patients with special needs
DESCRIPTION
Patients with Special Needs. Wichita Dental Hygienists’ Association January 10, 2008 Barbara M. Gonzalez, RDH, MHS. Disabilities. Disability = one or more life skills is altered by physical or mental impairment ADA = Americans with Disabilities Act Passed in 1990 Employment Environment. - PowerPoint PPT PresentationTRANSCRIPT
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Patients with Special Needs
Wichita Dental Hygienists’ AssociationJanuary 10, 2008
Barbara M. Gonzalez, RDH, MHS
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Disabilities
Disability = one or more life skills is altered by physical or mental impairment
ADA = Americans with Disabilities ActPassed in 1990EmploymentEnvironment
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Not your dentist’s ADA
The Americans with Disabilities Actenacted in 1990Covers employment, public services, public accommodations, etc.
http://www.usdoj.gov/crt/ada/statute.html
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What is a “Disability”?
Social PerceptionsThe Obvious
Wheelchair…Spinal cord injuryCerebral PalsyMuscular Dystrophy
– ALS (Lou Gehrig’s)
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“You don’t look disabled…”
Social Perceptions?The Not-so-Obvious
Sensory Deficits– e.g. hearing impaired
Seizure disordersChronic managed
– e.g. multiple sclerosis, lupusInfectious diseases
– e.g. HIV
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The Dental Hygienists’ Role
Make good use of anecdotal notesMeet basic patient needs, i.e.
Modified oral hygiene techniques & aidsGeneral Practice
Learn special techniques or skills, i.e.Sign languageWheelchair transfers
Specialized Practice
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PHYSICAL IMPAIRMENTS
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Visual Impairment
Half of legally blind Americans are 60+
Legal Blindness Visual acuity of 20/200 or less with optimal correction
10% of legally blind Americans are school age children or younger
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Etiology
TraumaIncidence is markedly decreased due to better workplace safety controls
Diseasei.e. macular degeneration, etc.
Structural / development defectsCataracts, etc.
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Major Problems Encountered
Unsolicited and inappropriate assistance by strangersMistaking blindness for DEAFNESSAddressing companions and not personVerbalizing pity
Visually impaired usually independent and productive sans other disabilities
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Barriers to Care
Accessing “yellow pages” to find dentistTransportationRelease time from workNegative attitudes about service dogs in office settingFinancialPhysical environment
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Physical Environment
Loose rugsPoor lighting
Legal blindness vs. total blindness
StepsSmall print / written formsUnwieldy doorsSudden changes in surface texture
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Assisting Your Patient
Verbal questioning to gain information
Schedule additional time
ASK for patient’s preferences
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Oral Manifestations
Same as general peer populationOral hygiene may be compromised
Poor OH may contribute to oral disease
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Patient Management
Greet patient upon arrivalDescribe office layoutEscort patient while describing changes, obstaclesOffer physical assistance
Do NOT take by hand!
Allow service dogs in operatory
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Patient Management
Introduce patient to other staff members
Designate one as primary communicator
Minimize noise!Identify sounds, smells, equipment
Allow them to touch
Inform patient upon approach to mouth
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Patient Management
Inform the patient upon leaving and returning to operatoryOHI – use hand-over-hand techniqueOHI – good verbal descriptionsOHI – use typodonts
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Hearing Impairments
Can exist with no other disabilityOften accompanies other disabilities
Cleft palate – 90%Cerebral palsy – 20%Down’s Syndrome – 70%
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Oral Manifestations
BruxismOthers as general population
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Barriers to Care
Difficulty contacting officeTDD
Telecommunications device for the deaf
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Patient Management
Allow interpreter into operatoryBUT, speak to the Patient!
Do not shout, unless directed to by patientMaintain voice volumeLearn simple ASL / SEE signs
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Patient Management
Write out information in advance of appointment
For children, use drawings or pictures
Use touch to communicateHearing aids often turned offOHI – use disclosing, visual cues
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Neuromuscular Disorders
Cerebral Palsy…Muscular dystrophyALS
Neurological Disorders
Multiple Sclerosis
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Cerebral Palsy
A static, non-progressive neuromuscular condition resulting from damage to brain, often peri-partumMotor dysfunction, weakness, un-coordination, paralysisMay be accompanied by other diagnoses
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Classifications of CP
Spastic – 50-75%S. diplegia, s. hemiplegia, s. quadriplegia
Athetoid dyskinetic – 15 – 25%Ataxic – 10%Hypotonic (Flaccid)- <10%Mixed – 5-10%
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Limb Involvement Classifications
MonoplegicHemiplegicParaplegicDiplegicQuadriplegicTriplegic
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Oral Manifestations
BruxismMalocclusionClenchingFood retention / pouching
CariesPlaque control
PeriodontitisGingivitis
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Patient Management
Schedule initial interview to acquaint with patientAssess
muscle / reflex patternsCommunication and comprehensionMedical conditions
Caregiver should participate
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Patient Management
Speak to adult patient as an adultSpeak to a child patient as a childGear information to patient’s level of intelligence, not communication
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Managing Reflex Patterns
Tonic labyrinthine reflexOccurs when head tilts backward
Asymmetric tonic neck reflexOccurs when head turns to side or away from midline
Gag reflexCough reflexBite reflexSwallow reflex
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Gag and Cough Reflex
If HypoactiveAt risk for aspirationUse small bursts of waterUse frequent suction
If HyperactiveFlex patient’s head with chin to chestIntroducing items intraorally will probably induce reflex
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Bite Reflex
Mouth prop may be helpful
Tie off!
Treat lingual as quickly as possible
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Mouth Gag (molt)
Adjustable
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Swallow Reflex
Swallow ReflexAvoid mouth propsBe patient!
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Retraction Issues
Tongue retraction may be difficult
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Patient Management
Allow adequate timeBe aware that un-coordination (ataxic) becomes aggravated with time Support patient with pillows, bean bags, restraints, as neededControl tonic neck reflex by cradling
May require second person
Sedation / Gen. Anesthesia
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Oral Hygiene Needs
Food retention a big problem!Frequent toothbrushingLubrication of gingival tissuesNutritional analysis
Cariogenicity Fluoride Frequent prophylaxesModified oral hygiene aids
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Spinal Cord Injury
Location of injury determines extent70% < 40 years of ageOverwhelmingly male50% auto or motorcycle accidents18% sporting accidents20+ % occupationalRemaining GSW, falls, etc.
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Other Considerations
Grieving ProcessShockDenialReactionMobilizationCoping
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Other Considerations
AngerDepressionWithdrawal
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Oral Manifestations
Depends on degree of injuryLower limb involvement onlyUpper limb involvement
Depends on nature of injuryFractured teethBroken jaw / facial bones
Attritionmouthstick
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Patient Management
Inspect office and operatories for barriers
Parking availabilityAccessible entranceDoorway widths (32 “+)Flooring materials Hallway width (36”+)Turnaround space (60”+)Restroom access
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Patient Management
Operatory AccessibilityWheelchair transfer access
Follow the patient’s leadUse the brakesHave adequate physical supportCheck urinary catheters during and after
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Oral Hygiene Needs
Extremely importantMouth and teeth often substitute for arms and handsModified aidsEngage caregiver
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Mental Disabilities
Mental IllnessMental Retardation
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Mental Illness
“an illness with psychological or behavioral manifestations and/or impairment in functioning due to social, psycholgic, genetic, physical/chemical, or biologic disturbance. The disorder is no limited to relations between the person and society. The illness is characterized by symptoms and/or impariment in functioning.”
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Mental Retardation
“A significant subaverage general intellectual functioning which originates during the developmental period and is associated with impairment in adaptive behavior”
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Adaptations
Mental illness requires adaptations in both physical and emotional realmsMental retardation requires adaptations in both physical and educational realms
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Mental Illness
Affects one-sixth of Americans at some point in their lifetimeChronic major depression affects 3-5% of total population
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Mental Illness
For womenPhobiasDepression
For MenChemical dependencePhobias
2-5% of populationAnxiety disorders
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Patient Management
ConsistencyRegularityReliability
Important for patients still working on stabilization
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Patient Management
Dietary analysisSugar addiction
Pain controlAnxiety issues
Informed consentCompliance
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Patient Management
Drug interactionsOral complications
What are side effects of meds?
Xerostomia often with psych meds
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Mental Retardation
Mild – 89% IQ 50-55 to 70 – “Educable”
Moderate – 6%IQ 35-40 to 50-55 – “Trainable”
Severe – 3.5%IQ 20-25 to 35-40
Profound – 1.5%IQ below 20 or 25
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Etiology
Acquired – 9%Physical disorders of childhoodEnvironmental / chemical influences
Inherited – 13%i.e. Down’s Perinatal problems i.e. FAS
Unknown – 75%
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Oral Manifestations
Thick lipsTooth anomaliesPeriodontal conditionsOral habitsDental caries
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Personalization of Care
Nutritional counselingSimplified OH techniquesRepetitive follow-up“An aggressive approach to preventive care, not an aggressive approach to the patient….”
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Patient Management
Tailor to patient skills and comprehensionSedation and/or general anesthesia may be requiredNEVER “HOM”
(hand over mouth)
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Oral Hygiene Needs
Prevention and SimplificationBetter to prevent than treat
Have patient demonstrate and repeat!KISSEngage caregiversTreat the Patient!
Talk to the patient, not about the patient
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HOME CARE HELPS
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Daily Oral Hygiene
Manual toothbrushes can be easily modified
For selfFor care-giver
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Specialized Toothbrushes
Collis Curve Brush 1-800-298-4818
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Specialized Brusheswww.colliscurve.com
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Specialized Brushes
The Surround1-800-722-7375www.specializedcare.com
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Specialized Brushes
DexTBrush1-800-352-9669www.prevdentspec.com
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Conclusion
PreparationRespectRecognize Limitations
PatientsYour own!
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Resourceshttps://ice.iqsolutions.com/nohic/poc/publication/general.aspx
(This resource has great tips!)
LinguaFix1-800-328-3899www.zirc.com
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Resources
Collis Curve Brush1-800-298-4818www.colliscurve.com
The Surround1-800-722-7375www.specializedcare.com
DexTBrush 1-800-352-9669www.prevdentspec.com