Introduction

‘Special needs’ is an umbrella term under which a staggering array of diagnoses may be included: from mild learning disabilities to profound mental retardation; food allergies to terminal illness; developmental delays that are transitory to those that are intractable; occasional panic attacks to serious psychiatric problems. The designation is useful for garnering needed professional help and services, setting appropriate goals, and gaining understanding for a child and his distressed family. The present chapter will focus on those children with developmental disability involving behavioral problems.

Therapeutic Access

Children with behavioral issues do not respond to traditional discipline nor do they necessarily wish to be subjected to the various procedures they may need to undergo. Their intellectual level is also not adequate for them to understand the need for compliance in the intricacies of a standard biomechanical apparatus. They require specialized and, often, simplified strategies that are tailored to their specific abilities and disabilities. If these important steps are not considered by the operator, therapeutic access may be impossible to obtain. The clinician needs to be understanding, flexible, and creative.

There are several specific areas in which the special needs patient will unintentionally obstruct the delivery of treatment (Becker and Shapira, 1996) and this is because he or she typically has shortcomings not usually seen in the normal child, such as (Shapira et al., 1999):

• Increased apprehension, reduced understanding, limited tolerance and short attention span
• Exaggerated gag reflex (which seems to be a consequence of fear)
• Inability to remain still for any appreciable time; uncontrolled body movements
• Reduced level of cooperation
• Drooling.

Under these conditions simple exercises such as the taking of radiographs or dental impressions become tasks of major proportions. In order to achieve these normally modest and simple aims, behavior modification techniques may need to be employed, with or without specific pharmacological aids and/or through conscious and deep sedation or with general anesthesia.

Over the past 20 years or so, both the absolute number and proportion of special needs children in society has increased (Waldman et al., 2000), in spite of prenatal diagnostic techniques and the improvement in prenatal identification of congenital anomalies. The main reasons are first, sophisticated medical care, both perinatal and adult, that has increased the survival rate of the newborn and their overall life expectancy. Second, given the enlightened attitude of society today, changing social policies and legislation, many more special needs children are seen as an integral part of their family, within adoptive families, or in sheltered housing and are thus far more visible in general, while three decades ago they were largely housed in institutions. This gradual but palpable process of ‘mainstreaming’ has brought about a greater awareness and appreciation on the part of the general public.

With their higher public profile, the present-day affluent society of the Western world has created a general improvement in quality of life for these children that, in turn, expresses itself in an increased demand for esthetics and normal function. The aim is acceptance into society, including the opportunity for employment towards self-sufficiency. As the direct result, the concern for facial appearance has become an item for discussion among their parents and this has generated a demand for orthodontic treatment (Becker and Shapira, 1996).

In general, the main goals of orthodontics are to improve the alignment and occlusion of the teeth and thus, to contribute to one of the more important factors involved in improvement of the facial appearance (Shaw et al., 1980). However, its efficacy is limited and cannot provide a satisfactory answer for every situation. Individual benefits that are principally associated with the patient’s own concept of him/herself might have been gained by the patient and these are often strongly influenced by those around him (Sticker, 1970).

Studies of the effects that dental appearance has on individuals and their surroundings have found this to be extremely important in overall facial esthetics (Lew, 1993). In adverse conditions, it is a principal focus for teasing among school children (Shaw et al., 1980), has a significant emotional impact on the individual, and is a factor used in social acceptability and personality judgment by others (Shaw, 1981).

In their everyday life, special needs children comprise a group of individuals who depend heavily on their families and others for their needs and welfare. From earlier observations (Oreland et al., 1987), we learn that they have malocclusion, which is more frequent, more severe, and more skeletally based than in the general population. Several conditions, such as cerebral palsy, Down syndrome, and mental retardation, exhibit increased prevalence of specific dental features (Cohen and Winer, 1965; Franklin et al., 1996), which can adversely affect function (Proffit et al., 2007). Yet, these patients are those least likely to receive orthodontic treatment.

Beneficial But Not Essential

The pediatric dentist must treat a patient to eliminate dental disease and to relieve pain, regardless of whether the child is cooperative in the dental chair and diligent in his routine homecare. At the same time, the dentist is duty-bound to encourage behavior alteration in both these areas. By contrast, orthodontics performed under these adverse conditions is contraindicated since a successful outcome is doubtful and iatrogenic damage, in the form of caries and gingival inflammation, is likely. Thus, while treatment need is often high and its object beneficial, orthodontics must still be considered to be an elective item. The order must therefore be reversed, with a sustained level of oral hygiene being first achieved, and this is the point where parental involvement will usually be essential.

Motivation and Expectation

The motivation for treatment in most of these cases comes from the parents of the disabled child, rather than from other medical or dental professionals (Becker et al., 2000). A majority of these children live at home, receiving daily one-on-one attention from highly motivated parents and siblings, who are often prepared to sacrifice much to improve the child’s wellbeing (Becker et al., 2000). Certainly many of the children will be sufficiently aware to believe that treatment is desirable, but there is a deep abyss between their ‘in principal’ agreement and the compliance that will be needed when the first clinical steps need to be taken.

The wearing of a simple orthodontic appliance, together with maintaining adequate oral hygiene either alone or permitting the parents to do it, may represent the first challenge of accepting responsibility on the part of the child. The special needs child is usually positively influenced by praise and compliments from the practitioner, the parent and those around him/her, when certain functions and stages are completed successfully and this all combines to form an environment that encourages compliance. A marred facial appearance is the principal factor motivating the request for orthodontic treatment among normal children but, in the present context, recognition of poor oral health and function and their improvement are parallel aims (Becker et al., 2000).

Patient Management

Special needs patients need much more time and understanding for progress to be made in treatment and this requirement may exceed the patience of many otherwise highly productive providers, since it is difficult to rise to the challenge and yet blend it with the smooth running efficiency of a regular orthodontic office (Waldman et al., 2000; Becker et al., 2001). Sedation or general anesthesia sessions are sometimes needed and it makes sense to include other specialists to perform any required endodontic, oral surgery, and restorative procedures, taking advantage of the potential that these modalities provide (Chaushu and Becker, 2000). An orthodontic environment that can accommodate all these specialists and provide a trained anesthetist close at hand is unlikely outside a hospital-type setting, which limits the capability of the purely orthodontic practice for the duration of the only the simplest of cases of this type.

Pretreatment Visits and Patient Assessment

Although true for every orthodontic case, there are four specific aims which have special relevance here, with the exception that in the present context they invariably demand more than a single visit to evaluate them. Morbidity due to medical conditions that feature hypotony and myopathy is high among this group, which means that food is not cleared from the mouth efficiently in normal function, manual dexterity is poor and most subjects practice no oral hygiene whatsoever. Pre-treatment visits are therefore essential and are used for four specific purposes:

• To allay the patient’s anxiety and raise confidence level in the dental chair
• To evaluate the existing level of homecare, to point out to both child and parent where it may be lacking
• Demonstrate how improvement can and must be achieved always with parental supervision, often with their active participation, as a precondition to acceptance for treatment
• To assess the level of actual compliance and whether this can be maintained through treatment.

At the first visit, the child and parent are shown the debris surrounding the teeth, the collections of food in the palatal vault, in the cheek area and elsewhere, together with the accompanying gingival inflammation, and are taught to recognize this situation. In order for the child to reach a level of oral hygiene consistent with the pursuit of orthodontic treatment, it is inevitable that the parent must be the dominant tooth brusher, with the child ‘finishing off’ the exercise to include him or her in accepting responsibility that will take them through later life. The act of tooth brushing carried out by a parent on a daily basis is itself a potentially helpful exercise, since it familiarizes the child with the insertion of foreign items into the oral cavity in a non-threatening environment, which helps to overcome apprehension and gagging (Becker and Shapira, 1996). Perhaps the most reliable sign of a good and potentially compliant patient is seen at the visit after oral hygiene instruction has been given and its importance stressed. The patient and parent arrive with an optimistic disposition, having put into practice what they have learned. However, the acid test is not merely to see clean teeth, but to check for the resolution of the gingival inflammation.

It has to be recognized that most visits for later orthodontic treatment will usually require using behavior management techniques and that sedation and general anesthesia will only be used for lengthy and involved procedures – perhaps two or three sessions for the duration of the treatment. For this reason, time spent in pretreatment preparation and evaluation is usually well spent (Chaushu and Becker, 2000). If the patient is unable to achieve a healthy mouth, the orthodontist should refuse to treat at that time and suggest follow-up at a later date.

Drawing Up a Tentative Treatment Plan

Treatment plans are usually the product of the gathering and collation of information contributed from a clinical examination, from photographic and radiographic records, a cephalometric analysis, plaster casts, and other aids to diagnosis and, under normal conditions, these records are simply and routinely acquired. In the present circumstances, these same diagnostic aids become a major undertaking which can frighten the child for months or years to come, if badly managed.

The answer may often be to formulate a general direction of treatment based on a clinical examination only and delay the needed diagnostic records for the first sedation session. This initial and tentative treatment plan may then be confirmed or adjusted in accordance with the new information. In this way, the first sedation session may be used for alginate impressions (to be rapidly cast), intraoral radiographs and photographs (to be quickly processed and viewed), a full treatment plan devised on the spot and, perhaps a further impression to make an initial simple removable plate. Other activities that may be usefully brought into this single session include scaling, fissure sealants, and minor restorations or even root treatments for traumatized central incisors, which is a common occurrence in these patients. At the conclusion of this important visit, the new records are studied and a reasoned working treatment plan established. This level of patient management requires a high degree of diagnostic and clinical skill on the part of the lead orthodontist.

Control of Adverse Behavior During Treatment

Orthodontics involves many visits for a variety of different treatment activities and functions and it must be clear from the outset that negative behavior cannot be controlled with general anesthesia at every visit. Certainly for the more anxious special needs patient, the difficult, the exacting, and the protracted visits and those in which more meticulous biomechanics is needed, pharmacological assistance will be needed, but these need to be properly planned and kept to a minimum. This means that the use of the ‘tell-show-do’ behavior modification techniques, with positive and negative reinforcement, needs to become the modus operandi for the most part of any treatment program, leaving a decision to be made regarding the supplementary modalities needed for those procedures that are poorly tolerated (Becker and Shapira, 1996).

A conscious and highly anxious patient can be brought to a relaxed state by pharmacological agents through several routes, including inhalation (nitrous oxide and oxygen), transmucosally (midazolam via nasal drops), orally (chloral hydrate, valium, midazolam), or intravenously (propofol). Through the use of these agents, the patient’s compliance may be assured for the duration of the treatment, increasing the range of procedures that may be performed on the unwilling and apprehensive patient, even permitting the orthodontist to provide treatment formerly considered impossible. Combinations of these drugs, such as midazolam (anxiolytic, sedative and amnestic) with nitrous oxide (analgesic and relaxing effects) can produce conscious sedation with virtually no side effects and may be used inexpensively for relatively short procedures (Malamed, 1995). General anesthetic carries with it the accompanying need for short term hospitalization, specialized operating theatre, and preoperative and postoperative care. Nevertheless, until recently it was considered the only answer for the more involved and lengthy procedures, such as the placement of a fully bracketed fixed appliance, possibly combined with the extraction of teeth in appropriate cases, despite the attendant morbidity and much higher cost (Jackson, 1967; Chadwick and Asher-McDade, 1997).

Several years ago, we introduced intravenous deep sedation as an alternative to general anesthesia and this has permitted us to increase the uptake of greater numbers of very difficult patients (Chaushu et al., 2002b) without the need for an operating room. The orthodontic clinic is the ideal environment to carry out orthodontic procedures, but it is required to be properly equipped for sedation with the availability of the services of an anesthetist, if sedation is to be performed. The sedation agent used is intravenous propofol, which induces a safe level of sedation very rapidly and is relatively free of side effects. Risk of aspiration and other emergencies is very low and the patient’s vital reflexes are maintained for the duration of the sedation. Intubation is not usually necessary and recovery is very fast. This modality permits medium duration procedures to be undertaken, including collaboration with oral surgery and endodontic specialists in the comprehensive treatment of the patient. Intravenous sedation has greatly improved our ability to achieve therapeutic access in these patients and has facilitated the smooth pursuit of treatment on an outpatient basis (Chaushu et al., 2002b).

Adapting Orthodontics to the Special Needs Child

Modifications to orthodontic treatment and the manner in which it is delivered are needed, if success is to be achieved with these patients.

• Pragmatic treatment aims: Ideal results are not always achievable because various adverse factors may be present in the particular individual, which dictate aiming for more limited goals.
• Record taking: We have already mentioned the problems involved in taking impressions and how these may be circumvented. Intraoral radiographs are often just as difficult to take in these cases, when the child is fully conscious, and these may need to be taken under sedation. On the other hand, extraoral films, such as panoramic radiographs and cephalograms are usually better tolerated. However, holding the head of a frightened child in a cephalostat, or having him/her sit still in a particular posture for several seconds while the X-ray tube circles the head, may not be possible and sedation may not be an asset in this situation. Accordingly, diagnosis may have to be made with fewer diagnostic aids, placing greater emphasis on the clinical examination.
• Modular treatment: A problem list should be drawn up and its various components prioritized into modules, beginning with the simpler tasks and progressing to the next, while being prepared to make adaptive alterations that may be needed at each stage.
• Simplified treatment methods:
  • Placement of removable appliances is very simple, is easily learned, and well tolerated (Becker et al., 2001). Adjustment and activation are made outside the mouth, which means that the patient’s mouth is not disturbed by the operator’s hands and by the insertion and manipulation of dental instruments. Oral hygiene is considerably easier than with fixed appliances, both for parent and child. It is recommended to continue their use to achieve as much as possible before moving on to the fixed appliance stage or, possibly, even to be in the position to occasionally eliminate it. Care should be taken in the design and construction of the removable appliance to include several retention clasps, so that even the more rebellious child with limited dexterity will have difficulty in removing it, until quickly becoming accustomed to its presence.
  • Appliances with a long range of action should be preferred, to increase the time/>
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