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 1990EmploymentEnvironment

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

What is a “Disability”?

Social PerceptionsThe Obvious

Wheelchair…Spinal cord injuryCerebral PalsyMuscular Dystrophy

– ALS (Lou Gehrig’s)

“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

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

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 strangersMistaking blindness for DEAFNESSAddressing companions and not personVerbalizing pity

Visually impaired usually independent and productive sans other disabilities

Barriers to Care

Accessing “yellow pages” to find dentistTransportationRelease time from workNegative attitudes about service dogs in office settingFinancialPhysical environment

Physical Environment

Loose rugsPoor lighting

Legal blindness vs. total blindness

StepsSmall print / written formsUnwieldy doorsSudden 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 populationOral hygiene may be compromised

Poor OH may contribute to oral disease

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

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

Patient Management

Inform the patient upon leaving and returning to operatoryOHI – use hand-over-hand techniqueOHI – good verbal descriptionsOHI – use typodonts

Hearing Impairments

Can exist with no other disabilityOften accompanies other disabilities

Cleft palate – 90%Cerebral palsy – 20%Down’s Syndrome – 70%

Oral Manifestations

BruxismOthers 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 patientMaintain voice volumeLearn simple ASL / SEE signs

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

Neuromuscular Disorders

Cerebral Palsy…Muscular dystrophyALS

Neurological Disorders

Multiple Sclerosis

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

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

MonoplegicHemiplegicParaplegicDiplegicQuadriplegicTriplegic

Oral Manifestations

BruxismMalocclusionClenchingFood retention / pouching

CariesPlaque control

PeriodontitisGingivitis

Patient Management

Schedule initial interview to acquaint with patientAssess

muscle / reflex patternsCommunication and comprehensionMedical conditions

Caregiver should participate

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

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

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

Bite Reflex

Mouth prop may be helpful

Tie off!

Treat lingual as quickly as possible

Mouth Gag (molt)

Adjustable

Swallow Reflex

Swallow ReflexAvoid mouth propsBe patient!

Retraction Issues

Tongue retraction may be difficult

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

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 extent70% < 40 years of ageOverwhelmingly male50% auto or motorcycle accidents18% sporting accidents20+ % occupationalRemaining GSW, falls, etc.

Other Considerations

Grieving ProcessShockDenialReactionMobilizationCoping

Other Considerations

AngerDepressionWithdrawal

Oral Manifestations

Depends on degree of injuryLower limb involvement onlyUpper limb involvement

Depends on nature of injuryFractured teethBroken 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 leadUse the brakesHave adequate physical supportCheck urinary catheters during and after

Oral Hygiene Needs

Extremely importantMouth and teeth often substitute for arms and handsModified aidsEngage caregiver

Mental Disabilities

Mental IllnessMental 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 realmsMental retardation requires adaptations in both physical and educational realms

Mental Illness

Affects one-sixth of Americans at some point in their lifetimeChronic major depression affects 3-5% of total population

Mental Illness

For womenPhobiasDepression

For MenChemical dependencePhobias

2-5% of populationAnxiety disorders

Patient Management

ConsistencyRegularityReliability

Important for patients still working on stabilization

Patient Management

Dietary analysisSugar addiction

Pain controlAnxiety issues

Informed consentCompliance

Patient Management

Drug interactionsOral 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 childhoodEnvironmental / chemical influences

Inherited – 13%i.e. Down’s Perinatal problems i.e. FAS

Unknown – 75%

Oral Manifestations

Thick lipsTooth anomaliesPeriodontal conditionsOral habitsDental caries

Personalization of Care

Nutritional counselingSimplified OH techniquesRepetitive follow-up“An aggressive approach to preventive care, not an aggressive approach to the patient….”

Patient Management

Tailor to patient skills and comprehensionSedation and/or general anesthesia may be requiredNEVER “HOM”

(hand over mouth)

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

HOME CARE HELPS

Daily Oral Hygiene

Manual toothbrushes can be easily modified

For selfFor care-giver

Specialized Toothbrushes

Collis Curve Brush 1-800-298-4818

Specialized Brusheswww.colliscurve.com

Specialized Brushes

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

Specialized Brushes

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

Conclusion

PreparationRespectRecognize Limitations

PatientsYour own!

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

(This resource has great tips!)

LinguaFix1-800-328-3899www.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