Protecting All Children’s Teeth

Special Needs

Introduction

Approximately 18% of US children and youth have a special health care need. Many of these conditions, including mental retardation, developmental disabilities, cerebral palsy, craniofacial abnormalities, and seizure disorders, can impact a child’s oral health.

By understanding the potential barriers to oral health care and the consequences of poor oral health in children with special health care needs, health professionals can identify at-risk patients early, provide anticipatory guidance, refer to appropriate dental professionals, and assist patients and families in overcoming barriers to accessing and utilizing care.

Learner Objectives

Upon completion of this presentation, participants will be able to:

Recall that dental care is the most common unmet need among the special needs population.

List barriers to accessing dental care. State reasons why children with special health care needs are at

increased risk for caries. Complete the oral health examination checklist at all routine

visits. Assist families in addressing oral hygiene concerns and suggest

techniques for optimizing oral care in children with special needs. Discuss appropriate timing of referral to a pediatric dentist and

list conditions that mandate early referral.

Access to Care

For children with special health care needs, access to care may be limited.

In the United States, dental care is the most common unmet need in thespecial needs population.

Children with special needs are twice as likely than their aged-matched peersto not have their dental needs met.*

Access to Care

Children with special health care needs may face the following barriers to accessing oral health care:   Transportation or physical access to the building  Financial strain, especially with multiple visits or restorative work Insurance coverage

If a child has numerous medical concerns, families may consider oral health a low priority.

Caries Risk

Children with special health care needs are at increased risk for developingcaries for the following reasons:

1. Diet2. Xerostomia3. Difficulties performing oral hygiene4. Gastroesophageal Reflux Disease and vomiting5. Gingival hyperplasia and crowding of the teeth

Caries Risk, continued

In children with special health careneeds, uncoordinated chewing mayleave more food in the mouth.

A weak, uncoordinated tongue maynot be able to adequately clean alloral surfaces.

Gagging on the toothbrush, paste, or saliva may inhibit complete brushing of all surfaces.

An inability to spit may result in the swallowing of toothpaste.

Tooth Eruption

Tooth eruption may be delayed, normal, or advanced in children with special health care needs.

Delayed eruption is more common in children with Down syndrome and hypothyroidism.

Malocclusion and Crowded Teeth

Malocclusion and crowded teeth occur more often in children with abnormal muscle tone (cerebral palsy), mentalretardation, and craniofacial abnormalities.

Crowded teeth are more difficult to clean, thereby increasing the risk of dental caries and periodontal disease.

Dental Anomalies

Teeth may vary in shape, size, or number.

Dental anomalies are a cosmetic concern and may increase the risk for caries.

Gingival Hyperplasia

Gingival hyperplasia usually occurs in children taking anti-epilepticmedications for seizures, especially phenytoin.

In addition to the cosmetic concern, gingival hyperplasia puts children at riskfor improper oral hygiene, impaired tooth eruption, difficulty chewing, andsevere gingivitis.

Trauma

Trauma to the face and mouth occurs more frequently in children with seizures, developmental delays, poor muscle coordination, and abnormal protective reflexes.

Some children with special needs exhibit self-injurious behavior, which may damage oral structures.

Bruxism

Bruxism is more common and often more severe in children with cerebralpalsy or severe mental retardation.

Bruxism may lead to enamel loss and difficulty with chewing or tooth sensitivity.

Children with suspected bruxism should be referred to a pediatric dentist for evaluation.

Problems With Oral Care

Children with special health care needs may not be able to fully cooperate with oral hygiene practices.

This may be the result of gagging, oral defensiveness, or behavioral issues.

They may also have difficulty tolerating fluorideliquid, toothpaste, varnish, sealants, or other caries prevention strategies.

Daily Preventive Care

Daily home preventive dental care may have to be tailored to meet thespecific needs of the child.

This is often best addressed by the dental health professionals involved incaring for the child.

Toothbrushing

If there are concerns about swallowingtoothpaste, families should minimize the amount of toothpaste used (less than a pea-sized amount) or use a non-fluoridated toothpaste.

If gagging is triggered by toothpaste, the teeth should be brushed with plain water.

Toothbrushing

For older patients with limited dexterity, consider the following options:

An electric or battery-powered toothbrush Extending the brush handle with a tongue depressor Widening the brush handle (wrapping it with a sponge) Using a mouth prop for brushing

Dental Office

Children with special health careneeds may require sedation evenfor routine cleanings, restorativeprocedures, and minimal oralsurgery.

If there is concern about a child’scooperation or ability to tolerateoral manipulation, consider referralto a pediatric dentist or a specialistwith training in sedation.

Pediatric Office Screening

Oral examination may be more difficult in a child with special health care needs. The primary care physician should make increased efforts to complete an examination checklist.

Early referral to a dental professionalcomfortable treating children with specialhealth care needs (typically a pediatricdentist) will help to ensure the oralexamination is complete and that allissues are addressed.

Examination Checklist

The oral examination of a child withspecial needs is similar to theroutine child oral examination.

Oral defensiveness, increased gagreflex, and oral motor hypotonicitymay make the examination moredifficult and should be documented.

Examination Checklist, continued

Practitioners should examine the following areas and document abnormalities:   Oral-facial anomalies Teeth   Gingiva

Referrals

All children with special health care needs fall into a risk category and should be referred to a dentist by 1 year of age.

Any child with evidence of caries or tooth, gingival, or eruption anomaliesshould be immediately referred to a dentist who is comfortable caring forchildren with special needs.

Dental Insurance

Dental insurance coverage may be a problem for some children who havespecial health care needs.

Most of these children qualify for Medicaid, which automatically qualifiesthem for comprehensive oral health services through the Early and PeriodicScreening and Diagnostic and Treatment (EPSDT) program.

Question #1

Which of the following is not a risk factor for caries in children with special

needs?

A. BruxismB. Gastroesophageal Reflux Disease. C. Xerostomia from the use of certain medications. D. A special diet that is often cariogenic.E. Oral motor hypotonicity.

Answer

Which of the following is not a risk factor for caries in children with special

needs?

A. BruxismB. Gastroesophageal Reflux Disease. C. Xerostomia from the use of certain medications. D. A special diet that is often cariogenic.E. Oral motor hypotonicity.

Question #2

You inform the family of a child with special needs that thepresence of gingival hyperplasia may put the child at risk

for whichof the following:

A. Premature tooth loss. B. Severe gingivitis. C. Increased likelihood of tooth-grinding.D. Increased risk of tooth injury from oral trauma. E. All of the above.

Answer

You inform the family of a child with special needs that thepresence of gingival hyperplasia may put the child at risk

for whichof the following:

A. Premature tooth loss. B. Severe gingivitis. C. Increased likelihood of tooth-grinding.D. Increased risk of tooth injury from oral trauma. E. All of the above.

Question #3

Which of the following methods will help to prevent children with

special needs from swallowing toothpaste? A. Using less than a pea-sized amount of toothpaste. B. Brushing the teeth with plain water.C. Using a non-fluoridated toothpaste.D. Using an electric or battery-powered toothpaste for children with

limiteddexterity.E. All of the above.

Answer

Which of the following methods will help to prevent children with

special needs from swallowing toothpaste? A. Using less than a pea-sized amount of toothpaste. B. Brushing the teeth with plain water.C. Using a non-fluoridated toothpaste.D. Using an electric or battery-powered toothpaste for children with

limiteddexterity.E. All of the above.

Question #4

True or False? For a child with special health care needs, early

referral to a pediatric dentist will help to ensure the oralexamination is complete.

A. TrueB. False

Answer

True or False? For a child with special health care needs, early

referral to a pediatric dentist will help to ensure the oralexamination is complete.

A. TrueB. False

Question #5

Based on the AAP risk group designations, by what age should

children with special health care needs be referred to a dentist?

A. 6 months.B. 9 months.C. 12 months.D. 18 months.E. 24 months.

Answer

Based on the AAP risk group designations, by what age should

children with special health care needs be referred to a dentist?

A. 6 months.B. 9 months.C. 12 months.D. 18 months.E. 24 months.

References

1. American Academy of Pediatrics Policy Statement. Oral health Risk Assessment Timing and Establishment of the Dental Home. Pediatrics. 2003; 111(5): 1113-1116. Available online at: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;111/5/1113. Accessed June 20, 2007.

2. Barzel R, Holt K, Isman B et al. Special Care: An Oral Health Professional’s Guide to Serving Young Children with Special Health Care Needs. Available online at: http://www.mchoralhealth.org/SpecialCare. Accessed May 30, 2007.

3. Casamassimo P, Seale S, Ruehs K. General dentists’ perceptions of educational and treatment issues affecting access to care for children with special health care needs. J Dent Educ. 2004; 68(1):23–28.

4. Guideline on Management of Persons with Special Health Care Needs. American Academy of Pediatric Dentistry Clinical Guidelines, Council on Clinical Affairs; 2008, Pediatr Dent; 33(6):142-146. Available online at: http://www.aapd.org/media/Policies_Guidelines/ G_SHCN.pdf. Accessed May 25, 2012.

References, continued

5. McPherson M, Arango P, Fox H et al. Commentary: A New Definition of Children With Special Health Care Needs. Pediatrics. 1998; 102(1): 137 –139.

6. Newacheck PW, McManus M, Fox HB et al. Access to Health Care for Children With Special Health Care Needs. Pediatrics. 2000; 105(4):760-766.

7. Newacheck PW, Strickland B, Shonkoff JP, et al. An Epidemiologic Profile of Children With Special Health Care Needs. Pediatrics. 1998; 102(1):117-121.

8. Perlman SP, Friedman C, Kaufhold GH. Special Smiles: A Guide to Good Oral Health for Persons with Special Needs. Available online at: http://media.specialolympics.org/soi/files/healthy-athletes/Special%20_Smiles_Good_Oral_Health_Guide.pdf. Accessed June 20, 2007.

9. Southern Association of Institutional Dentists - Self-Study Course. 2001. Available online at: http://saiddent.org/modules.asp. Accessed June 20, 2007.

10. van Dyck PC, Kogan MD, McPherson MG et al. Prevalence and Characteristics of Children with Special Health Care Needs. Arch Pediatric Adolesc Med. 2004; 158(9): 884-890.