. Barriers to care:

1. Physical obstacles such as doorways and stairs; finding their way in new surroundings is difficult for blind.
2. Lack of transportation; arranging transportation and/or relying on caregiver for scheduling and transportation is cumbersome.
3. Lack of communication; MORE challenging for sensory-impaired individuals; can sometimes cause healthcare providers to be apprehensive about communicating with them.
4. Economic issues; good employment opportunities may be MORE limited for sensory-impaired person.

E. Professional and homecare:

1. For visually impaired:

a. Positioning of caregivers and others to visual advantage of patient (directly in front of patient).
b. Verbally oriented approach; explain procedures before performing them; always use “tell, touch, feel” approach; do NOT leave the room without advising patient.
c. Use of large visual aids and materials and/or provision of tape-recorded homecare instructions.
d. AVOID shining operatory lamp in patient’s eyes and yelling loudly.

2. For hearing impaired:

a. Elimination of loud or background noises when attempting to communicate, such as high- or low-speed suction (high-volume evacuator [HVE]), radio, or piped-in music.
b. If patient has some hearing, direct speech to the hearing ear; do NOT wear mask.
c. Positioning of caregivers and others so patient can see facial features (particularly lips and tongue) of person speaking; do NOT wear mask.
d. Use of sign language (manual communication that includes finger spelling), message board, or interpreter if patient NOT able to read lips (speech); provide written homecare instructions; MUST ask patient which means of communication is preferred and how communication can be improved.

F. Patient or caregiver education:

1. For visually impaired:

a. Extremely descriptive explanations are IMPORTANT because they make use of other senses (particularly hearing), which are better developed.
b. Use appropriate changes in tone of voice when providing information, since facial expressions may NOT be seen.
c. Involves explanation and demonstration (on the hand) of each procedure; patient should handle visual aids to improve understanding; caregiver should be involved as needed.

2. For hearing impaired:

a. Use of demonstration is particularly effective when explaining techniques of oral care.
b. May use mirror, interpreter, sign language, or message board to explain things that are NOT easily demonstrated.
c. Includes take-home written instructions for effective reinforcement.

CLINICAL STUDY

Age 70 YRS SCENARIO
Sex imageMale image Female Patient has kept regular dental visits and was seen 3 months ago for his routine maintenance appointment. On intraoral examination the newly hired dental hygienist finds that he has a very red marginal gingiva around #20, which is a full crown.
Chief Complaint “My gums are really bleeding on this tooth!”
Medical History
Hearing impaired, hearing aids in both ears
Streptomycin toxicity as child

Current Medications None Social History Post office employee
1. What should the dental hygienist do about the patient’s hearing device? Where should the hygienist stand when speaking to him?
2. Of what significance is the fact that he has bleeding gums?
3. What is the significance of the redness around #20?
4. To whom should the hygienist refer the patient to for #20?

1. The dental hygienist should face the patient without wearing the mask when speaking to him and have him turn off the hearing device during noisy procedures.
2. Bleeding gingiva could be indicative of a change in his oral hygiene care level, and the hygienist must find out what the patient is doing and how to help him with this problem.
3. Marginal redness around #20 could indicate that the crown is invading the biological width of the tissues.
4. The dental hygienist can only refer patients to the general dentist, although it is known that this patient may need to see a periodontist. However, the supervising general dentist must make that referral.

Cognitive Disabilities

Common cognitive disabilities include intellectual disability (mental retardation), cerebral palsy, autism, attention deficit–hyperactivity disorder or attention deficit disorder, learning disorder, Alzheimer’s disease. Mental illness is considered separately in the next section.

A. Intellectual disability (mental retardation): MOST common developmental disability (Box 16-2).

1. Below-average intellectual functioning (IQ below 70 to 75) caused by chromosomal disturbances; by infection, trauma, or disturbance during fetal development; by trauma or infection during birth; or by trauma or nutritional deficiencies during childhood.

a. Down syndrome (trisomy 21): form particularly IMPORTANT in dentistry because of associated intraoral anomalies (short, narrow palate; large, fissured tongue) and risk factors for periodontal disease (Figure 16-1). Usually walk with a “waddle” and have dexterity problems, so homecare can be a problem.
b. Fetal alcohol syndrome (FAS): disorder associated with prenatal exposure to alcohol. Intellectual disability (mental retardation), poor coordination, behavioral disorders, growth disturbances, and abnormal facial features (epicanthal folds, low nasal bridge, small head, and small mouth [micrognathia]) (Figure 16-2).

2. Systemic concerns tend to be MORE extensive in more severely intellectually disabled (mentally retarded) individuals.

a. Affected individuals tend to have characteristic physical traits and body stature; head, face, eyelids, ears, nose may be malformed, depending on syndrome and severity.
b. Other medical problems commonly associated with intellectual disability (mental retardation):

(1) Leukemia.
(2) Congenital heart abnormalities.
(3) Infectious hepatitis and respiratory infections.
(4) Epilepsy and neuromuscular disorders.

3. Oral signs:

a. Delayed or irregular tooth eruption; small, cone-shaped, fused, or missing teeth; malocclusion.
b. Repercussions of mouth breathing and tongue thrusting, with drooling (sialorrhea) possible; cracked lips.
c. Increased risk of periodontal disease.

4. Risk factors:

a. At risk for systemic and local infections because of weakened immune system.
b. Increased risk of hepatitis B infection if has been institutionalized.
c. Difficulty modifying behavior.
d. Poor coordination.

5. Barriers to care:

a. Dependence on caretaker to make and keep dental appointments.
b. Cost of dental care.
c. Mental limitations:

(1) Build trust; communicate at developmental level; speak simply.
(2) Reward good behavior; restraints and sedation to manage behavior are recommended ONLY when necessary.

6. Professional and homecare:

a. Frequent oral prophylaxis to reduce risk of periodontal disease.
b. Lubrication of lips to reduce risk of cracking.
c. Awareness that gag reflex may be strong.
d. Use of anticholinergic drugs for reducing excess salivation during intraoral procedures.

7. Patient or caregiver education:

a. Repetition of simple, demonstrable homecare procedures with patient and caregiver.
b. Caregiver supervises and/or performs oral hygiene procedures depending on abilities.
c. Discussion of periodontal risk and need for excellent daily homecare, frequent progressive oral prophylaxis and examination.

B. Cerebral palsy (CP): limitation ranges from mild to severe.

1. Developmental, neuromuscular disorder that results in NO ability to control muscular movement (spasticity).
2. Caused by variety of injuries to the brain (e.g., infection, trauma, poisoning, anoxia), before, during, or not long after birth.
3. Systemic concerns: chronic contraction of muscles, poor coordination and dexterity, intellectual disability (mental retardation) in LESS than half, learning disabilities caused by sensory impairment (hearing and vision), possibly respiratory impairment.

a. Affected individuals who have seizure disorders take appropriate drugs, antiepileptics.
b. Communication is often difficult because of motor difficulties (see earlier discussion).

4. Oral signs:

a. Lack of control of facial muscles; causes difficulties in speech (dysarthria), chewing, and swallowing (dysphagia); may have drooling (sialorrhea).
b. Difficulty keeping mouth open during dental appointments.
c. Temporomandibular joint disorder (TMD), tongue thrusting, mouth breathing, bruxism, attrition.
d. Caries and periodontal disease related to inability to practice good oral hygiene measures because of limited coordination.
e. Gingival hyperplasia if taking phenytoin (Dilantin); degree of hyperplasia is related to level of oral care (i.e., as dental biofilm increases, so does hyperplasia).

5. Risk factors: inadequate fluoride intake, soft diet, poor motor control, with NO ability to properly maintain own oral care.
6. Barriers to care:

a. Communication difficulties between patient and dental professional; low self-esteem may also influence desire to communicate.
b. Unfamiliarity of dental office; causes emotional distress, thereby increasing spastic movement.
c. Dependence on caregiver, lack of mobility.
d. Lowered ability of dental professional to provide thorough treatment because of patient’s physical limitations.

7. Professional and homecare:

a. Building trust, desensitizing patient to dental routines, encouraging complete communication.
b. Realizing that communication barriers do NOT indicate incomprehension.
c. Avoiding injury to patient or clinician from uncontrolled movements during instrumentation (fulcrums are a must); do NOT move chair without notice; padding or restraints may be necessary to provide assistance in cooperating for the procedure; may need wheelchair transfer (discussed later).
d. Preventing aspiration of water or other materials placed in the oral cavity.
e. Using anticholinergic drugs to reduce excess salivation during intraoral procedures.
f. Involving caretaker and/or assistant during treatment to prevent injury and expedite treatment.
g. Assisting during seizures (during seizure activity, patient should NOT be moved; area should be cleared of items that may cause injury during convulsive movement).
h. Using muscle relaxants, sedation, and general anesthesia when they will be of benefit.
i. Using sheet, blanket, bean-bag chair to make patient feel secure.

8. Patient or caregiver education:

a. Adaptations of toothbrushes and floss handles as needed.

Related posts:

  1. 10: Medical and Dental Emergencies
  2. 8: Microbiology and Immunology
  3. 15: Dental Biomaterials
  4. 14: Pain Management
  5. 6: General and Oral Pathology
  6. 3: Anatomy, Biochemistry, and Physiology

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Jan 1, 2015 | Posted by in Dental Hygiene | Comments Off on 16: Special Needs Patient Care

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