Patients with Special Needs

Wichita Dental Hygienists’ AssociationJanuary 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 ActPassed in 1990

Employment

Environment

Not your dentist’s ADA

The Americans with Disabilities Actenacted in 1990

Covers employment, public services, public accommodations, etc.

http://www.usdoj.gov/crt/ada/statute.html

What is a “Disability”?

Social PerceptionsThe Obvious

Wheelchair…

Spinal cord injury

Cerebral Palsy

Muscular Dystrophy– ALS (Lou Gehrig’s)

“You don’t look disabled…”

Social Perceptions?The Not-so-Obvious

Sensory Deficits– e.g. hearing impaired

Seizure disorders

Chronic managed – e.g. multiple sclerosis, lupus

Infectious diseases – e.g. HIV

The Dental Hygienists’ Role

Make good use of anecdotal notes

Meet basic patient needs, i.e.Modified oral hygiene techniques & aids

General Practice

Learn special techniques or skills, i.e.Sign language

Wheelchair transfersSpecialized Practice

PHYSICAL IMPAIRMENTS

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

Etiology

TraumaIncidence is markedly decreased due to better workplace safety controls

Diseasei.e. macular degeneration, etc.

Structural / development defectsCataracts, etc.

Major Problems Encountered

Unsolicited and inappropriate assistance by strangers

Mistaking blindness for DEAFNESS

Addressing companions and not person

Verbalizing pity

Visually impaired usually independent and productive sans other disabilities

Barriers to Care

Accessing “yellow pages” to find dentist

Transportation

Release time from work

Negative attitudes about service dogs in office setting

Financial

Physical environment

Physical Environment

Loose rugs

Poor lightingLegal blindness vs. total blindness

Steps

Small print / written forms

Unwieldy doors

Sudden changes in surface texture

Assisting Your Patient

Verbal questioning to gain information

Schedule additional time

ASK for patient’s preferences

Oral Manifestations

Same as general peer population

Oral hygiene may be compromised

Poor OH may contribute to oral disease

Patient Management

Greet patient upon arrival

Describe office layout

Escort patient while describing changes, obstacles

Offer physical assistanceDo NOT take by hand!

Allow service dogs in operatory

Patient Management

Introduce patient to other staff members

Designate one as primary communicator

Minimize noise!

Identify sounds, smells, equipmentAllow them to touch

Inform patient upon approach to mouth

Patient Management

Inform the patient upon leaving and returning to operatory

OHI – use hand-over-hand technique

OHI – good verbal descriptions

OHI – use typodonts

Hearing Impairments

Can exist with no other disability

Often accompanies other disabilitiesCleft palate – 90%

Cerebral palsy – 20%

Down’s Syndrome – 70%

Oral Manifestations

Bruxism

Others as general population

Barriers to Care

Difficulty contacting officeTDD

Telecommunications device for the deaf

Patient Management

Allow interpreter into operatoryBUT, speak to the Patient!

Do not shout, unless directed to by patient

Maintain voice volume

Learn simple ASL / SEE signs

Patient Management

Write out information in advance of appointment

For children, use drawings or pictures

Use touch to communicate

Hearing aids often turned off

OHI – use disclosing, visual cues

Neuromuscular Disorders

Cerebral Palsy…

Muscular dystrophy

ALS

Neurological Disorders

Multiple Sclerosis

Cerebral Palsy

A static, non-progressive neuromuscular condition resulting from damage to brain, often peri-partum

Motor dysfunction, weakness, un-coordination, paralysis

May be accompanied by other diagnoses

Classifications of CP

Spastic – 50-75%S. diplegia, s. hemiplegia, s. quadriplegia

Athetoid dyskinetic – 15 – 25%

Ataxic – 10%

Hypotonic (Flaccid)- <10%

Mixed – 5-10%

Limb Involvement Classifications

Monoplegic

Hemiplegic

Paraplegic

Diplegic

Quadriplegic

Triplegic

Oral Manifestations

BruxismMalocclusionClenchingFood retention / pouching

CariesPlaque control

PeriodontitisGingivitis

Patient Management

Schedule initial interview to acquaint with patient

Assess muscle / reflex patterns

Communication and comprehension

Medical conditions

Caregiver should participate

Patient Management

Speak to adult patient as an adult

Speak to a child patient as a child

Gear information to patient’s level of intelligence, not communication

Managing Reflex Patterns

Tonic labyrinthine reflexOccurs when head tilts backward

Asymmetric tonic neck reflexOccurs when head turns to side or away from midline

Gag reflex

Cough reflex

Bite reflex

Swallow reflex

Gag and Cough Reflex

If HypoactiveAt risk for aspiration

Use small bursts of water

Use frequent suction

If HyperactiveFlex patient’s head with chin to chest

Introducing items intraorally will probably induce reflex

Bite Reflex

Mouth prop may be helpful

Tie off!

Treat lingual as quickly as possible

Mouth Gag (molt)

Adjustable

Swallow Reflex

Swallow ReflexAvoid mouth props

Be patient!

Retraction Issues

Tongue retraction may be difficult

Patient Management

Allow adequate time

Be aware that un-coordination (ataxic) becomes aggravated with time

Support patient with pillows, bean bags, restraints, as needed

Control tonic neck reflex by cradlingMay require second person

Sedation / Gen. Anesthesia

Oral Hygiene Needs

Food retention a big problem!Frequent toothbrushingLubrication of gingival tissuesNutritional analysis

Cariogenicity

Fluoride Frequent prophylaxesModified oral hygiene aids

Spinal Cord Injury

Location of injury determines extent

70% < 40 years of age

Overwhelmingly male

50% auto or motorcycle accidents

18% sporting accidents

20+ % occupational

Remaining GSW, falls, etc.

Other Considerations

Grieving ProcessShock

Denial

Reaction

Mobilization

Coping

Other Considerations

Anger

Depression

Withdrawal

Oral Manifestations

Depends on degree of injuryLower limb involvement only

Upper limb involvement

Depends on nature of injuryFractured teeth

Broken jaw / facial bones

Attritionmouthstick

Patient Management

Inspect office and operatories for barriers

Parking availabilityAccessible entranceDoorway widths (32 “+)Flooring materials Hallway width (36”+)Turnaround space (60”+)Restroom access

Patient Management

Operatory AccessibilityWheelchair transfer access

Follow the patient’s lead

Use the brakes

Have adequate physical support

Check urinary catheters during and after

Oral Hygiene Needs

Extremely important

Mouth and teeth often substitute for arms and hands

Modified aids

Engage caregiver

Mental Disabilities

Mental Illness

Mental Retardation

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.”

Mental Retardation

“A significant subaverage general intellectual functioning which originates during the developmental period and is associated with impairment in adaptive behavior”

Adaptations

Mental illness requires adaptations in both physical and emotional realms

Mental retardation requires adaptations in both physical and educational realms

Mental Illness

Affects one-sixth of Americans at some point in their lifetime

Chronic major depression affects 3-5% of total population

Mental Illness

For womenPhobias

Depression

For MenChemical dependence

Phobias

2-5% of populationAnxiety disorders

Patient Management

Consistency

Regularity

Reliability

Important for patients still working on stabilization

Patient Management

Dietary analysisSugar addiction

Pain controlAnxiety issues

Informed consent

Compliance

Patient Management

Drug interactions

Oral complications

What are side effects of meds?Xerostomia often with psych meds

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

Etiology

Acquired – 9%Physical disorders of childhood

Environmental / chemical influences

Inherited – 13%i.e. Down’s

Perinatal problems i.e. FAS

Unknown – 75%

Oral Manifestations

Thick lips

Tooth anomalies

Periodontal conditions

Oral habits

Dental caries

Personalization of Care

Nutritional counseling

Simplified OH techniques

Repetitive follow-up

“An aggressive approach to preventive care, not an aggressive approach to the patient….”

Patient Management

Tailor to patient skills and comprehension

Sedation and/or general anesthesia may be required

NEVER “HOM”(hand over mouth)

Oral Hygiene Needs

Prevention and SimplificationBetter to prevent than treat

Have patient demonstrate and repeat!

KISS

Engage caregivers

Treat the Patient!Talk to the patient, not about the patient

HOME CARE HELPS

Daily Oral Hygiene

Manual toothbrushes can be easily modified

For self

For care-giver

Specialized Toothbrushes

Collis Curve Brush 1-800-298-4818

Specialized Brushes

www.colliscurve.com

Specialized Brushes

The Surround1-800-722-7375

www.specializedcare.com

Specialized Brushes

DexTBrush1-800-352-9669www.prevdentspec.com

Conclusion

Preparation

Respect

Recognize Limitations

Patients

Your own!

Resourceshttps://ice.iqsolutions.com/nohic/poc/publication/general.aspx

(This resource has great tips!)

LinguaFix

1-800-328-3899

www.zirc.com

Resources

Collis Curve Brush1-800-298-4818www.colliscurve.com

The Surround1-800-722-7375www.specializedcare.com

DexTBrush 1-800-352-9669www.prevdentspec.com