Management of a Child

with Disabilities during

Dental Treatment – I

Mahmooda Farheen
P.G. II year.
 Contents

•Introduction
•Special care dentistry
•Need for dental services
•Barriers to care and philosophies of management
•General considerations
•Preventive dentistry
•Management during Dental Treatment
•Mental Disability
•Cerebral palsy
•Autism
•Attention Deficit Hyperactivity Syndrome(ADHD)
•Dyslexia
•Conclusion
•References
 INTRODUCTION

Disability: is the functional limitation within the individuals caused by

physical, mental or sensory impairments.

Handicap: is the loss or limitation of opportunities to take part in the

normal life of the community on an equal level with others due to
physical and social barriers.

Developmental disability is not a term denoting clinical diagnosis but is

a diverse group of chronic conditions that are due to mental or physical
impairments that begins before an individual reaches adulthood.
Definition:

According to AAPD (2014-15) - A person should be considered

to have dental disability, if there is pain, infection, or lack of
functional dentition that leads to : Restriction of nutritional
intake adequate for growth and energy needs, Delays or
otherwise alters growth and development, Inhibits
participation in life activities and diminishes quality of life.

According to WHO – Disabled child is one who over an appreciable

time is prevented by physical or mental condition from full
participation in normal activities of his age group , including those of a
social, recreational, educational, vocational in nature.
 Classification of special health care needs children

Frank and winter (1974) According to Nowak (1976)

Blind or partially sighted Physically handicapped- Polio

Deaf and partially deaf Mentally handicapped- Retardation
Educationally subnormal Congenital – cleft lip and palate
Epileptic Convulsive- epilepsy
Maladjusted Communication-deafness
Physically handicapped Systemic- hemophilia
Defective of speech Metabolic- juvenile diabetes
Senile Osseous disorder- rickets
Malignant disorder- leukemia

According to Agerholm (1975)

Intrinsic category: The handicapped condition cannot be eliminated/
separated/improved significantly in the child. e.g. cerebral palsy, mental
retardation
Extrinsic category: The handicapped condition may be made better with strategic
meticulous care. Social deprivation is an example.
According to Damle (2000)

•Physical handicap e.g. Monoplegia, Paraplegia

•Mental handicap e.g. Down syndrome
•Sensory handicap e.g. Deafness, Blindness
•Medically compromised e.g. Hemophilia, leukemia
•Multihandicap

Considering the variations in the types of treatment modalities and

for convenience of management, they can be categorized as:
•Developmentally disabled child
•Medically compromised patients
 Special Health Care Needs

The AAPD defines special health care needs as “any physical,

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

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.
 Need for dental services

•There is a general agreement that the population with disabilities has

higher rates for poor oral hygiene, gingivitis and periodontitis than
general population.

•Moderate or severe gingivitis has been found almost universally with

increasing age and degree of mental retardation, especially for
individuals with Down syndrome.

•Patients who were unable to perform their usual activity because of

their chronic health issues were reported to have less dental visits as
compared to other categories.
 Barriers to care and philosophies of management

Problem Area Examples Manifesting Problem Area

Accessibility Offices not physically accessible.

Offices not on public transportation routes.
Office procedures not accommodating to
Special needs scheduling issues.
Financial Office does not accept Medicaid.
Office not familiar with alternative funding
Patient receives public assistance.
Poor vocational training, lack of employment or
Underemployment.
Inadequate health coverage.
Psychosocial Competing health issues.
Fear of health care.
Intellectual deficits.
Social deprivation.
Low priority for oral health.
Mobility and Stability Uncontrolled movement
Muscle weakness
Short attention span
Hyper kinesis

Communication Lack of speech

Sensory impairment
Intellectual impairment

Medical Medications
Allergies (latex)
Congenital deformities
Compromised life activity
Limited life span
Oral/systemic relationships(cleft palate)
 General considerations

1. Dental office access:

One of the first precondition in the management of a disabled child

is accessibility of dental offices and operators. It requires
establishment of barrier-free facilities to accommodate people with
all kinds of disabilities.
Disabled Accessibility Guidelines
2. First dental visit
The first dental appointment is very important and can set the stage for
subsequent appointments.

By scheduling the patient at a designated time (early in the day) and

allowing sufficient time to talk with the parents (or the guardian) and the
patient before initiating any dental care, a practitioner can establish an
excellent relationship with them.

Initial demonstration of sincere interest in the child often proves

advantageous and saves time throughout the entire treatment process.

Obtaining an informed consent is imperative.

 Assessing Disabled Child

Management scale (Menius, 1971)

•MS I: The patient is easy to manage, cooperative and friendly.

•MS II: The patient has some reluctance but responds well to verbal
management by the operator. There may be some hesitancy, some
whining or slight amount of crying. The patient may be docile but may
require mouth prop. This may be categorizes as a “potentially good
patient”

•MS III: The patient is unable or unwilling to reason out. Cooperation

may be considered poor but the patient is manageable with minimal
resistant and a mouth prop.
•MS IV: The patient requires restraint to allow any treatment,
although with much difficulty. There is screaming, loud noise, some
struggling and combativeness. Premedication may be needed in
addition to the restraint.

•MS V: The patient is extremely difficult to manage and requires

complete restraint. There is much screaming, struggling and it is
necessary for accomplishing any definitive treatment to deeply sedate
the patient or place under General Anesthesia.

•MS VI: Small uncooperative child, who only needed a minimal

amount of treatment, which did not warrant the use of general
anesthesia. Child treated using physical restraints.
Medical Consultation:
When appropriate, the physician should be consulted regarding
medications, sedation, general anesthesia (GA), and special restrictions
or preparations that may be required to ensure the safe delivery of oral
health care. The dentist and staff always should be trained and prepared
to manage a medical emergency.

Patient Communication:
An attempt should be made to communicate directly with the patient.
Dental staff may need to communicate in a variety of non-traditional
ways. A parent, family member, or caretaker may need to be present.
Behavior Guidance:

SHCN children may display resistant behaviors because of anxiety or a lack of

understanding of dental care.

Most patients with SHCN can be managed in the dental office using simple behavior
management techniques such as tell, show, and do.

Protective stabilization can be helpful in some patients as well the use of mouth
props and blocks.

However, in SHCN with severe behavioral problems, sedation or GA may be the

only option to successfully perform dental treatment.

The dentist should consider the evaluation of behavior using one of the behavioral
analysis rating scales such as Frankl rating scale.
3.RADIOGRAPHIC EXAMINATION:

•Adequate radiographic records are often necessary in planning dental

treatment for the child with SHCN.
•Assistance from the parent and dental auxiliaries and the use of
immobilization devices may be necessary to obtain the films.
.
•For patients with limited ability to control film position, intraoral films with
bite-wing tabs are used for all bite-wing and periapical radiographs.
When standard radiographic series is beyond the physical and emotional
capacities of the patient, the alternatives which can be used are as follows:
•lateral jaw projections
•Anterior occlusal projections
•Buccal bitewing radiograph
 Preventive Dentistry

Predisposing factors that make restorative dental care harder to obtain

when it is necessary.

After the diagnosis, the dentist should determine the patient’s needs,
assume the responsibility for formulating an individual program for the
child, and adequately communicate to the parents and patient how such a
program can be affected.

Use of a Caries-Risk Assessment Tool (CAT) to integrate these dental

risk factors.
 HOME DENTAL CARE

•Dental education of parents/guardians/caregivers is important to

ensure children with SHCN do not jeopardize their overall health by
neglecting their oral health.

•Home dental care should begin in infancy; the dentist should teach the
parents to gently cleanse the incisors daily with a soft cloth or an infant
toothbrush.

•For older children who are unwilling or physically unable to cooperate,

the dentist should teach the parent or guardian to clean teeth twice a day
using correct tooth brushing techniques, safely immobilizing the child
when necessary.
• Technique often recommended is the
horizontal scrub method- it is easy to
perform.

•A soft, multitufted nylon brush should

be used.

•Electric toothbrushes have also been

used effectively by children with SHCN.

•Daily flossing, with supervision or the

use of floss holders, is essential to
maintain optimal gingival health.
 DIET AND NUTRITION

•A proper noncariogenic diet is essential to a good preventive program for a child

with SHCN.

•Assess the diet by reviewing answers on a diet survey with the parent, allowances
must be made for certain conditions for which dietary modifications are required.

•Any dietary recommendations should be made individually after proper

consultation with the patient’s primary physician or dietitian.

•The oral side effects of their medications should be reviewed with the parents or
guardians at each visit

•Particular emphasis should be placed on discontinuation of the nursing bottle by

12 months of age and cessation of at-will breast-feeding after teeth begin to erupt.
 FLUORIDE EXPOSURE

• Judicious use of systemic fluoride

•Topical fluoride after a regularly scheduled professional prophylaxis. Also, 5%

neutral sodium fluoride varnishes have been shown to be beneficial.

•An American Dental Association–accepted dentifrice containing a therapeutic

fluoride compound should also be used daily.

•Some clinicians treating patients suggest a daily regimen of rinsing with 0.05%
sodium fluoride solution.

•Nightly application of a 0.4% stannous fluoride or 1.1% sodium fluoride brush-

on gel has also been successfully used to decrease caries in children.
 PREVENTIVE RESTORATIONS

•Pit and fissure sealants have been shown to reduce occlusal

caries effectively.

•For a patient who requires dental work under general

anesthesia, deep occlusal pits and fissures should be restored
with amalgam or long-wearing composites to prevent further
breakdown and decay.

•Patients with severe bruxism and interproximal decay may

need their teeth restored with stainless steel crowns.
 REGULAR PROFESSIONAL SUPERVISION

Close observation of caries-susceptible patients and regular dental

examinations are important in the treatment of patients with SHCN.

Although most patients are seen semiannually for professional

prophylaxis, examination, and topical fluoride application, certain
patients can benefit from recall examinations every 2, 3, or 4
months.
 MANAGEMENT OF A CHILD WITH SPECIAL HEALTH CARE
NEEDS DURING DENTAL TREATMENT

•The principles of behavior management are even more important

in treating a child with SHCN

•If patient cooperation cannot be obtained, the dentist must

consider alternatives such as protective stabilization, conscious
sedation, or general anesthesia to allow performance of the
necessary dental procedures.
 PROTECTIVE STABILIZATION

The parents, or guardian must be informed and must give consent, and the consent
must be documented, before protective stabilization is used. They should have a
clear understanding of the type of stabilization to be used, the rationale, and the
duration of use.

The AAPD Behavior Guidance indicates that the need to diagnose and treat, as well as
to protect the safety of the patient, parent, staff and practitioner, must justify the use of
stabilization.
The use of protective stabilization is indicated in the following situations:

• A patient requires immediate diagnosis and/or limited treatment and cannot

cooperate because of lack of maturity, mental or physical disability.

• A patient requires diagnosis or treatment and does not cooperate after other
behavior management techniques have failed.

• The safety of the patient, staff, parent or practitioner would be at risk without the
use of protective stabilization.
The use of stabilization is contraindicated in the following situations:

• A cooperative non-sedated patient.

• Patients who cannot be safely stabilized due to medical or physical

conditions.

• Patients who have experienced previous physical or psychological

trauma from protective stabilization (unless no other alternatives are
available).

• Nonsedated patients with nonemergent treatment requiring lengthy

appointments.
Protective stabilization should not be used as punishment.

Should not be used solely for the convenience of the staff.

The patient’s record should display an informed consent, the

indications for use, the type of stabilization used, and the duration of
application.

The tightness and duration of stabilization must be monitored and

reassessed at regular intervals. Stabilization around the extremities or
chest must not actively restrict circulation or respiration.
Stabilization should be terminated as soon as possible in a patient who
is experiencing severe stress or hysterics to prevent possible physical or
psychological trauma.

If a child requires extensive dental treatment and cooperation cannot

be achieved by routine psychological, physical, or pharmacologic
measures, the use of general anesthesia in a controlled atmosphere is
recommended.
The following are commonly used for protective stabilization:
Body
Papoose Board
Triangular sheet
Pedi-Wrap
Beanbag dental chair insert
Safety belt
Extra assistant

Extremities
Posey straps
Velcro straps
Towel and tape
Extra assistant

Head
Forearm-body support
Head positioner
Plastic bowl
Extra assistant
Common mechanical aids for maintaining the mouth in an open position –

Padded and wrapped tongue blades

The Molt Mouth Prop

Bite blocks

Caution must be exercised to prevent

injury to the patient, and the prop
should not be allowed to rest on
anterior teeth.

The patient’s mouth should not be forced beyond its natural limits discomfort and panic
will result in further resistance or even airway compromise.
The beanbag dental chair insert was developed to help comfortably
accommodate hypotonic and severely spastic persons who need more
support and less stabilization in a dental environment.
 Does Protective Stabilization of Children During Dental Treatment Break Ethical
Boundaries? A Narrative Literature Review

Geovanna de Castro Morais MACHADO1 , Ana Paula MUNDIM2 , Mauro Machado do PRADO3 , Cerise Castro
CAMPOS3 , Luciane Rezende COSTA4 1Dentistry Graduate Program, Universidade Federal de Goias (UFG), Goiania-GO,
Brazil. 2Faculty of Dentistry, Instituto Tocantinense Presidente Antônio Carlos Porto (ITPAC), Porto Nacional-TO, Brazil.
3Department of Oral Prevention and Rehabilitation, Faculty of Dentistry, Universidade Federal de Goias (UFG), Goiania-GO,
Brazil. 4Department of Oral Prevention and Rehabilitation, Faculty of Dentistry, Universidade Federal de Goias (UFG), Brazil

Aim: Protective stabilization, a method for immobilizing or reducing the ability of a

patient to freely move his or her body, raises ethical concerns that should be
discussed. This narrative literature review aimed to discuss the bioethical aspects
involved in the use of protective stabilization in normally developed children who
exhibit behavior management problems in dental care

Conclusion: The use of protective stabilization in pediatric dentistry breaks ethical

boundaries if the dentist is not trained in the application of the method, does not
analyze the risks, benefits, and potential harm of the method, insists on its use for
several appointments and for non-emergency procedures, does not respect the
parents’ opinion and the child’s autonomy (even though in construction), and does
not consider local law.
 Acceptance and Use of Protective Stabilization Devices by Pediatric Dentistry
Diplomates in the United States
Authors: Davis, Dustin M.1; Fadavi, Shahrbanoo2; Kaste, Linda M.3; Vergotine, Rodney4; Rada, Robert5
Source: Journal of Dentistry for Children, Volume 83, Number 2, May 2016, pp. 60-66(7)
Publisher: American Academy of Pediatric Dentistry

Purpose: To assess acceptance and use of protective stabilization devices (PSD) by Pediatric Dentistry
Diplomates.

Methods: Surveys were electronically mailed in 2013 to 2922 members of the American Board of
Pediatric Dentistry's (ABPD) College of Diplomates. Bivariate (assessing provider personal and practice
characteristics) and multivariate analyses were performed on reported acceptance and use of PSD.

Results: Response rate was 28 percent. Providers more likely to report acceptance and use of PSD were
those in practices with lower SES patient base, where there was the perception that patients' parents were
more accepting of PSD, and those with low patient volume. Provider who were more likely to report
acceptance and use of PSD were female, not working solely in private practice, and from Southeast or
North Central regions of the U.S. Neither PSD use during residency nor ABPD Board cohort (<2009
versus 2009-2013) was associated with current acceptance or PSD use. Upon multivariate assessments of
practice and personal characteristics, only perception of parent acceptance was associated with provider
acceptance whereas perception of parental acceptance, practitioner sex and practice setting were
associated with provider use of PSD.

Conclusions: Practitioner sex, practice setting, region, and perception of parental acceptance are all
important factors related to PSD acceptance and use.
 INTELLECTUAL DISABILITY

Intellectual disability is a general term used when an individual’s

intellectual development is significantly lower than average and his or
her ability to adapt to the environment is consequently limited.

The condition varies in severity and cause.

The diagnosis of intellectual disability (previously referred to as “mental

retardation”), as defined by the AAPD, requires sub average
functioning (below 70-75 on standardized measures) in 2 or more of the
following adaptive skill areas: communication; self-help; home living;
social and interpersonal skills; use of community resources; self-
direction; health and safety “functional academics,” leisure and work.
 Epidemiology

•About 3% of the world population is estimated to be mentally

retarded.

• In India, 5 out of 1000 children are mentally retarded (The Indian

Express, 13th March 2001).

• Mental retardation is more common in boys than girls.

•With severe & profound mental retardation mortality is high due to

associated physical disease.
Classification Based on levels of cognitive functioning:
1. Mild: IQ=55-70; 85% of ID, functions at the sixth grade level, may live
independently or in supervised setting; can successfully support self, usually no
etiology found.

2. Moderate: IQ=40-55; 10% of ID; second grade academic level, adequate self-
help care, may need assistance, lives at home or in group home, unskilled or
semiskilled work with supervision.

3. Severe: IQ=25-40, 3% to 4%, preschool academic abilities-sorting and matching,

may be nonverbal or minimally verbal, may use communication device, poor fine
motor skills and requires supervision for activities of daily living (ADLs), lives with
family or in group homes.

4. Profound: IQ less than 25. 1% to 2%, may not ambulate, requires close
supervision and assistance with ADLs, may be totally dependent for hygiene.
 Etiology
Postnatal
Prenatal

Inherited disorders Cerebral Trauma

Thyroid disorders Poisoning
Kernicterus Brain infections

Natal

Hemorrhage
Hypoxia
Hypoglycemia
Disorders associated with Mental Disability
 SIGN AND SYMPTOMS

• Failure to achieve developmental milestones

• Deficiency in cognitive functioning such as inability to follow
commands or directions
• Failure to achieve intellectual developmental markers
• Reduced ability to learn or to meet academic demands
•Expressive or receptive language
•Psychomotor skill deficits
•Difficulty performing self-esteem
•Irritability when frustrated or upset
•Depression or labile moods
•Acting-out behavior
•Persistence of infantile behavior
•Lack of curiosity.
 DIAGNOSIS
• History collection from parents & caretakers
• Physical examination
•Neurological examination
•Assessing milestones development
• Investigations
– Urine & blood examination for metabolic disorders
– Culture for cytogenic & biochemical studies
– Amniocentesis in infant chromosomal disorders
– chorionic villi sampling
– Hearing & speech evaluation
 Oral Manifestation

• Advanced cases of baby bottle tooth decay/early childhood caries.

• Prescription-medication-induced dental decay.

• Altered salivary flow and tooth decay ,”placating” tooth decay , malocclusions
, fractured and non vital teeth , soft tissue complications and bruxism.

• Major loss of tooth structure , leading to an eventual extraction , can affect

developing speech patterns.

• Unmonitored food consumptions.

•Abnormal jaw development , marked alterations in mastication , poor

esthetics.

• Poor dental hygiene , dental plaque and gingivitis calculus, intense halitosis.

• Gingival overgrowth.
 Dental Management

1)Familiarization (Desensitization) – The apprehensive child patient needs

to be desensitized to reduce his anxiety and fear of things around him
that maybe unknown to him by familiarizing him with the environment
of the dental office.

2) Effective communication –It is important to make the child understand

the proceedings by uncomplicated and simple verbal interaction. These are
effectively used in Educable Mentally Retarded (EMR) and Trainable
Mentally Retarded (TMR).

3) Active Listening - This helps to easily and effectively assess the

communication skills and attentiveness of the child patient.
4) Short appointment time – The attention span of children is small thus
short appointments are predictably uneventful.

5) Structuring and schedule – The treatment must be provided at times

when the dentist and the operator are least fatigued likewise at the
starting of the day.

6) Positive Reinforcement – The presentation of behaviour by the child

that is desirable throughout the procedure must be positively reinforced
by a social or material reward.
 CEREBRAL PALSY (CP):
•Cerebral palsy describes a group of permanent disorders of the
development of movement and posture, causing activity limitations that are
attributed to non-progressive disturbances that occurred in the developing
fetal or infant brain.

•Often accompanied by disturbances of sensation, perception, cognition,

communication, behaviour, by epilepsy and by secondary musculoskeletal
problems.
 Classification of Cerebral Palsy

1) Spastic cerebral palsy = as much as 70% of children inflicted by CP fall

under this type. The muscle involved is hyper mobile and undergoes
exaggerated contraction.

2) Dyskinetic (athetoid cerebral palsy)=only 15% cases of cerebral palsy

are of dyskinetic type. Characteristically the involuntary movements are
twisty or writing (athetosis) or quick jerky (choreoathetosis). There are
abnormal patterns of chewing and swallowing and also of speech.

3) Ataxic cerebral palsy = 5% of cases of are of this type. The involved

muscles are unable to contract properly thus resulting in partial
performance of voluntary movements. The symptoms involve staggered
gait and poor kinesthesis.
4) Mixed Cerebral Palsy = This kind of cerebral palsy shows features
of more than one subtype of cerebral palsy. It is seen in not more
than approximately 10% cases.

5) Hypotonic Cerebral Palsy = In one of these less common types of

cerebral palsy there is flaccidity of involved muscles with their
reduced tonicity. Thus the muscles improperly respond to
stimulation.

6) Rigid cerebral palsy – it is another less common type of CP. The

affected muscle groups are in a persistent state of contraction
without any stimulation.
 Etiology:
Prenatal
Postnatal
Hypoxia
Genetic disorders
Cerebral infarction
Multiple gestations
Hyper bilirubinemia
Teratogenic exposure
Respiratory distress syndrome
Maternal fever
Meningitis
Intra ventricular hemorrhage
Perinatal

Asphyxia
Premature birth
Blood incompatibility
Infection
 Clinical Manifestations

• Abnormality of muscle tone

• No control over movements
• Muscle weakness
• Contractual deformities
• Spasticity and loss of coordination
• Apraxia
• Impaired sensation of movement
• Impaired proprioception
 Oral Manifestations

•Child may have gastro esophageal reflux as well as episodes of

vomiting. It can lead to dental erosion or loss of tooth structure.

•Gingival overgrowth due seizure medications.

• Oro facial findings include the head is tensely reclined. The

mouth is open and facial movements are tensed.

• Uncoordinated movements of tongue.

• Jaw dislocation.

• Tongue thrusting during swallowing and speaking.

 Dental Management
A. Patient using a wheelchair should be considered to be treated in the
wheelchair itself. To transfer the patient the two person lift is to be
incorporated.

B. The patient must be stabilized and maintained in the midline of the dental
chair with both arms and both legs as close to the midline as comfortable.

C. In order to minimize severe gag reflex two modified radiographic

technique are available: one is the 45 degree oblique head plate and other is
the reverse bite wing (Buccal technique).

D. It must be on the operator to work as efficiently as possible and minimize

the fatigue of the muscles involved.
Assistive stabilization based on the neurodevelopmental treatment approach
for dental care in individuals with cerebral palsy.
Source: Quintessence International . Sep2007, Vol. 38 Issue 8, p681-687. 7p. 2 Black and White Photographs, 1
Chart.
Author(s): Santos, Maria Teresa Botti Rodrigues; Manzano, Felipe Scalco
Abstract: Objective: To study the effects of positioning individuals with cerebral palsy (CP) on a
dental chair according to the neurodevelopmental treatment (NDT) approach, to establish the
best position to perform dental care in the safest and most efficient manner in such individuals.
Method and Materials: A group of 158 noninstitutionalized patients (78 males and 80 females)
with CP (mean age 10.5 [SD ± 4.6]) were enrolled in the study. The behavior management
techniques used were tell-show-do, voice control, assistive stabilization, oral premedication, a
combination of techniques, and general anesthesia. Results: The tell-show-do and voice control
techniques were effective for only 36 (22.8%) of the patients who were collaborators: 3 presenting
spastic diplegic, 23 presenting spastic hemiplegic, 4 presenting spastic double hemiplegic, and 6
presenting ataxic CP. The totality of patients with spastic quadriplegic CP, dystonic CP with
athetosis, and mixed CP required all the combined forms of assistive stabilization and postural
maintenance. The majority of the individuals with spastic diplegic CP required head and upper
member stabilization and a mouth prop. Among the dental care treatments performed,
preventive care (dental prophylaxis, sealants, and fluoride application) was performed on 78
(50.0%) patients, restorative dentistry on 40 (25.6%), and oral surgery on 38 (24.4%).
Conclusion: Present data suggest that the use of assistive stabilization was effective and
permitted the dental care of individuals with CP at the outpatient clinic level, while reducing the
number of patients referred for general anesthesia and ensuring better quality of life for this
patient population regarding oral health.
 Home Dental Care for Cerebral Palsy Patients

• A well lit location must be chosen so that one can properly look into
one’s mouth.
• Whatever be the manner in which a parent helps the child to brush his
teeth the head of the child must always be supported.
• Almost all of the medications prescribed to children contain sucrose.
Thus a child on oral medications must get their teeth cleansed after each
medication.
• Tuna et al. concluded that Daily application of 10% w/v CPP-ACP paste
effectively changes saliva buffering capacity and plaque pH, thus
promoting caries prevention in the primary and mixed dentition of CP
children.
 Autism Spectrum Disorders (ASDs)

•ASDs consist of five subtypes, which include autistic disorder; Asperger

syndrome; Rett’s syndrome; childhood disintegrative disorder (CDD) and
pervasive developmental disorder— not otherwise specified.

• Recent studies estimate the prevalence of all ASDs to be in the range of

6.5 to 6.6/1,000.
 Etiology

• Genetic-3 to 8 percent recurrence risk if a family already

has a autistic child

• Syndromes-fragile- x , Rett syndrome

• Medical conditions-tuberous sclerosis complex

• Prenatal factors- intrauterine rubella,cytomegalo

inclusion disease

• Postnatal factors-infantile spasm, herpes simplex.

ASDs are lifelong neurobiological disorders manifested by a wide range of
abilities and outcomes.
Despite the broad range of severity, all ASDs share common deficits in 3
areas of functioning:

1. Language; (Only two thirds of autistic children achieve some functional

speech)

2. Social skills; (little or no attachment to their parents)

3. Restricted, repetitive, and stereotyped patterns of behaviour, interests,

and activities; (self-sufficient, introvert, want to be alone and frequently
relate well to objects).
 Oral Manifestations

•Higher susceptibility to caries

•Gingivitis and poor oral hygiene

•Damaging Oral Habits – tongue thrusting, bruxism, pica, lip and

cheek biting.
Dental Management

1) The first appointment should be short and positive, the child may be
allowed to bring items that comfort him like a toy.
2) The child must always be dealt with or at least approached in a non-
threatening manner.
3) Autistic infants show an intense desire to maintain a consistent
environment, even the smallest changes in the environment may trigger
extreme anxiety in the child. Thus parental suggestions are of utmost
importance.
4) When autistic children are held they show extreme resistance to the
same and react inappropriately to fearful situations. They are extremely
sensitive to loud noises and movements that maybe felt.
6) The child must be allowed to sit on the dental chair in order to properly
familiarize with the dental operatory environment.
7) The dentist must talk calmly and in short phrases. The autistic children
are prone to tantrums and aggressive behaviour. The light must be kept out
of the eyes.
8) The key to all kinds of behaviour modification techniques incorporated
to encourage desirable behaviour lies in adequate incorporation of positive
reinforcement.
9) Moderate pressure such as wrapping a child with a papoose board can
be used to calm autistic children.
10) Despite all such measures some children must still need general
anaesthesia or sedation so that proper pediatric dental therapy can be
delivered.
 The Journal of the American Dental Association
Volume 142, Issue 3, March 2011, Pages 281-287
Applied behavior analysis: Behavior management of children with autism spectrum disorders
in dental environments
Methods
The authors conducted a search of the dental and behavioral analytic literature to identify
management techniques that address problem behaviors exhibited by children with ASDs in
dental and other health-related environments.
Results
Applied behavior analysis (ABA) is a science in which procedures are based on the principles of
behavior through systematic experimentation. Clinicians have used ABA procedures successfully
to modify socially significant behaviors of people with ASD. Basic behavior management
techniques currently used in dentistry may not encourage people with cognitive and behavioral
disabilities, such as ASD, to tolerate simple in-office dental procedures consistently. Instead,
dental care providers often are required to use advanced behavior management techniques to
complete simple in-office procedures such as prophylaxis, sealant placement and obtaining
radiographs. ABA procedures can be integrated in the dental environment to manage problem
behaviors often exhibited by children with an ASD.
Conclusions
The authors found no evidence-based procedural modifications that address the behavioral
characteristics and problematic behaviors of children with an ASD in a dental environment.
Further research in this area should be conducted.
Abstract
Aim
To assess dental caries experience and periodontal treatment needs among Libyan children diagnosed
with autistic spectrum disorder (ASD).
Materials and methods
A cross-sectional, comparative case–control study was used, in which dental caries experience of 50
children with ASD was compared with that of 50 controls. The children with ASD were recruited from
Benghazi Centre of Children with ASD, Libya. Controls were recruited from school children and
matched for age, gender and socioeconomic status. DMFT, dmft for dental caries experience and
CPITN for periodontal treatment needs were calculated according to WHO criteria by a calibrated
examiner. Scores for DMFT as well as CPITN indices were compared using bivariate analysis.
Results
The data analysed for this study comprised observations from a group of children (cases = 50)
diagnosed with ASD matched with healthy children (controls = 50). Consequently, each group
consisted of 40 males and 10 females aged between 3 and 14 years (mean 7.29 ± 3.11). The ASD
children showed significantly lower means for DMFT and dmft teeth as well as higher periodontal
treatment needs (p > 0.05).
Conclusion
Children with ASD were found to be more likely caries-free and have lower DMFT scores and higher
unmet periodontal treatment needs than did the unaffected control children.
Dental discomfort questionnaire: its use in children with
autism spectrum disorder; role of DDQ based approach
in recognition of symptomatic expressions due to dental
pain in children with autism spectrum of disorders.

DR. B. Chandana
2010-2013
 PECS IN AUTISTIC CHILDREN -- A
PICTURE’S WORTH
Autism spectrum disorder (ASD) is a Picture exchange communication system (PECs) is a
neurodevelopmental condition characterized by a unique augmentative and alternative communication
triad of deficits involving social interaction, system that uses flashcards to represent objects, people or
communication, thinking and behavioral skills. activities to promote functional communication in ASD
patients.

PRE-VISIT PARENT
CONSULTATION

CHILD HOME DENTAL

PREPARATION TREATMENT PLAN

DENTAL
APPOINTMENT

With perseverance and commitment PECS will eventually lead to the desired communication
 Attention Deficit Hyperactivity Syndrome (ADHD)

Attention deficit hyperactivity disorder (ADHD) is defined as a problem

of not being able to focus, being overactive, not being able to control
behaviour, or a combination of these.

For these problems to be diagnosed as ADHD, they must be out of the

normal range for a person's age and development.

SUBTYPES:
Predominantly Hyperactive Impulsive
Predominantly Inattentive
Combined Hyperactive Impulsive and Inattentive
 Prevalence

The mean worldwide prevalence of ADHD is between 5.29% and 7.1% in

children and adolescents (<18 years).

The prevalence of ADHD in India among primary school children was

found to be 11.32%. .
Prevalence was found to be higher among the males (66.7%) as
compared to that of females (33.3%).
 Etiology

•Cause is unknown some abnormal brain function of genetic

making has been documented.

•Children of parents with both ADHD and substance abuse

disorder were at the highest risk for developing ADHD.

•Epigenetic: exposure to alcohol, inutero tobacco or lead

exposure, premature birth, head injury.

•Malnutrition may also be related to ADHD.

 Oral manifestations

•Trauma: increased risk of injury due to increased violence.

•Oral Hygiene: due to inactiveness and hyperactivity, children are unable
to perform regular routine activity like tooth brushing.
•Diet and appetite is altered due to medication leading to increased
caries risk.
•Behavioural management problem.
•More caries in both primary and permanent dentition.
•ADHD patients produced less than 0.5 g of saliva than normal. But
salivary flow rate is greater than the normal.
•Uncomplicated crown fractures are more common than complicated
crown fractures.
•General hygiene is poor i.e. presence of plaque and calculus.
 Dental management

Management of the child with ADHD involves four broad

approaches:

•Behavior modification

•Educational (counseling)

•Pharmacological

•Lifestyle changes
Special Care
Parental supervision is a must while performing oral hygiene procedures
and also for diet control

Anticipatory guidance should be provided to parents on how to prevent and

manage dental injuries, as these children are prone to the same.

Home care instructions should be given in a written format, as these

children are extremely forgetful and disorganized

Custom-fabricated occlusal splints are recommended for the treatment of

bruxism.

Syrups should be substituted with capsules or tablets as soon as the child is

able to swallow them to prevent the chances of decay.

Preventive programs and continuous reinforcement should be emphasized

to minimize the need for complex restorative treatment.
 Dyslexia

•Dyslexia is a developmental condition, a type of learning disability that

specifically impairs a person’s ability to read.

•It is manifested in the form of difficulty in reading and acquiring skill in

spelling and reading, decoding similar looking words like d and b.

•It occurs despite normal or high intelligence, dyslexia breaks down the
relationship between reading and intelligence.
It is a persistent, chronic condition that exists or stays with the person
for lifetime and does not represent a transient developmental lag.

It is both familial and heritable as maximum children (65%) appear to

have a dyslexic parent and dyslexia sibling (40%).

It is one of the most common neurobehavioral disorders and affects

both the sex equally.
 Theories

• Evolutionary hypothesis

• Visual theory

• Phonological care

• Double deficit hypothesis

• Cerebellar deficit hypothesis

• Perceptual noise exclusion theory

• Magnocellular theory
Types of Dyslexia
 Clinical features

* Short attention spans

* Distractibility

* Hyperactivity

* Mild speech impairment

* Difficulty in reading, spelling, spoken language and writing

* Child with poor self-esteem

* Social interaction is poorly developed due to difficulty in

spoken language

* Anxiety and lack of confidence

 Diagnosis

Mainly by clinical via history and observation. Additional method

includes psychometric assessment, neurological examination,
laboratory measures such as imaging studies, electro
encephalography, and chromosomal analysis.
 Oral manifestations

•Poor oral hygiene, dental caries and malocclusion are some of the oral
features that can be seen.

•Stress levels are high in these children ultimately leading to habits

such as nail biting which consequently leads waring and notching of
incisal edge of anteriors.

•Halitosis is another feature.

 Management

Parents role

Pediatricians role

Dentist role
 Conclusion

A child with impairment presents dental team a challenge for

examination as well as treatment procedures. It is important that every
effort should make to optimize oral function and facial appearance and
thereby encourage a positive self-image. Some degree of flexibility,
working familiarity with common oral conditions is required to provide
optimal dental care for child with impairment.
 References:

•McDonald and Avery Dentistry for the Child and Adolescent • 9th Edition

•Pediatric Dentistry: Infancy through Adolescence 6th Edition

•Pediatric dentistry for special child – Priya Verma Gupta

•Dental Management of Children with Special Health Care Needs (SHCN)

– A Review British Journal of Medicine & Medical Research 17(7): 1-16,
2016, Article no.BJMMR.28426 ISSN: 2231-0614, NLM ID: 101570965

•Dental management considerations in children with attention-deficit

hyperactivity disorder. ASDC J Dent Child. 1992 May-Jun;59(3):196-201.

•Dyslexia in children--a brief review. Malleedi Shanthi Indian Journal of

Dental AdvancementsJanuary 1, 2014
Thank you