8

Special Needs Patients

Nancy Dougherty

Case 1
Trisomy 21 (Down Syndrome)/New Patient

A. Presenting Patient

• 6-year-, 6-month-old, African-American male
• Diagnosed with Trisomy 21 (Down syndrome) (see Background Information 1)
• New patient visit

B. Chief Complaint

• Mother states, “My son has been to other dentists, but they were not able to take care of him”

C. Social History

• Patient attends school; in class for children with special educational needs
• Mother is primary caregiver
• Lower mid-level socio-economic status
• Patient has two sisters, ages 8 and 11

D. Medical History

• Cardiac: Ebstein’s anomaly (congenital defect of tricuspid valve). Patient’s defect is mild and has not required surgical repair. He is not currently on any medications and is followed by pediatric cardiology on an outpatient basis (see Fundamental Point 1).
• History of frequent otitis media and upper respiratory infections.
• Patient was hospitalized at age 3 for myringotomy and placement of tympanostomy tubes. Due to post-operative complications, patient was required to stay in the hospital for three days post-operatively.

E. Medical Consult

• Cardiology consult requested. Patient cleared for routine dental treatment. Antibiotic prophylaxis not required.

F. Dental History

• Mother has taken patient to three other dentists, but she was dissatisfied with care provided.
• Patient’s behavior was uncooperative for previous dental examinations.
• Optimal water fluoridation levels
• Patient is not a frequent snack eater, but does drink large amounts of sugary beverages.
• Patient does not brush teeth himself. Allows mother to brush his teeth under duress.

G. Extra-oral Exam (Figures 8.1.1 a–b)

• Patient has characteristic facies of Trisomy 21, as discussed in the background information.
• No other significant findings

Figure 8.1.1a–b. Facial photographs

H. Intra-oral Exam (Figures 8.1.2 a–c and Fundamental Point 2)

• Early mixed dentition
• Erupting mandibular central incisors
• Poor oral hygiene
• Generalized marginal gingival inflammation
• Caries-free dentition
• Occlusion: class III skeletal relationship, mesial step primary molars

Figure 8.1.2a–c. Intra-oral photos showing generalized marginal gingival inflammation.

I. Diagnostic Tools

• Radiographs were not obtained for the following reasons:
  • Patient was unable to cooperate for radiographic exam
  • No caries were noted
  • It was determined that the patient would require sedation for radiographic exam; due to absence of caries and the patient’s past history of post-anesthesia complications, the practitioner did not feel sedation presented an appropriate risk/benefit balance for this patient at this time (see Fundamental Point 3).

J. Differential Diagnosis

• N/A

K. Diagnosis and Problem List

Diagnosis

• Trisomy 21
• Congenital heart defect (triscuspid valve prolapse)
• Frequent otitis media
• Gingivitis
• Poor oral hygiene
• Malocclusion

Problem List

• High caries risk due to special needs status, high intake of sugared beverages, and poor oral hygiene
• Lack of a dental home
• Increased risk for periodontal disease due to poor oral hygiene and compromised immunity
• Increased risk for ectopic eruption or impaction of teeth, especially in maxillary arch (due to maxillary hypoplasia)

L. Comprehensive Treatment Plan (see Fundamental Point 4)

• Establish a dental home
• Dental prophylaxis and topical fluoride
• Encourage parent to reduce sugared beverage intake
• Encourage improved oral hygiene, (in this case, with parent) focusing on brushing and flossing
• Three-month recall
  • Re-evaluate caries risk
  • Re-evaluate oral hygiene status
  • Monitor eruption of permanent dentition
  • Re-evaluate patient’s ability to cooperate for radiographic exam. If cooperative, take radiographs to evaluate for interproximal caries and development of permanent dentition.

M. Prognosis and Discussion

• There have been reports that individuals with Trisomy 21 have a lower incidence of dental caries than the general population. However, they do experience caries and this patient’s high intake of sugary beverages and poor oral hygiene increases his risk for caries. Dietary modifications and increased recall visits including topical fluoride treatments should reduce this patient’s caries risk.
• This patient is at high risk for development of periodontal disease due to a combination of compromised immune response and poor oral hygiene. Improved oral hygiene and increased recall visits, including prophylaxis and monitoring for periodontal problems, may help improve this patient’s periodontal prognosis.
• Behavioral capabilities, both in the dental setting and at home, are always a consideration when treating children with intellectual disabilities. There is a wide range of behaviors in children with Trisomy 21, and many of them are treatable for routine dental care with little or no modifications in care necessary. Diagnostic exams for this particular patient were compromised by the fact that he has, up to now, been uncooperative for radiographs. An oral examination, prophylaxis, and fluoride varnish treatment were made possible with the mother’s assistance, holding her child in the dental chair. Tell-show-do was used with limited effectiveness. As per the mother’s report, the child’s behavior also makes it difficult for her to accomplish adequate oral hygiene at home. An attempt was made to keep the dental visit as atraumatic as possible, and it is possible that, in the future, the child may become more cooperative. As discussed earlier, these children are at an increased risk for complications related to sedation and general anesthesia, and careful consideration must be made for each individual as to whether or not an anesthetic procedure is warranted for routine diagnostic and dental procedures.

N. Complications and Alternative Treatment Plan

• If this patient had clinically detectable caries, would the behavior management techniques previously used be adequate to accomplish needed treatment?
• If this child had cervical spine (atlanto-axial) instability, how might the practitioner need to modify the way in which dental care was delivered?
• Would there be any differences in this child’s orthodontic care at this age if his behavior was cooperative?

Bibliography

American Academy of Pediatric Dentistry. 2011–2012. Guideline on Caries-risk Assessment and Management for Infants, Children, and Adolescents, Reference Manual. Pediatr Dent 33(6):110–15.

Freeman SB. et al. 1998. Population-based study of congenital heart defects in Down syndrome. Am J of Medical Genetics 16;80(3):213–17.

Mitchell RB, Call E, Kelly J. 2003. Ear, nose and throat disorders in children with Down syndrome. Laryngoscope 113(2):259–63.

National Institute of Child Health and Human Development. www.nichd.nih.gov/health/topics/Down_Syndrome.cfm.

Pilcher, ES. 1998. Dental care for the patient with Down syndrome. Down Syndrome Research and Practice 5(3):111–16.

Shaw L, Saxby MS. 1986. Periodontal destruction in Down’s syndrome and in juvenile periodontitis; how close a similarity? J of Periodontology 57:709–13.

Yavuzyilmaz E. et al. 1993. Neutrophil chemotaxis and periodontal status in Down syndrome patients. J of Nihon University School of Dentistry 35:91–5.

SELF-STUDY ANSWERS

1. Congenital heart defects, cognitive impairment, compromised immune response, thyroid disorders, cervical spine instability, increased risk for development of leukemia, increased incidence of early development of senile dementia

2. Hypoplastic midface, mild microcephaly, upslanted palpebral fissures, short neck

3. Hypodontia, microdontia, delayed dental eruption, ectopic dental eruption, dental impactions, crowding of maxillary dentition, relative macroglossia, class III malocclusion

4. Increased incidence of airway anomalies, small naso-pharyngeal complex, hypotonia, obesity, increased incidence of congenital heart defects, increased incidence of spinal deformities and instability

5. Individuals with Trisomy 21 have a compromised immune response, which places them at increased susceptibility for chronic infectious processes. This is the probable explanation for their relatively high incidence of periodontal disease.

Case 2
Cerebral Palsy, Bronchopulmonary Dysplasia

A. Presenting Patient

• 8-year-, 2-month-old Caucasian male
• Diagnosed with cerebral palsy, bronchopulmonary dysplasia, asthma, and mild intellectual disability

B. Chief Complaint

• Patient presenting for recall appointment; last dental visit was 18 months ago

C. Social History

• Patient attends school; is in a class for children with special educational needs
• Child lives at home with mother, father, and 3 older siblings
• Father works full time; mother is a full-time homemaker
• Socio-economic status is lower middle class

D. Medical History (see Background Information 1)

• Premature birth (child was born at 26 weeks gestational age, birth weight = 978 g) (see Fundamental Point 1)
• Cerebral palsy, mixed type (spastic and dyskinetic)
• Status post bronchopulmonary dysplasia secondary to long neonatal course of positive pressure ventilation
• Hospitalization for aspiration pneumonia at age 2
• Mild/moderate asthma, currently managed with Flovent (fluticasone) and albuterol inhalers used on a daily basis
• Mild intellectual disability

E. Medical Consult

• Consulted with primary care physician to ascertain patient’s current respiratory status, which is stable

F. Dental History

• Has been managed at the same dental clinic since 3 years of age
• Attendance at clinic has been sporadic (last visit 18 months ago)
• Positive behavior for brief procedures, but very active in dental chair: Try to keep appointments short
• Not a frequent snacker, eats mostly at meal time
• Optimal water fluoridation levels
• Brushes without supervision (once or twice per day)

G. Extra-oral Exam (Figure 8.2.1)

• No significant findings

Figure 8.2.1. Facial photograph

H. Intra-oral Exam (see Figures 8.2.2a–c and Fundamental Point 2)

• Early mixed dentition (slightly delayed for age)

Figure 8.2.2a–c. Intra-oral photos showing generalized marginal gingivitis and mandibular crowding

Occlusion

• 9-mm overjet, anterior open bite
• Moderate crowding of the lower arch
• Mesial step primary molars, class I canines

Poor Oral Hygiene

• Generalized marginal gingivitis
• Clinical exam suggests caries-free dentition

I. Diagnostic Tools

• Radiographs (bitewings and a panoramic film) were attempted, but were of poor diagnostic quality due to patient’s difficulty staying still

J. Differential Diagnosis

• N/A

K. Diagnosis and Problem List

Diagnosis

• Cerebral palsy
• Cognitive impairment (mild)
• Status post bronchopulmonary dysplasia with current mild/moderate asthma

Problem List

• Irregular use of a dental home
• Gingival inflammation due to poor oral hygiene
• High caries risk due to poor oral hygiene and asthma medications
• Unknown caries status of interproximal surfaces
• Large overjet increases risk of traumatic dental injury
• Moderate mandibular crowding

L. Comprehensive Treatment Plan

• Dental prophylaxis (sedation may be necessary)
• Fluoride treatment
• Review of oral hygiene and diet (with parent and child)

• Orthodontic consultation
  • Space analysis to evaluate arch length
  • Evaluate patient’s behavior regarding his ability to cooperate for orthodontic treatment (if treatment is indicated at this time).
• Three-month recall
  • Re-evaluate caries risk
  • Re-evaluate oral hygiene and soft tissue status

M. Intra-Oral and Post-operative Images

• N/A

N. Prognosis and Discussion

• Although the patient is in a high risk category for dental caries due to poor oral hygiene, he has never had a carious lesion. The prognosis for continued periodontal pathology is high due to poor hygiene, but could improve with better daily oral hygiene. Even performing a thorough prophylaxis may be difficult and sedation may be considered (see Fundamental Point 4).
• The prognosis for malocclusion is poor. Although the patient is fairly cooperative for oral examinations and prophylaxis, it is not clear what his level of cooperation would be for lengthier or more complicated treatments. This must be evaluated and taken into consideration before a decision is made to begin orthodontic treatment.

O. Complications and Alternative Treatment Plan

• If the patient had dental caries present, would the behavior management techniques previously used be adequate to accomplish the needed treatment?
• Is this child an appropriate candidate for in-office sedation, or would he be better managed in a hospital operating room setting, if treatment needs dictated?
• Would there be any difference in this child’s orthodontic treatment at this age, if behavior was not a consideration?

Bibliography

American Academy of Pediatric Dentistry. 2011–2012a. Guideline on Caries-risk Assessment and Management for Infants, Children, and Adolescents, Reference Manual. Pediatr Dent 33(6):110–15.

American Academy of Pediatric Dentistry. 2011–2012b. Policy on Dietary Recommendations, Reference Manual. Pediatr Dent 33(6):53–4.

American Academy of Pediatric Dentistry. 2011–2012c. Periodicity of Examination, Reference Manual. Pediatr Dent 33(6):102–9.

American Academy of Pediatric Dentistry. 2011–2012d. Management of the Developing Dentition, Reference Manual. Pediatr Dent 33(6):229–41.

American Academy of Pediatric Dentistry. 2011–2012e. Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures, Reference Manual. Pediatr Dent 33(6):185–201.

Bax M, Goldstein M, Rosenbaum P, et al. 2005. Proposed definition and classification of cerebral palsy. Dev Med Child Neurol Aug; 47(8):571–6.

Blayney M, Kerem E, Why/>

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