Handicapped children in Dental Clinic

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Handicapped children in Dental Clinic

  • Child Definition

    • conception (kandungan) – 18 years (Convention of Child Right /CRC & Indonesian Child Protection Right)
    • Based on :
      • anatomical growth (epipyphise closed, reproductive system maturation etc. )
      • Psychosocial development (adolescent → adulthood)
    • Child not a miniature of adult !!
    • Specific aspects : growth and development
  • Increases of all child function

    • intraurine=saat hamil


  • Children Developmental Aspect


  • Program untuk anak di negara berkembang

    • Child survival


    • Increase quality of life

      • Love/Asih
      • Care
    • children protection

  • Faktor Penyebab Gangguan Proses Tumbuh Kembang

    • Determinant
    • Pembagian Menurut
  • Definition Special health care needs

    The American Academy of Pediatric Dentistry (AAPD):

    "any physical, developmental, mental, sensory, behavioral, cognitive, or emotional impairment or limiting condition that requires medical management, health care intervention, and/or use specialized services or programs.

  • Disabled child or Handicapped child includes all the children that have

    • Mental conditions
    • Physical conditions
    • Medical conditions
    • Social conditions
  • Classification of disabled patients

    • Disabilities by specific dentistry problems • Physical disabilities • Sensorial disabilities • Neuro-psychological disabilities • Disabilities by chronic diseases (renal,heart,cancer etc) • Disabilities by immunological diseases

    • Poorly informed patients and parents about the needs and possibilities of dental care
    • Lack of motivation of patients and their parents or guardiansas the severity of the primary disease is greater, the interest of the parents and guardians fоr oral health is lower
    • Lack of incentives for dentists to work with people with special needs access and communication, more time is needed for intervention
    • Insufficient number of trained dental staff
      • training, education, specialization
      • poor organization of dental services in stationary institutions,
      • a central register
      • Lack of interdisciplinary collaboration, adequately equipped

    • Associated with mental abilities of the child and his awareness
    • poor oral hygiene,
    • significant presence of soft and hard deposits on teeth,
    • presence of periodontal disease,
    • high percentage of untreated carious teeth with all the attendant complications associated with them,
    • a small number of filled teeth, large number of extracted teeth compared to the healthy population
    • trauma and damage the teeth and mouth
  • Handicapped patients in dental clinic

    • First Dental Visit :
      • Establish an excellent relationship with the parents, guardian and the patient.
      • Initial dental examination.
      • Through medical & dental history.
      • You must be prepared to discuss the patient health status & possible planned dental treatments with the physicians.
  • Common oral & dental problems

    • Poor oral hygiene plaque
    • Gingivitis & periodontitis
    • Caries Lesions
      • Soft diets: >> Sugar
      • Psycho drugs: > salivation.
    • Malocclusion
    • Dental abrasions
    • Para functional habits (Bruxism)
  • At the time of treatment we must consider factors such

    • The level of dependency

    • Type of disability

    • Associated systemic disease

    • Effect of medications

    • Level of oral hygiene

    • Malocclusion

    • Functional problems related to mastication (Presence of frequent dental traumas)

    • Behavior during treatment

    • Patient's diet :

      (Type, texture, frequency and the quantity of carbohidrates consumed)

  • Neuro-psychological disabilities

    • Intelectual Disability

      • Definisi

        individual's intellectual development is significantly lower than everage and whose ability to adapt to their environment is consequently limited.

      • Kategori

        The WHO recommends the division of the mentally subnormal into three broad categories :

        1. Mild Subnormal with IQ of 50-69 and a mental age in the adult of 8 to 12 years.
        2. Moderate Subnormal with IQ 20-49 and a mental age in the adult of 3-7 years.
        3. Severe subnormal with IQ 0-19 and a mental age in the adult of 0-2 years. *There are many organic causes & syndromes that can cause or accompany.
      • Dental Problems on Intelectual Disability

        • Anomalies in the dento facial morphology and in the dental eruptive pattern
        • Enamel hypoplasia
        • Delayed eruption
        • High palatal vault with a hypoplastic maxilla
        • Tendency for Class II malocclusion with an open bite
        • Over retained primary dentition
    • Down Syndrome

      We may found :

      • Supernumerary teeth
      • Microdontia
      • Macroglosia
      • A bifid, fissured or excrotal tongue There are specific facial characteristics, ocular anomalies and premature fusion of the cranical sutures in the patients.
      • High incidence of rapid destructive periodontal disease.
    • Cerebral Palsy

      is a collection of disabling disorders caused by insult and permanent damage to the brain in the prenatal and perinatal periods, during which time the central nervous system is still maturing.

      This disability might involve muscle tone with disruption of movement and posture, dysfunction and paralysis.

      • Three most common types of Neuromuscular dysfunctions

        1. Spasticity
        2. Athetosis
        3. Ataxic


      • Classification According to Affected Area by This Disorder

        1. Monoplegia
        2. Hemiplegia
        3. Diplegia
        4. Quadriplegia


  • Patients with mental, developmental, or physical disabilities who do not have the ability to understand, assume responsibility for, or coorporate with preventive oral health practices are susceptible as well.

  • Oral health is an inseparable part of general health and well-being.

  • The American with Disabilities Act (AwDA) defines the dental office as a place of public accomodation. Thus, dentist are obligated to be familiar with these regulations and ensure compliance.

  • Dental treatment of a child with Intelectual disability

    1. Behavior management techniques can be used for patients with mild or moderate retardation.
    2. Dental procedures must be explained slowly, simply and repetitively.
    3. Give only one instruction at a time. Reward the patient with compliments after each procedure.
    4. Actively listen to the patient. People with intelectual disability often have trouble with communication.
    5. The visits should be short. Minimal new procedures should be introduced at each appoinment.
    6. Gradually progress to more difficult procedures.
    7. We must learn from the parents or guardians about the patient's habits, comprehensive words or gestures to facilitate our work.
    8. Before using physical restriction on patients, suitability must be considered for each case and with parental or guardian concent.
    9. We must consider the patient's behavior, his age and the type of dental treatment needed.
    10. We may utilize elements of partial or total restriction, or collaboration of 2 or 3 helpers.
    11. Sedation techniques can also be used such as oral premeditation.
    12. General anesthesia should be used only in cases where physical restriction, behavior management and conscious sedation have all failed or were ineffective in providing the most efficient care.

    With adequate preparation the dentist and the staff can provide a valuable service.

    By thoroughly understanding the patient's degree of intelectual disability and abilities and by exercising patience and understanding, the dentist

  • Recommendations

    • The main objectives of care are:

      • to motivate the patient and caregiver to maintain oral health
      • prevent infection and tooth loss and
      • prevent the need for extensive treatment that patients may not be able to tolerate due to their physical or mental condition and make appointments pleasant and comfortable.
      1. Creating a Barrier-Free Environment

      The American with Disabilities Act (ADA) of 1992 sets standarts and building codes for new construction to create barrier-free or universal design environments that make facilities and services usable by everyone.

      • Design characteristics for Barrier-Free Facility
        • Clearly marked and designated wide parking spaces close to the building
        • Accessible front entrance with ramp and curb cut at appropriate grades and surfaces
        • Interior and exterior doors that are wide and easy to open
        • Wide corridores to allow a 360-degree turn in a wheelchair without bumping into a wall
        • Clear floor space with nonskid surfaces
        • Signs posted no higher than five feet from the floor
        • Elevators in buildings with two or more floors
      1. Special Care Dentistry (SCD) :

      "Special care dentistry is the delivery of dental care tailored to the individual needs of patients who have disabiling medical conditions or mental or psychological limitations that require consideration beyond routine approaches"

      • SCD may be necessary for persons with severe movement disorders, chronic mental illness, persons who are adults in age but who function at a child's level, and those with serious medical conditions who are at risk for adverse outcomes in the dental setting unless treated by a knowladgeable practitioner.
      • Communication with all members of the health care team, family, caregiver, physician, social services, and the dental team is essential.
      • The following questions will help each dental office assess preparedness to offer the needed services
        • Does the office have handicap access?
        • Are members of the dental team comfortable or have experience with transferring patients to dental chair
        • Is the dental health team familiar with the oral health problems faced by people with disabilities?
        • Does the office have mouth props or supportive devices to aid patients who may have difficulties in opening their mouths?
        • Is the dental health team knowladgeable about assistive devices to enable these patients to be more independent in managing their own oral hygiene?
        • Are members of the dental healthcare team able to develop a personal oral hygiene program for an individual with intellectual/physical disabilities based on his or her level of understanding and ability?
      1. Assessment, Planning and Appoinment Scheduling
      • Most patients with a disability, or their caregivers, will be prepared to discuss treatment issues when they first contact the office to schedule an appoinment.
      • An accurate and current health history is essential. Depending on the disability and/or medical condition, a consultation with the patient's physician, counselor, and other members of the rehabilitation team may be necessary to ensure treatment is safe and effective.
      • Pretreatment planning helps to determine what preparation needs to be taken before the appoinment.
      • A phone interview can provide a disability profile detailing problems or limitations that impact care.

      For example, if the patient is using a wheelchair, what is the degree of mobility and will there be a need for help in transferring the patient to the dental chair?

      • Does the patient need antibiotic premedication for treatment?
      • Who will legally provide consent for treatment?
      • What are the patient's likes, dislikes, fears and limitations?
      • Appoinments may be dependent on transportation issues such as reserving special Vehicles.
      • There should be no conflict with bowel and bladder elimination, meals or medicine schedules. For the young patient, naptime can be a consideration.
      • A mid-morning appoinment may be the most ideal time
      • A persons with disabilities often need time to prepare for the visit, wait time is usually minimal, and early in the day the patient and the staff are at their best.
      1. Desensitization
      • Individuals with special needs may benefit from methods that help desensitize them to dental treatment.

      • Before the visit family members or caregiver can familiarize the patient with oral care and a day daily tooth brushing routine at home in familiar suroundings.

      • Dental team members can instruct caregiver in proper technique to avoid any injury.

      • Illustration of proper procedure allowing for head stabilization during toothbrushing



      • Protective Body Stabilization

        • Disabled patients frequently have problem with support, balance and even aggressive behavior.
        • In the office, stabilization may be used to make the patient feel comfortable and secure.
        • Pillows, rolled blankets or towel may be placed under the patient's knees and neck to prevent muscle spasms and provide additional support.
        • A beanbag chair placed on the dental chair will conform to the patient's body while filling the space between the patient and the dental chair.
        • To minimize movement a member of the dental team or caregiver may gently hold the patient's arms and/or legs in a comfortable position.
        • A team member can sit across from the operator and lightly place their arm across the patient's upper body to keep the working field clear.
        • A child may lay on top of a parent in the dental chair, with the parent's arms around the child.
        • Mouth props may be necessary to provide due to a lack of ability, or unwillingness to keep their mouth open
        • Use of a mouth prop not only provides protection from the patient suddenly closing their mouth but can improve access and visibilty for the dental team.


      1. Informed consent :
      • Informed concent from the patient or legal caregiver must be obtained before treatment.
      • An explanation regarding the need for stabilization, proposed methods, risks and benefits, and possible complications is necessary.
      • Documentation in the record must include :
        • Informed concent
        • Indication for use
        • Type of protective stabilization
        • Duration of application
        • Behavior evaluation during procedure
        • The level of success or failure of the procedure

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