Patients with special needs

This chapter introduces Section IV of Diagnosis and Treatment Planning in Dentistry. The scope of this chapter is intentionally broad and will address the diagnosis, treatment planning, and management of a wide range of patient conditions that can be considered to reflect special needs.

The management of several important selected clinical needs is discussed in greater detail later in this text. Treatment planning for the substance-abusing individual, the anxious or phobic patient, patients with psychological problems, adolescents, older adults and patients who are motivationally compromised or financially limited is addressed in the other chapters of this section. This chapter serves as an overview and introduction to those chapters and, in addition, discusses a variety of special needs conditions not specifically addressed elsewhere in the book.

The U.S. government defines persons with disabilities as individuals with a physical or mental impairment that substantially limits one or more major activities of daily living (ADL). Census 2000 identified 49.7 million individuals in the United States with some type of long-lasting condition or disability. In developed countries, the elderly constitute an increasingly large component of the population, and it is now estimated that almost one-third of the population will be older than 60 years by 2050.

This group is prone to health problems in general and to oral health problems in particular. Patients with disabilities, and especially elderly patients with disabilities, frequently reside in nursing homes. According to the National Nursing Home Survey in 2004, the United States had 16,000 nursing facilities with approximately 1.7 million beds. The average facility has 107 beds and an 86% occupancy rate. Moreover, with the growing numbers of older adults worldwide, nursing homes will be expected to provide residence and care for a significant portion of this population.

A strong relationship between disability status and oral health status has been identified. Individuals with special needs are more likely to exhibit gingivitis or periodontitis and to have poor oral hygiene. Improvement of oral health in individuals with special needs can lead to improved quality of life. Unfortunately, however, many of these individuals have limited access to oral healthcare, and their oral health needs remain unmet. ,

Patients with special needs may provide the dental team with unusual and interesting challenges in both planning and delivering dental treatment. Treatment modifications required may range from slight (e.g., giving the patient more time to communicate or providing physical support in the dental chair) to complex (providing treatment for a patient who is bedridden and requires full-time skilled nursing care). The range of oral health services runs the gamut from simple pain relief to complete oral rehabilitation. All patients seek high-quality treatment delivered with compassion, integrity, and safety, and the patient with special needs is no different. These patients will often be unusually appreciative of the time and effort that the dental team invests in their care.

The stated goal of special care dentistry is “to improve the oral health of individuals and groups in society who have a physical, sensory, intellectual, mental, medical, emotional, social impairment or disability, or, more often, a combination of a number of these factors.” The process of achieving that goal can be challenging, but it also presents unique opportunities and inestimable rewards for all the members of the dental team. The mission of the authors of this chapter is to help the reader develop both the skill set and comfort level to diagnose the problems of such a patient, devise a treatment plan that promotes oral and general health within the limits of the patient’s circumstances and temperament, and deliver treatment in a manner that is safe, effective, compassionate, and affirming of the patient’s sense of self. Most of these patients can be managed very successfully within the context of a general dentistry practice. Armed with this knowledge and with a willingness to try, providing care can be a rewarding opportunity for the dentist, and in some instances, a life-changing experience for the patient.

Identifying the patient with special needs

The distinction between the patient designated as “special care” or “special needs” and the more typical dental patient who may need small accommodations to be comfortable or to facilitate efficient treatment may sometimes seem indistinct. Indeed, all patients deserve individualized and compassionate and, in a manner of speaking, “special care.” Every patient has the right to be treated as a unique individual by the dental team. This may be manifested in small but significant ways, such as addressing the patient in a preferred manner, or using a mouth prop to reduce strain on a sensitive temporomandibular joint (TMJ). The patient with special needs, although typically seeking the same types of services and therapy, will require an even more intentional, strategic, and individualized approach to care. Broadly speaking, patients with special clinical needs are those patients who live with significant mental, physical, psychological, or medical challenges and who, as a result, require significant modifications to treatment planning and delivery of oral healthcare. The following list of physical or mental conditions can be categorized as “special care” or “special needs”:

  • Autism

  • Mental retardation (Down syndrome)

  • Traumatic brain injury

  • Cerebral palsy

  • Mental illnesses (psychoses or neuroses of various diagnoses)

  • Medically compromised conditions (e.g., congestive heart failure, unstable angina, cancer, transplant, human immunodeficiency virus [HIV]-acquired immunodeficiency syndrome [AIDS])

  • Severe dental anxiety or phobia

  • Craniofacial abnormalities (craniofacial syndrome, Apert’s syndrome, cleft palate)

  • Certain congenital illnesses (e.g., hemophilia)

  • Various dementias (Alzheimer’s, Parkinson’s, multi-infarct dementia)

  • Severe depression or pseudodementia

  • Physical disability, such as severe rheumatoid arthritis

Patients with special needs may require modifications in both the kind and scope of dental treatment. Certainly, specific physical, medical, psychological, or psychosocial problems will have a bearing on the kinds of modifications to the dental treatment plan that will be necessary. Equally important, the severity of the disorder will have an effect on what the necessary modifications will be. For example, an individual with mild autism who can cooperate during restorative procedures and is responsive to preventive therapy may be treated with minimal or no modification to treatment. At the other extreme, a patient in the late stages of Alzheimer’s disease is a poor candidate for anything beyond basic preventive and acute care services.

Identifying the patient with special needs

The distinction between the patient designated as “special care” or “special needs” and the more typical dental patient who may need small accommodations to be comfortable or to facilitate efficient treatment may sometimes seem indistinct. Indeed, all patients deserve individualized and compassionate and, in a manner of speaking, “special care.” Every patient has the right to be treated as a unique individual by the dental team. This may be manifested in small but significant ways, such as addressing the patient in a preferred manner, or using a mouth prop to reduce strain on a sensitive temporomandibular joint (TMJ). The patient with special needs, although typically seeking the same types of services and therapy, will require an even more intentional, strategic, and individualized approach to care. Broadly speaking, patients with special clinical needs are those patients who live with significant mental, physical, psychological, or medical challenges and who, as a result, require significant modifications to treatment planning and delivery of oral healthcare. The following list of physical or mental conditions can be categorized as “special care” or “special needs”:

  • Autism

  • Mental retardation (Down syndrome)

  • Traumatic brain injury

  • Cerebral palsy

  • Mental illnesses (psychoses or neuroses of various diagnoses)

  • Medically compromised conditions (e.g., congestive heart failure, unstable angina, cancer, transplant, human immunodeficiency virus [HIV]-acquired immunodeficiency syndrome [AIDS])

  • Severe dental anxiety or phobia

  • Craniofacial abnormalities (craniofacial syndrome, Apert’s syndrome, cleft palate)

  • Certain congenital illnesses (e.g., hemophilia)

  • Various dementias (Alzheimer’s, Parkinson’s, multi-infarct dementia)

  • Severe depression or pseudodementia

  • Physical disability, such as severe rheumatoid arthritis

Patients with special needs may require modifications in both the kind and scope of dental treatment. Certainly, specific physical, medical, psychological, or psychosocial problems will have a bearing on the kinds of modifications to the dental treatment plan that will be necessary. Equally important, the severity of the disorder will have an effect on what the necessary modifications will be. For example, an individual with mild autism who can cooperate during restorative procedures and is responsive to preventive therapy may be treated with minimal or no modification to treatment. At the other extreme, a patient in the late stages of Alzheimer’s disease is a poor candidate for anything beyond basic preventive and acute care services.

Role of the general dentist in management of the patient with special needs

Recognizing, managing, and treating all oral healthcare problems presented by individuals with special needs is within the scope of general dentistry. The general dentist has several roles to play in the management of the patient with special needs:

  • Recognize that a patient has special needs.

  • Perform an initial oral examination, making adjustments to the process as appropriate.

  • Consult with other oral healthcare providers as needed regarding the patient’s condition and treatment.

  • Referral to a hospital dentistry unit or an academic health center when indicated.

  • Generate a plan of care for the patient, the complexity of which will depend on multiple factors, including (1) patient’s dental needs, (2) anticipated level of cooperation, (3) patient’s ability to carry out effective oral self-care, and (4) availability and extent of support from a caregiver.

  • Engage the patient, and surrogates as indicated, to achieve informed consent.

  • Educate the patient and caregivers in the importance of oral health and its relationship to systemic health; work with them to establish a daily oral care program.

  • Execute the plan of care in a compassionate and professional manner.

  • Provide long-term maintenance care.

  • Engage and encourage the participation and support of caregivers during all steps of the therapeutic process: examination, treatment plan formulation, active treatment, and maintenance therapy.

  • Respond to physician’s requests regarding the following:

    • Oral health assessment

    • Clearance before medical surgery

    • Management or treatment of oral infections or other oral health problems

The dental team has the responsibility to help the patient with special needs maintain a functional, healthy oral condition. For such patients, this can necessitate considerable time, effort, and creativity. The ultimate goal is to help the patient achieve an optimal state of oral health consistent with what his or her mental and physical condition will permit.

Access to care

Access to care is an important issue in the management of the patient with special needs. If the patient is homebound, can dental services be brought to that location? If the patient is living independently, does he or she have transportation to the dental office? Once brought to the dental office, are environmental modifications in place to accommodate his or her needs? If the patient lives in a residential facility, can dental services be provided on site, or should the patient be brought to the dental office? Four components of the access to care issue are considered in this section.

Transportation

Many modes of transportation can be used to bring a patient to a dental appointment, including personal conveyance, public transportation (bus or taxi), ambulance, or van (sponsored by social services, government, transit authority, or private enterprise). Often a personal friend or relative will offer to bring the patient in the patient’s or the friend’s or relative’s own vehicle. The mode of transportation may have an effect on the appointment scheduling for a patient. For instance, the dentist may try to provide more treatment or an extended appointment time for an individual conveyed by ambulance.

Residency

Many patients with special needs live in facilities other than a private home, apartment, or condominium. Such facilities include rest homes, nursing homes, and continuing care retirement centers. Several approaches to delivering dental care to these individuals are available.

  • In-house dental unit. The facility may have a fully equipped dedicated dental operatory permanently on site or may share a room equipped for dental care that is also used at other times by a hair stylist or podiatrist.

  • Comprehensive mobile dental operatory. This can be a complete dental operatory with all the amenities, including a full-sized dental unit with wheels built into the chair base. All equipment, materials, and supplies are packaged and transported by truck. Typically, the mobile operatory is delivered to the facility and set up to be fully operational on the same day. This format allows the dentist to provide a complete range of oral healthcare services on site.

  • Portable units. Portable dental units are easily transportable “fold-up” units stored in cases/containers and assembled on site by the dental team. These self-contained units typically include their own sources of water, suction, and compressed air. If electricity is not available, a portable generator can provide power. Designed primarily to serve in the mission field or at temporary military installations, this type of setup is adaptable to a wide variety of settings. Although in theory, a full range of services can be provided, the limited suction and air capacity, less ergonomic chair, and lack of many of the comforts and amenities of a fixed base setting make it difficult for the dentist and staff to carry out extended or complex procedures day after day.

  • Vans or buses with dental facilities on board. In this type of installation, a complete dental operatory with dental chair, x-ray head, sources for compressed air and suction, and a complete array of dental equipment, instruments, and supplies is housed and ready for use in a fully functioning van or bus. Using this mode of operation, the dental team drives to a convenient parking area, hooks up to an existing electrical and water supply, if available, and is prepared to see patients who need only to be brought to the van to receive dental treatment.

  • Delivery to the dental office. In some cases, patients living in nursing homes or continuing care facilities are transported to a dental care facility. Often it is a caregiver, family member, or friend who brings the patient in, or it may also be someone on the dental team.

Additional information on alternative modes of care delivery is provided in Chapter 17 .

Some of the options described previously (portable units, dental van or bus, delivery to the dental office) can be implemented for the home-bound patient. In addition, the dental team may provide in-home rudimentary dental services, as described in Chapter 17 .

Office accommodations

If the dental team elects to treat special needs patients in the dental office, the facility must be properly designed and equipped to deliver care in a manner that is comfortable and safe for the patient, and efficient for the dental team ( Box 12-1 ). ( See Video 12-1, Tour of an Operatory for Special Needs Patients on Evolve.)

BOX 12-1
Suggested Environmental Features to Accommodate Patients With Special Needs

  • Handicapped parking clearly marked

  • Ramps for wheelchair access

  • Automatic doors (wide enough for wheelchair or gurney)

  • Reception window accessible from a wheelchair

  • Handicapped-accessible restrooms (automatic doors * )

  • Operatory door wide enough for wheelchairs or gurney *

  • Operatory size large enough to accommodate wheelchair, gurney, * staff, and dental equipment

  • Extended tubing length on the dental unit

  • Control of noise

*Higher-level accommodations that may not be practical or possible to retrofit in an existing office.

American dental offices must comply with standards established in the Americans with Disabilities Act. Some state and local jurisdictions may also have laws or ordinances that are relevant. The dentist who anticipates seeing patients with disabilities should consult the document “Americans with Disability Act Standards for Accessible Design”.

Funding sources

As with all other patients, the dental team must establish with the patient and/or caregiver how dental treatment will be paid for. Several potential funding sources can be considered.

Private pay

Many special care patients have their own or family financial resources with which to pay for oral health services. If a designated power of attorney or legal guardian has taken over financial responsibilities, costs of treatment and financial resources will be discussed with this individual.

Medicare

In the United States, Medicare is a health insurance program for persons 65 years or older, some individuals with disabilities who are younger than age 65, and individuals with end-stage renal disease requiring dialysis or renal transplant. There are strict limitations as to the types of dental treatment covered by Medicare, however. For example, Medicare does not cover routine dental treatment, such as cleanings, restorative treatment, dentures, or extractions. However, Medicare Part A (hospital insurance) will pay for certain dental procedures performed while a patient is in the hospital. As of 2013, Medicare will pay for the following:

  • 1.

    Comprehensive examination in a hospital inpatient setting preceding kidney transplantation or heart valve replacement.

  • 2.

    Extractions in preparation for radiation treatment for oral cancer. (The patient is responsible for the cost of any prosthetics, however.)

  • 3.

    Dental services that are an integral part of a medical procedure, such as reconstruction of the jaw after an accident or facial tumor removal.

It is important to note that, according to cms.gov, coverage of dental care is not determined by the necessity of the dental care but by the type of service provided and the anatomic structure involved in the procedure. Therefore it is important to verify with Medicare which dental procedures are covered before initiation of treatment.

Medicaid

In the United States, Medicaid is the federally sponsored, state and/or county-administered insurance program for blind, disabled, and indigent individuals. Medicaid dental coverage for both adults and children varies from state to state. For the patient to benefit from this form of assistance, the dental team must be knowledgeable about and comply with all the rules and restrictions, as well as with the fee schedule for the Medicaid plan in the patient’s jurisdiction.

Other sources

Other possible sources of financial support for the special care patient in the United States include Supplemental Security Income (SSI), pensions, and religious or other nonprofit groups. Social workers and case managers are well trained in optimizing federal, state, and community-based resources for clients under their care.

Throughout the world, there is great variability in the level of governmental support for oral healthcare. Western European countries have traditionally placed a high priority on the provision of basic dental services both to their general population and to special needs populations, such as the elderly, infirmed, and impaired. Programs and benefits are determined for the most part by national policy.

Planning for specific conditions

As noted earlier in this chapter, many conditions can be appropriately designated as “special needs.” The following paragraphs discuss briefly six relatively common special needs conditions that are not addressed in depth elsewhere in this text.

Patients with developmental delay or cognitive disorders

At the outset, the patient’s level of cooperation must be diagnosed to help the dental team determine which treatments can be performed and in what setting. Prevention is of paramount importance. Oral home care coaching and dietary analysis and counseling are extremely important. The caregiver must be heavily involved in providing the patient’s oral home care and maintenance of the patient’s oral health. If the patient is fully cooperative, routine dental care can be provided in the office setting. If the patient is combative or uncooperative, however, the decision needs to be made as to the setting in which care will be provided. Alteration or modification of the treatment goals from the ideal is often necessary. If a complete examination, radiographs, and treatment are necessary, then general anesthesia is usually indicated. When the patient is partially cooperative, the decision becomes more difficult. If the patient is not both clinically and legally competent, then treatment goals, risks, benefits, and limitations of each mode of treatment must be explained fully to the caregiver.

Traumatic brain injury

Patients with a history of traumatic brain injury may be treated similarly to individuals with cognitive disorders. The level of potential cooperation must be assessed as noted previously. Similar decisions regarding setting and extent of treatment will be made for patients with head injuries. It must be recognized, however, that the functionality of the patient with traumatic brain injury can change dramatically over time. The patient may progress from an uncooperative, combative individual to one who is fully cooperative. The dental treatment plan can be changed, sometimes drastically, with changes in the patient’s physical ability and cognitive function. Although initially, dental treatment may be limited to palliative and acute care, with full recovery, the patient may become an ideal candidate for comprehensive definitive treatment. From the time of the injury and throughout the recovery phase, the caregivers often must be intensely involved in providing for the general and oral healthcare needs of these patients.

Severe coagulopathies

Hemophilias A and B and von Willebrand’s disease are three well-known disease-induced coagulopathies requiring specific management plans. If invasive therapy is anticipated (including mandibular blocks), then factor replacement is necessary. Postoperatively, an antifibrinolytic agent may be prescribed to assist in stabilizing the initial clot. There are instances of hemophiliacs with inhibitor to the very factor they require for coagulation. For example, the hemophilia A patient with inhibitor will exhibit an immune response to the administered factor and will thus require a continuous infusion to clot properly. Discussion with the patient’s hematologist, describing the nature of planned dental procedures, should take place before dental treatment. These patients often require infusion of coagulation factor before dental procedures.

Additionally, several anticoagulant medications that are frequently prescribed to prevent thrombi, strokes, coronary artery occlusions, and/or myocardial infarctions may have implications for the provision of some dental procedures. For example, patients who take warfarin (Coumadin) on a daily basis may need to discontinue or decrease the dose 2 to 3 days before invasive treatment. A current international normalized ratio (INR) value (preferable to a prothrombin time) is an important preoperative measure. The INR provides a standard measure of coagulability. However, the patient who requires oral surgery or any dental treatment likely to cause bleeding (including uncomplicated tooth extractions) typically does not require alteration of Coumadin dosage unless the individual’s INR is greater than 3.5 to 4.0, provided that local hemostatic measures such as gel foam and primary closure are used. High-risk patients may need to be admitted and heparinized after discontinuing Coumadin. The heparin is then discontinued 4 to 5 hours preoperatively and resumed soon after surgery. The half-life of heparin is approximately 4 to 6 hours, and that of Coumadin is 3 to 4 days. Low-molecular-weight heparins can also be used to anticoagulate a patient and can be administered at home by the patient. This medication typically need not be discontinued before invasive treatment, because the half-life is approximately 24 hours. Discussion with the patient’s physician, including a thorough explanation of the planned dental procedure, should take place before invasive dental treatment. Furthermore, risks and benefits to discontinuing or decreasing the dosage of Coumadin should be discussed.

Other oral anticoagulants, such as antiplatelet medications (e.g., dipyridamole, ticlopidine, aspirin, ibuprofen), direct thrombin inhibitors (dabigatran etexilate), or factor Xa inhibitors (rivaroxaban, apixaban, edoxaban, betrixaban, darexaban, eribaxaban, and idrabiotaparinux) may need to be discontinued or dosages decreased before surgery depending on anticipated blood loss and the planned extent of the surgery. Again, consultation with the patient’s physician concerning the planned dental procedures should take place before any invasive dental treatment. Risks and benefits to discontinuing or decreasing dosage of these medications should be discussed.

Acquired immunodeficiency syndrome

The dental team must be vigilant in recognition of the occurrence or progression of the oral manifestations of HIV/AIDS, including Kaposi’s sarcoma, candidiasis, oral hairy leukoplakia, HIV-associated periodontal diseases, or other opportunistic infections. Good oral hygiene instruction and oral home care are critical to managing the oral health of the patient with AIDS. If invasive treatment is planned, a complete blood count (CBC) must be evaluated. The platelet count should be at least 50,000, and the absolute neutrophil count should be higher than 1000. If the absolute neutrophil count is lower than 1000, antibiotic premedication is required. Physician consultation is always advisable when invasive treatment is planned. Viral load and CD4 counts are indicators as to the level of control of the illness.

Patients under hospice care

By definition, the patient in hospice care has an anticipated life expectancy of 6 months or less. Frequently, it is much less than 6 months, because hospice care is often called late in the disease process. Palliative care and pain control are of great importance. If invasive treatment is planned, depending on the diagnosis, a CBC may be necessary. Any patient-requested dental treatment that is not life threatening should be provided if feasible. For example, if the patient desires a reconstruction, and the dental team is capable of providing this care, then it is justifiable to proceed. Informed consent must be obtained, listing diagnoses, alternatives, and costs. Code status should be designated (e.g., Do Not Resuscitate/Do Not Intubate/Full Code [see the In Clinical Practice: Physician Orders Related to Resuscitation box later in this chapter]). Occasionally, the dental team may be called on to evaluate a patient who is losing weight because of a refusal to eat. In this situation, it is appropriate for the dentist to do a limited evaluation to discern whether the refusal to eat results from oral pain or, for example, an ill-fitting denture. Here, a comprehensive assessment is not necessary, and the dental treatment can be limited to strategic efforts to alleviate the pain or improve the functionality of the denture.

Patient evaluation

Ideally, the patient with special needs will be identified at the time of the initial appointment through a matter-of-fact query by office staff: “Do you have any physical or other limitations that we can assist you with on your arrival?” If the patient answers affirmatively, he or she should first of all be assured of a welcome to the practice and that any necessary effort to provide accommodation will be made. The patient should be asked to bring any available medical records and names and contact information for other healthcare providers; a list of all medications; and any available dental images or records. An effort should be made to determine whether the patient has a guardian or caregiver. If such a person has been designated, that person should be invited to attend at least the initial visit. Some dental offices find it useful to develop a specific form or questionnaire for such patients that will characterize any special needs and individual expectations. On arrival, the patient should be greeted warmly and given an explanation of what to expect at this first visit. If the patient has brought any documentation, forms, questionnaires, or images, these should be received, recorded, and copied, and returned to the patient or caregiver as appropriate. If a caregiver or family member accompanies the patient, he or she should be recognized and thanked for assistance in providing care for the patient.

After introductions, the patient is escorted to the operatory, and the examination process begins. The patient may be more comfortable if the caregiver or family member is also present during the examination, and that should be encouraged. A patient with special care requirements is evaluated with the same basic approach as described in Chapter 1 of this text. Although an initial attempt should be made to complete a typical examination, depending on the level of the patient’s ability to cooperate, parts of the examination may not be completed effectively. Strategies for managing such a situation will be described later in section, Physical and Oral Examination .

Initially, the patient may have difficulty becoming acclimated to the new and strange surroundings. The dental team must be flexible and accepting of the patient’s behavior and limitations. As the team converses and interacts with the patient in a kind, gentle, and caring manner, the patient will often lower defenses and anxiety will abate. The patient may become sufficiently comfortable to allow at least a brief look, a moderately complete examination or, in a best-case scenario, a complete oral examination. If the examination is not completed at the initial visit, the dentist (in consultation with the caregiver) may reappoint the patient, with the goal of completing the examination at a future date when the patient is less stressed and more comfortable with the dental office setting. If the patient is physically unable or mentally incapable of cooperating for a comprehensive evaluation, some form of sedation or general anesthesia may be necessary.

Chief concern and history of the chief concern

To properly address specific needs that the patient or the caregiver perceives to be important, it is critical to evaluate the patient’s chief complaints or concerns. Characterization of the chief concern often gives the dentist a sense of the patient’s or caregiver’s oral health philosophy and knowledge. If the patient is unable to articulate his or her wishes and concerns, the chief complaint can be derived from a variety of other sources, including family members, physician, caregiver, social worker, or case manager. If the dentist believes that addressing the chief concern is unrealistic or unreasonable, then the issues involved must be explained to the patient and caregivers or other individuals who may be involved in the decision making. For example, if the family of an individual with dementia desires complex restorative treatment, but the patient appears uncooperative and lacking in the capacity for preventive care, then the family must be informed as to why this option cannot be implemented. Addressing the chief concern is often the starting place for identification of issues central to the ultimate management of the patient and will provide a touchstone from which to begin the education of the patient and caregivers.

General health history and review of systems

Although important as a baseline of information for all patients, obtaining a thorough and complete health history for the special care patient can be of life-preserving significance. Answers to questions regarding hospitalizations, major illnesses, surgical procedures and complications, medications, and allergies are essential if the patient is to be treated safely and effectively. Because of the complex physical status of many of these patients, an exclusive use of only a standard health history form with close-ended questions will be inadequate. Instead, an open-format mode of questioning, or a questionnaire supplemented with follow-up questions, is frequently necessary to provide a complete history. In addition to the patient interview, the history can be taken from a variety of other sources, including family members, caregivers, nurses, physicians, case managers, and the patient’s medical records.

The phrasing of questions must be consistent with the patient’s level of understanding and education. Layperson’s terms and colloquialisms can appropriately be used to take a good history. Even with this open format, however, it is imperative that the dentist use a standardized and consistent “branching-tree” series of questions ( Box 12-2 ).

BOX 12-2
Example of a “Branching-Tree” Questioning Process

The branching-tree questioning process refers to a method in which, after an affirmative response to a general question, more-specific questions are asked to ascertain the dimensions of a particular condition, problem, or concern. For example, if the patient gives an affirmative answer to the question, “Do you suffer from angina pectoris?” the following questions are commonly asked:

  • What is the frequency of the pain?

  • When does the pain typically occur? (after meals, related to exertion, specific time of day)

  • What is the duration of the pain?

  • What is the character of the pain (sharp/dull/crushing)

  • What is the severity of the pain? (mild/moderate/severe/intolerable)

  • What exacerbates the pain? (exercise, position, or posture)

  • What alleviates the pain? (rest, nitroglycerin)

  • Does the pain radiate? If yes, where?

  • Do you take antianginal mediation? (frequency, amount)

  • Have you visited an emergency room for this condition? (frequency, treatment received)

The review of systems (ROS) , an integral part of the health history, consists of a sequential series of questions about each organ system. Inherent in this process are checks and balances that prompt the patient to remember aspects of his or her history that may have been missed in the questionnaire or in previously discussed sections of the history. Key topics to be listed in a typical review of systems are included in Box 12-3 .

BOX 12-3
Common Issues Included in a Review of Systems

  • Head, Eyes, Ears, Nose, Throat—hearing, vision, glaucoma, sinus/allergies, mouth ulcers, oral cancer

  • Neurologic—strokes, seizures, trauma, lightheadedness, Parkinson’s disease

  • Neck—arthritis (spondylitis), trauma, subluxation, mobility, masses

  • Cardiovascular—myocardial infarction, angina pectoris, valvular disorders/murmurs (nature of, how diagnosed), atherosclerosis, hypertension, peripheral vascular disease

  • Pulmonary—tuberculosis exposure, asthma, smoking, emphysema, bronchitis

  • Gastrointestinal—polyps, ulcers, reflux, indigestion, liver/gallbladder disorders

  • Genitourinary—kidney/bladder disorders, incontinence, renal failure (dialysis and type)

  • Endocrine—adrenal gland, diabetes, thyroid disorders, pituitary

  • Hematologic—bleeding disorders, clotting problems, anemia (type)

  • Musculoskeletal—weaknesses, prosthetic joints, arthritis

  • Other—cancer, chemotherapy, radiation, metabolic disorders (for head and neck cancer, need dosages and portals of radiation, history of hyperbaric oxygen)

Oral health history

Many questions on the oral health history are the same as for all patients (for example, frequency of check-ups and oral prophylaxis), but there are additional questions that have particular relevance and importance for the patient with special care requirements. It will be helpful to learn the setting for past dental care (i.e., general dental office, hospital-based clinic, operating room [OR], or other). Did the patient receive sedation or general anesthesia? It is also important to learn what type of specialty care the individual has received and the nature of the treatment. The dentist should inquire about each of the dental specialties in an effort to gain a comprehensive understanding of the patient’s dental experience. The patient’s specific daily oral care regimen should be ascertained. It may be necessary to ask caregivers to describe their routines for cleaning the patient’s mouth. In fact, it is important to determine whether the patient’s mouth can be cleaned, and whether he or she is cooperative with such care. Important questions to be asked of the patient or caregiver include the following:

  • How often do you brush your teeth? What times during the day? How much time do you spend brushing? Do you use a mechanical or a manual toothbrush? What type of toothpaste do you use?

  • Do you floss? How often and when? Do you use floss aids?

  • Do you use other cleaning devices?

  • Do you use mouth rinses? Gels? Other forms of fluoride?

  • Do you have plaque or tartar buildup?

Caregivers should be asked whether a mouth prop is needed when assisting the patient with oral home care.

Also included in this section of the patient history is a dietary analysis. The patient or caregiver should be questioned about the following:

  • How much table sugar do you use?

  • Do you consume soft drinks or sodas? If so, how often? With meals? How quickly consumed (sip or gulp)?

  • Do you consume two or more fruit drinks or juice per day?

  • Do you eat hard candy or other sweets? If so, what type? How often?

  • Do you ingest acidic foods or beverages (such as citrus fruits, vinegar, or artificially sweetened soft drink or soda) on a regular basis (especially between meals)?

  • How often do you consume snacks or baked goods?

An understanding of the nutritional intake and dietary history is important for any patient but can be critical for the patient with special needs. Sugary “comfort foods” may be readily available and more appealing than healthier foods. Caregivers may use such foods to pacify their patients and reduce the required caregiving time or lessen caregiver stress. Especially when coupled with poor oral home care, such patients will often be afflicted with many active carious lesions and be at high risk for new caries development.

It is critically important to educate patients and caregivers about the hazards of a cariogenic diet and suboptimal oral home care.

Patients who are deemed to be at high risk for caries are good candidates for the use of a diet diary. Patients with active caries, for whom the cause of the dental caries is not clearly evident, can definitely benefit from the compilation of a comprehensive diet history. The diet diary can be used to identify hidden and overt sugar and acid sources and can serve as the basis for counseling relating to dietary habits and those food items detrimental to dental and oral health. The patient is usually instructed to keep a diet diary for 5 to 7 days, writing down all food items and beverages consumed ( Box 12-4 ).

BOX 12-4
Example of a Single Day From a Patient’s Diet Diary

Breakfast

  • Sugared cereal

  • Toast and grape jam

  • 2 glasses of OJ

  • Cup of coffee with tablespoon of sugar and milk

Lunch

  • Meatloaf

  • Black beans

  • Fruit cup

  • Bread and butter

  • Candy bar

  • 1 regular soda

Dinner

  • Hunan chicken and vegetables

  • Fried rice

  • Pecan pie

  • Fruit Loops and milk (during evening)

When the patient returns to the office, a member of the team reviews the diary in detail with the patient and caregiver when appropriate. It is often helpful to circle those food items harmful to the patient’s teeth. Dietary recommendations are then made to the patient and/or caregiver ( Box 12-5 ). After this review, it is often helpful to compose a follow-up letter for the patient and caregiver reviewing relevant dietary and oral home care issues and formalizing the dental team’s recommendations and goals for the patient ( Box 12-6 ). Such a letter can be an important part of the process of educating, encouraging, and empowering the patient and/or caregiver.

BOX 12-5
Dietary Tips for Special Needs Patients and Their Caregivers

  • Limit consumption of refined sugars, especially between meals. Drinks such as pure fruit juice and fruit drinks, milk, and dietary supplements often contain large amounts of fermentable carbohydrates and can cause cavities—particularly in the absence of good plaque control.

  • Limit consumption of acidic substances and beverages—especially between meals. Acidic substances, including carbonated beverages, can dissolve tooth structure and contribute to cavities. Diet sodas are particularly damaging.

  • After consuming acidic or sugary between-meal snacks, rinse the mouth with water to flush away sugars and dilute acids in the mouth.

  • Do not brush for at least 30 minutes after acid exposures.

  • Fresh fruits, vegetables, meat products, whole grains, cheeses, and water are generally good foods for oral health.

  • Fluoride use should be encouraged—fluoridated toothpaste, mouth rinse, gels, and varnish have all been shown to be helpful for patients who are at risk for cavities.

BOX 12-6
Example of a Follow-Up Letter to a Patient Regarding His or Her Oral Health and Recommendations for Oral Disease Prevention

May 1, 20__

Dear Mr. Smith,

My staff and I have appreciated the opportunity to work with you to improve your oral health during the past two appointments. I believe that we have made real progress in oral health promotion in preparation for restoring your dentition and getting you on the road to keeping your teeth for your entire lifetime! I hope that all your questions about brushing/flossing techniques and diet have been answered. If not, please do not hesitate to contact me or to bring them up at our next appointment.

As we discussed, several areas in your diet raise concerns relating to good oral health:

  • 1.

    Fruit Loops and other sweet cereals are particularly devastating if oral hygiene procedures are not carried out soon after eating.

  • 2.
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Jun 3, 2016 | Posted by in General Dentistry | Comments Off on Patients with special needs
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