“Disabilities” is an umbrella term under which a staggering array of diagnoses may be included, from mild learning disabilities to profound intellectual disability; from food allergies to terminal illness; from developmental delays that are transitory to those that are intractable; and from 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 or her distressed family. This chapter will focus on 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 may also be inadequate 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 child with disabilities 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 children without disabilities, 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 tasks such as taking radiographs, making dental impressions, and bonding orthodontic brackets become tasks of major proportions. To address these normally modest and routine procedures, behavior modification techniques may need to be employed, with or without specific pharmacological aids, including conscious and deep sedation or general anesthesia.

Over the past 20 years or so, both the absolute number and proportion of persons with disabilities in society have increased (Waldman et al., 2000), despite prenatal diagnostic techniques and the improvement in prenatal identification of congenital anomalies. The main reasons are first that sophisticated medical care, both perinatal and adult, has increased the newborn’s survival rate and overall life expectancy. Second, given the more enlightened attitude of society today, as well as changing social policies and legislation, many more children with disabilities 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 40–50 years ago they were largely housed in institutions. This gradual but palpable process of “mainstreaming” has brought about greater awareness and appreciation on the part of the general public.

With these children’s higher public profile, the present‐day affluent society of the Western world has created a general improvement in their quality of life, which expresses itself in an increased demand for esthetics and normal function. The aim is acceptance into society, including the opportunity for employment toward 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 it cannot provide a satisfactory answer for every situation. Individual benefits that are principally associated with patients’ own concept of themselves might have been gained by those patients and these are often strongly influenced by the people around them (Sticker, 1970).

Studies of the effects that dental appearance has on individuals and their surroundings have found it to be extremely important in overall facial esthetics (Lew, 1993). In adverse conditions, dental appearance is a principal focus for teasing and bullying 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, children with disabilities comprise a group of individuals who depend heavily on their families and others for their welfare. From earlier observations (Oreland et al., 1987), we learn that they have malocclusion that is more frequent, more severe, and more skeletally based than in the general population. Several conditions, such as cerebral palsy, Down syndrome, and intellectual disability, 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.

Pretreatment visits, patient assessment, and future management

For every orthodontic case in routine orthodontic practice, assessment of the patient’s future compliance potential is an essential part of the pretreatment examination, which may usually be completed within a short half‐hour initial visit. In the context of the child with disabilities, this assessment has particular relevance and it may take as many as three, four, or five additional visits to learn what may be expected of the child and the parent. Due to medical conditions that feature hypotony and myopathy, morbidity is high among this group, which means that food debris is not efficiently cleared from the mouth and is commonplace. Manual dexterity is much reduced and inadequate for adeptly wielding a toothbrush, with most subjects practicing no oral hygiene whatsoever. Pretreatment visits are therefore essential and are used for four specific purposes:

• To allay the patient’s anxiety and raise the confidence level in the dental chair.
• To evaluate the existing level of homecare oral hygiene, to point out to both child and parent where it may be lacking.
• To demonstrate how improvement can and must be achieved always with parental supervision, often with active parental 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 partially masticated food in a high 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 them 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, by another individual and in a nonthreatening 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 show the dentist clean teeth, which may have been brushed solely on the day of the visit. Rather, it should be to check for resolution of the gingival inflammation, which can only occur with efficient elimination of food debris and biofilm with at least twice‐daily regularity over a sustained period.

Maintenance of adequate oral hygiene among patients receiving orthodontic treatment with removable appliances is obviously easier than for those with fixed appliances. The patient’s teeth and the removable orthodontic appliance may be brushed separately, under more favorable conditions. Those with fixed orthodontic appliances face the additional challenge of plaque removal due to the retentive properties of brackets and other components and, without a parent’s help, they are surely doomed to fail. Orthodontic treatment is often performed on teenagers who might lack motivation and, without long‐term compliance, will inevitably result in caries and gingival inflammation (Petrauskiene et al., 2019).

Despite extensive preventive measures utilized over the years, white spot lesion development in association with orthodontic treatment remains a serious clinical problem. It is difficult to stem the long‐term deterioration of these lesions, even after appliance removal. It was therefore suggested by the American Academy of Pediatric Dentistry (AAPD, 2018) and the European Academy of Paediatric Dentistry (EAPD, 2009) that topical fluorides should be used in children considered to be at increased risk for caries development, such as children undergoing orthodontic treatment. Needless to say, the effect of the topical applied fluorides would be much greater when combined with good oral hygiene and the use of fluoride toothpastes. Fluoride varnishes are very effective, easily applied products that enhance remineralization. The varnishes are used as a preventive measure to reduce demineralization of the enamel around the brackets and promote the remineralization of existing carious lesions. Application in the dental office minimizes the need for individual patient compliance with the home use product (Weintraub, 2006). According to the reference manual of the AAPD (2018), the most commonly used agents for professionally applied fluoride treatment are 5% fluoride varnish (22,600 ppm) and acidulated phosphate fluoride (AFP; 1.23% F, 12,300 ppm). A meta‐analysis of 23 clinical trials favors the use of the fluoride varnish (Weyant et al., 2013; Zhou et al., 2019). Advantages of fluoride varnishes, especially over other topical fluoride regimens, include protection of enamel in the absence of patient compliance and continuous fluoride release over a long period of time. The application of a fluoride varnish was shown to result in a 44.3% decrease in enamel demineralization in patients undergoing orthodontic treatment (Zabokova‐Bilbilova et al., 2014). Some studies have recommended an application even every 90 days to promote adequate protection (Vivaldi‐Rodrigues et al., 2006).

It should be recognized that most visits for the duration of orthodontic treatment will require the use of behavior management techniques. Sedation and general anesthesia should only be used for essential, lengthy, and involved procedures – perhaps one or two such occurrences during the treatment. For this reason, time invested in pretreatment preparation and critical scrutiny is usually time well spent (Chaushu and Becker, 2000). If the parent–patient “team” is unable to achieve a healthy mouth at home, following a series of visits for prophylaxis, oral hygiene instruction, and caries prevention education, then the orthodontist should refuse to treat at that time and suggest follow‐up to review the status at a much later date. The parent should be encouraged with reassuring departing words, such as “the office door is open to you in the future, but you must be prepared and able to attend to the homecare, with demonstrable and consistently satisfactory results.” The orthodontist cannot afford to rely on the promise of future compliance from a parent anxious to begin treatment. Orthodontic therapy is almost never an emergency situation and the results of adequate oral hygiene are usually clinically apparent within a few weeks.

Children with disabilities require much more time and understanding for progress to be made in treatment and this requirement may exceed the endurance of many otherwise highly productive providers, since it is difficult to rise to the challenge and yet blend it with the smoothly run 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 take advantage of the clinical access that these modalities provide to address other dental treatment needs, including endodontic, oral surgical, and restorative procedures (Chaushu and Becker, 2000). An orthodontic facility that can accommodate all these specialists and provide a trained anesthetist close at hand is not often to be found outside a hospital‐type setting. Accordingly, the capability of the purely orthodontic practice to successfully manage more than the simplest of cases of this type, in the integrative context, may be limited.

Orthodontic records

Treatment plans are usually the product of the gathering and collation of information contributed from a clinical examination, photographic and radiographic records, cephalometric analysis, digital models or plaster casts, and other aids to diagnosis. Under normal conditions, these records are simply and routinely acquired, in order to establish a diagnosis and treatment plan, before any treatment is commenced. Patient anxiety is commonly translated into an exaggerated gag reflex, making intraoral radiography and impression taking impossible to achieve and causing many orthodontists to raise their hands in despair. In the present (often anxiety‐loaded) environment, these same diagnostic aids may become a major undertaking as alginate‐heaped impression trays, the orthodontist’s gloved fingers, and instruments are introduced into the mouth. When the orthodontist nevertheless persists forcefully to achieve the all‐important goal of collecting these essential records, an objectively successful but badly managed outcome may result in a frightened child for months or years to come. Each of these problems may be overcome very satisfactorily today. Thus, extraoral (panoramic) radiography may usually be employed as a satisfactory alternative to periapical radiographs and the use of an intraoral digital scanner for digital models is an excellent and preferred alternative to alginate impression taking, particularly in the treatment of highly anxious children with disabilities (Christopoulou et al, 2022). The use of such scanners has proven to be as accurate as conventional alginate impressions (Tomita et al., 2018). Furthermore, alginate materials may sometimes have an unpleasant smell/taste, a poor impression must be repeated, and inaccuracy is sometimes seen only after cast pouring.

A standardized lateral or P‐A skull radiograph for cephalometric evaluation requires accurate positioning of the head in the cephalostat and may often be impossible to acquire, because this is dependent on the typically painful head posture‐restraining influence of the ear rods in the external auditory meatus, for the duration of the exposure.

Overall treatment plan

At the conclusion of this important first visit, the new records are studied and a reasoned working treatment plan established. This should start with the simpler and more easily achieved tasks before moving on to those that are more ambitious, on a stage‐by‐stage itemized list of individual aims of the patient’s treatment. In this manner, the treatment may become a confidence‐building series of visits, which should be looked on as an investment for the future dental and wider medical experience of the patient.