DENTAL MANAGEMENT

OF HANDICAPPED CHILDREN
CHILDREN CUILDREN WITH SPECIAL HEALTH CARE NEEDS (CSHCN)
 DENTAL MANAGEMENT
OF
CHILDREN WITH SPECIAL
HEALTH CARE NEEDS (CSHCN)
By the end of this chapter, the student must be able to:

1- Define handicapped children.

2- Know the classification for children with special health care needs.
3- Identify the management of children with special health care needs.
Specific Management of CSHCN
1-Endocrine disorders
Diabetes Mellitus (DM)

Definition:

DM is a complex multifactorial, genetically derived

endocrine disease. It represents an abnormality in
glucose, protein and fat metabolism due to insulin
deficiency or impaired insulin utilization.
Specific Management of CSHCN
1-Endocrine disorders
Diabetes Mellitus (DM)
Classification:
*Type I:
-Insulin Dependent DM (IDDM).
- Manifested in children and adolescence.
*Type II:
-Non Insulin Dependent DM (NIDDM).
-Manifested in adult obese female.
* Other types of DM occurring secondary to specific conditions as:
- Gestational diabetes (during pregnancy).
- Malnutrition related diabetes.
-Impaired glucose tolerance.
Specific Management of CSHCN
1-Endocrine disorders
Diabetes Mellitus (DM)
General signs and symptoms:
- Polyurea (Frequent urination).
-Polydipsia (Increased thirst).
- Polyphagia (Increased hunger).
-Loss of weight.
-Ketoacidosis.
-Chronic skin infection.
-Blurred vision.
-Numbness in extremities.
-Delayed wound healing.
Specific Management of CSHCN
1-Endocrine disorders
Diabetes Mellitus (DM)
Oral manifestations:
1- Decreased salivary flow rate and in severe cases xerostomia (due to impaired function
of salivary glands) with the result:
a-Dry mucosa that will be easily damaged and more susceptible to opportunistic infection
as oral candidosis.
b- Plaque accumulation and increased incidence of dental caries and periodontal diseases.
2- Burning tongue: may result from xerostomia and diabetic
neuropathy.
3-Increased glucose content in saliva, consequently plaque microflora is altered with
increasing the risk of dental caries and periodontal disease.
4- Impaired taste sensation.
Specific Management of CSHCN
1-Endocrine disorders
Diabetes Mellitus (DM)
Dental management of DM:
Dental management of well controlled and uncontrolled diabetic patient:
- Before dental visit the patient should be instructed to:
1-Take his medication either insulin or oral hypoglycemic drugs.
2- Eat his breakfast to prevent hypoglycemia.
- Early morning appointments are preferred.
- Don't keep the patient waiting.
- Short and stress free dental visit with atraumatic dental procedures.
- Antibiotic prescription is very important especially in patients with severe oral infections
or following dental surgeries as the patient usually shows low body resistance, recurrent
infection, multiple abscesses and delayed wound healing.
Specific Management of CSHCN
2-Cardiac diseases

Cardiac diseases are classified into two main categories:

A-Congenital heart disease. B-Acquired heart disease.
A-Congenital heart disease.
Cyanotic or Acyanotic.
Oral manifestations:
-Cyanotic gingiva.
-Cyanotic tongue.
-Delayed eruption ofprimary and permanent dentition.
- Increased risk of dental caries and periodontal diseases.
- Bluish white appearance of the teeth.
- Sometimes enamel hypoplasia could be found in those patients.
Specific Management of CSHCN
2-Cardiac diseases

Dental management of patients with

congenital heart diseases:
1- Any dental procedure that may interfere with the integrity of oral mucosa or exposed
pulp tissue may lead to bacteremia, so antibiotic prophylaxis is highly recommended.
2 Preoperative oral antiseptic mouth rinse such as 0.2 chlorohexidine gluconate is also
recommended.
3-Conscious sedation or general anesthesia are preferable for those atients to minimize
fear and stress which may lead to change in blood pressure. (Consultation with the
physician is a must).
Specific Management of CSHCN
2-Cardiac diseases

B-Acquired heart disease:

1-Rheumatic fever. 2-Infective bacterial endocarditis.
1-Rheumatic fever.
It is a very serious inflammatory disease that occurs as a delayed sequela to
pharyngitis or tonsillitis by group A βeta hemolytic streptococci.The heart valves, joints,
skin and central nervous systems are the mostly affected by that type of infection.
Cardiac involvement is the most significant pathologic sequela of rheumatic
fever,which could be fatal in some cases or may lead to chronic rheumatic heart disease as
a result of scarring and deformity of the heart valves.
Specific Management of CSHCN
2-Cardiac diseases

2-Infective bacterial endocarditis

It is a microbial infection of heart valves or endocardium as a result of
bacteremia. It may be acute or subacute.
Dental management of patients with acquired heart disease:
Prophylactic antibiotic regimen is highly recommended for those patients.
According to the American Heart Association:
1- Amoxicillin (Unasyn or Augmentin)→for children 50 mg/kg given orally one hour before
dental treatment. e.g.:a child weight 20 kg x 50 mg =1000 mg(i.e.one gm).
2-In patients who is unable to take oral medication:
Ampicillin 50 mg/kg IM injection 30 minutes before treatment.
3- In patients allergic to penicillin: Clindamycin e.g.:Dalacin-C.Or Erythromycin orally one
hour before treatment.
Specific Management of CSHCN
2-Cardiac diseases

*Dental procedures requiring prophylactic antibiotic:

Any dental procedure could induce bleeding as:
- Extraction of a tooth.
-Scaling and root planning.
- Endodontic treatment and instrumentation beyond the apex.
- Placement of orthodontic band.
- Intraligamentary local anesthesia.
- Dental implants.
Specific Management of CSHCN
2-Cardiac diseases

*Dental procedures not requiring prophylactic antibiotic:

- Filling and restoration.
- Local anesthesia injection.
- Placement of rubber dam.
- Oral impression.
- Removal of sutures.
- Shedding of primary teeth.
- Placement of orthodontic brackets.
- Taking radiographs.
Specific Management of CSHCN
3-Bleeding disorders

Hemophilia

Patients with bleeding disorder present a great challenge to the dentist

due to the presence of hemostatic problems. Hemophilia A is the most obvious
bleedir disorder and results from deficiency in factor VIII (known as
antihemophil factor).
Deficient factor VIII is an x- linked recessive trait and transmitted from
the mother (carrier) to her sons.
Specific Management of CSHCN
3-Bleeding disorders

Oral manifestations:
1- Spontaneous bleeding from oral mucosa, gingiva, lips,palate and2 tongue.
2- Poor oral hygiene due to irregular tooth brushing (fear of patient from3
excessive bleeding from his gingiva).
3- High dental caries incidence as the patient cannot eat hard or fibrous food
and usually eats soft carbohydrates.
Specific Management of CSHCN
3-Bleeding disorders

Dental management for hemophilic patient:

1 -Analgesics as aspirin and anti-inflammatory drugs should not be used as i may

alter platelets function and increase the risk of bleeding.
2- Local anesthesia:
Nerve block is contraindicated as it may lead to hematoma in the lateral
laryngeal wall that may block the airway and may be fatal. Therefore,
infiltration anesthesia is recommended for those patients and should contain
vasoconstrictor.
Specific Management of CSHCN
3-Bleeding disorders

3-Periodontal therapy:
- Gingivitis can predispose to spontaneous gingival bleeding so instructions for
brushing cannot be over locked.
- Supragingival calculus can be removed atraumatically with ultrasonic scaler or
hand instrument.
- Subgingival scaling and root planning could be performed but with replacement
therapy with the factor deficiency.
Specific Management of CSHCN
3-Bleeding disorders
4- Restorative treatment:
- Rubber dam should be used to isolate the operating field and to protect the
cheeks, lips and tongue.
- Precautions should be taken during preparation of the teeth for crowns.
- For taking an impression the periphery of the tray should be lined with wax to
prevent injury of soft tissue.
5-Pulp therapy:
- Pulpotomy and pulpectomy are preferred than extraction and indirect p
procedure is preferred than Pulpotomy.
- If vital pulp is exposed an intrapulpal injection should be given to con' pain.
Bleeding from the pulp chamber doesn't present a significant problem and
could be controlled by pressure with a cotton pellet.
Specific Management of CSHCN
3-Bleeding disorders
6-Oral surgery:
- For patient undergoing dental surgeries or even extractions, Consultation with the
hematologist for preoperative evaluation and postoperative management.
- Before oral surgery the patient should receive blood transfusion.
- Simple extraction of permanent or primary teeth can be done by 40% factor replacement
one hour before dental procedure.
- Direct topical application of hemostatic agents such as bovine thrombin or surgicel may be
used after extraction.
- The use of suture should be avoided unless it enhances healing.
- The patient should take liquid diet for 72 hours and soft diet for 10 days this to prevent
chewing of any hard food to avoid disturbance of the soft tissue or the formed blood clot.
- Normal exfoliation of primary teeth does not require factor replacement and bleeding could
be controlled by direct finger pressureand gauze with topical application of local hemostatic
agent.
Specific Management of CSHCN
4-Neuromuscular disorders

a-Epilepsy b-Cerebral palsy

Epilepsy
Definition:
Epilepsy is an abnormal electrical activity in the cerebral neurons that results in
certain changes in the normal balance between the excitatory and inhibitory
influences on the activity of the nerve cell.
Etiology:
- Idiopathic: Genetic or acquired.
- Post traumatic - post infectious.
- Post toxic (lead or arsenic poisoning).
- Or secondary to brain injury.
Specific Management of CSHCN
4-Neuromuscular disorders
Clinical manifestations:
*Grand Mal Seizures:
- Preceded by momentary aura (smell, taste and vision).
- Twitching of muscles.
- Followed by generalized convulsion with tonic and clonic phases of muscular spasm.
Tonic phase→Lasts for 30 seconds and characterized by:
- Dilated pupil.
- Head thrown back.
- Abdomen and limbs contracted.
- Contraction of the jaw's muscle.
- Tongue may be severely bitten.
Clonic phase → Spasm in which rigidity and relaxation is alternate in rapid succession.
After this phase, the body returns back to normal within 15 minutes to 8 hours.
Specific Management of CSHCN
4-Neuromuscular disorders
*Petit Mal Seizures:
-Characterized by no aura.
-The attack lasts for few seconds.
-The patient loses his consciousness for few seconds with or without spasm.
-This patient represents a little difficulty for the dentist to manage him.

Drug therapy of epileptic patient:

Dilantin (Phenytoin) : is the widely used drug to suppress the seizures.
Recent studies have shown that gingival hyperplasia is the most common side
effect of dilantin and occurs in about 32- 84 % of patients using the drug.The
reason behind this is still not clear
Specific Management of CSHCN
4-Neuromuscular disorders

Dental management of the epileptic patient:

*Management of the gingival hyperplasia.
*Management of epileptic patients in the dental clinic.

Management of the gingival hyperplasia:

1- Preventive and oral hygiene measures, instructions and gingival curettage.
2-Gingivectomy to return the gingiva to its normal anatomy.
3- After surgery: Follow up by the dentist to prevent gingival hyperplasia again.
Chlorohexidine may be beneficial in prevention of recurrence of the condition.
Specific Management of CSHCN
4-Neuromuscular disorders

Dentist should avoid the precipitating factors

that may lead to convulsions as:
1- Operating light (should not be focused on the patient's eyes).
2-Loud noise and high music.
3-Insufficient sleeping hours before dental appointments.
Management of patient having seizure in the dental office:
1-All appliances such as matrix bands, rubber dam clamp ...etc should be removed quickly.
2- Put the patient in a supine position with his head tilted to the side that saliva or any vomits
can exit and possibility of aspiration is reduced.
3- Dentist should try to maintain patent airway by suctioning of any secretions to prevent
aspiration.
4-Patient's extremities should be gently restrained to uncontrolled
movements.
5-Wooden tongue blades or rubber mouth props should be tied to string for easy removal and
to prevent injury of the tongue.
Specific Management of CSHCN
4-Neuromuscular disorders
Cerebral palsy:
(Muscular impairment with mental retardation).
Definition:
Cerebral palsy in not a single disease entity but rather a collection of disabling conditions
caused by permanent damage to the brain in the prenatal and perinatal period.
Etiology:
-Decreased oxygenation to the brain.
-Traumatic injury during labor and its complications.
- Infection such as meningitis.
-Congenital defects in the brain.
- Accident or trauma to the brain.
-Premature births.
Specific Management of CSHCN
4-Neuromuscular disorders

General manifestations:
- Mental retardation in 60 % of the cases.
- Seizures disorders and hyperirritability.
- Sometimes sensory disorders are present as hearing or visual
impairments.
- Speech disorders as the patient cannot articulate because of lack of
control of speech muscles.
- Abnormal limb position and limited control of the neck muscles.
Specific Management of CSHCN
4-Neuromuscular disorders
Oral signs and symptoms:
1-Periodontal diseases due to:
a-Eating soft diet as the patient cannot chew food as a result of poor muscular
coordination.
b- Neglection of the oral hygiene and tooth brushing due to lack of manual
dexterity.
c-Patients taking anticonvulsants (dilantin) show a degree of gingival hyperplasia.

2-Dental caries due to:

a- Poor oral hygiene.
b- Impaired chewing and swallowing willIlead to poor eating habits as soft diet.
c-Patients show higher incidence of enamel hypoplasia.
Specific Management of CSHCN
4-Neuromuscular disorders
3-Malocclusion:
a- Protrusion of maxillary anterior teeth.
b- Excessive overbite and overjet.
c-Open bite.
d-Unilateral crossbite.
The most important causative factor of malocclusion may be:
1)Disharmony between intraoral and perioral muscles.
2)Uncoordinated and uncontrolled movement of the jaws, lips and tongue.
4-Bruxism:which may to:
- severe attrition of primary and permanent teeth.
- Loss of the vertical dimension.
- TMJ disorders.
Specific Management of CSHCN
4-Neuromuscular disorders

5- Trauma of maxillary anterior teeth due to: -

- Repeated fall accidents.
- Protrusion of maxillary teeth.

6-Tongue thrust and mouth breathing.

.
Specific Management of CSHCN
4-Neuromuscular disorders
Dental management:
1- It is preferable to treat the patient while he is sitting in his wheel chair.
2- It is advisable not to treat the patient in a supine position as the patient shows
difficulty in swallowing.
3- Impaired cough reflex of those patients make the use ofrubber dam is so
important to prevent aspiration of any foreign body.
4- Use mouth prop to protect the tongue from involuntary movement of the jaws.
5- Avoid abrupt movement of the instrument intraorally.
6-Stabilization of the head is important to avoid
7-General anesthesia is preferred for those patients.
Specific Management of CSHCN
5-Sensory handicapping conditions
A-Deafness and hearing impairments.
B-Blindness and visual impairments.

A-Dental management of patient with hearing impairment:

*Oral manifestations:
Sometimes deafness is accompanied by:
- Bruxism.
- Poor oral hygiene due to inability to learn adequately oral hygiene instructions.
Specific Management of CSHCN
5-Sensory handicapping conditions

*Dental management:
1-In the first appointment determine how the child desire to communicate e.g.:
-With lip reading.
- With sign language.
- Writing notes or combination of these.
2-Face the patient and maintain visual contact with him.
3-Employ Show - Do approach and allow the patient to use other sensations as taste or
touch to communicate.
4- If the child is wearing a hearing aid, it should be turned off before dental procedure, as
those children are very sensitive to vibration coming out of handpiece.
5-Keep smile, calm and communicate kindly.
Specific Management of CSHCN
5-Sensory handicapping conditions

B-Dental management of patient with visual impairment(Blindness):

*Oral manifestations:
1- Poor oral hygiene due to visual impairment.
2-Hypoplastic teeth.
3- Traumatic injury shows an increased incidence than normal child.
4-Early childhood caries due to prolonged bottle- feeding.
Specific Management of CSHCN
5-Sensory handicapping conditions

*Dental management:
1-Describe the dental office in detail.
2-Sit close to the patient and maintain physical contact with the child e.g.
holding his hand.
3- Allow the patient to ask questions about the treatment.
4-Utilize Tell-Do approach and allow the patient to touch, taste and smell for
explaining the treatment.
5- Maintain a relaxed atmosphere and limit the patient's dental care to one
dentist.
Specific Management of CSHCN
6-Respiratory disorders

Asthma
Definition:
It is a chronic inflammatory disease of the airway and characterized by
cough,wheezing, chest tightness and shortness of breath.

*Oral manifestations:
1-High caries rate due to:
- Repeated administration of medicines containing sugars.
- Also, prolonged use of bronchodilators can lead to decreased salivary flow rate.
Specific Management of CSHCN
6-Respiratory disorders

2-Repeated use of corticosteroids can lead to:

- Dry mouth.
- Oral candidiasis and sometimes tongue enlargement.

3-Gingivitis:
Patients with asthma show a high rate of gingivitis due to:
- Frequent inhalation of steroids.
- Mouth breathing.
- Impaired immunological factors.
Specific Management of CSHCN
6-Respiratory disorders

4-Orofacial abnormalities due to:

- Impaired respiratory function.
- Mouth breathing.
Studies showed that there is an increase in the facial height, high palatal vault,
greater overjet and high prevalence of posterior cross-bite.
Specific Management of CSHCN
6-Respiratory disorders
Dental management:

* General consideration:
1-Oral hygiene instructions and fluoride supplements.
2- Instruct the patient to rinse his mouth after using the inhaler.
3-Prescribe antifungal drug for patients taking corticosteroids nebulizer.
Specific Management of CSHCN
6-Respiratory disorders
Dental management:
*In the dental office:
1- The major concern of the dentist is to prevent the acute attack in the
clinic.Therefore,the patient should bring the inhaler (bronchodilator) at each
visit.
2- Antihistaminics could be taken to minimize bronchoconstriction.
3-The dentist should avoid certain factors that may predispose the attack during
dental treatment as:
- Improper positioning of suction tip, cotton rolls and fluoride trays position.
-Prolonged supine position.
-Any material with a strong odor as methylacrylate, enamel or dentin dust or
rubber dam sheets.
Specific Management of CSHCN
6-Respiratory disorders

If the attack occurs during dental treatment:

-The dentist should immediately discontinue the procedure and allow the
patient to assume more comfortable position.
- Establish and maintain a patent airway.
- Give oxygen via a facemask.
- The dentist can give epinephrine 0.01 mg/kg subcutaneously to a maximum
dose 0.3 mg.
- General anesthesia is not preferred as:
1-It may lead to hypoxia and pulmonary edema.
2- There is a risk of postoperative lung collapse.
Therefore, patients require bronchodilator before general anesthesia.
Mental handicapping

Down's syndrome:
(Mongolism,Trisomy 21)
Down's syndrome is the leading cause of mental retardation. It occurs in
about 1 of every 660 live births. It is associated with an extra chromosome 21, 50
each cell contains three number 21 chromosomes rather than two.This yndrome
is most common among first bom infants of women over 35 years of age.
Clinical features which influence the dental and oral health:
1-Mental retardation.
2- Abnormal immune system with high incidence of periodontal diseases which
may be aggravated by some local factors such as tooth morphology, bruxism,
malocclusion and poor oral hygiene.
Mental handicapping

3- Chronic upper respiratory tract infection due to: -

- Mouth breathing
- Xerostomia.

4-Hypotonia: decreased muscle tone of the lips and cheeks which may lead to
inefficient chewing.
Mental handicapping

Oral manifestations:
1-Prognathic class III relationship, which lead to open bite.
2-Mouth breathing and xerostomia.
3-Protruded scrotal tongue.
4- Delayed teeth eruption and exfoliation.
5- Microdontia and partial anodontia.
6- The roots of the teeth tend to be small and conical.
7-Rapid destructive periodontal diseases.
8-Lower caries index.
Mental handicapping

Dental management:
Many children with Down's syndrome are affectionate and cooperative,
and dental procedures can be provided without compromise if the dentist
works slight slower pace. Light sedation and immobilization may be indicated in
those children who are moderately apprehensive. Severely resistant patients
may require gene anesthesia.