Orthodontic care for the person with special needs: an overview.

At first consideration, orthodontic care for the child or adolescent with special needs may appear to be superfluous in light of all the other parameters governing such an individual's daily existence. After all, dally lifestyle maintenance issues such as feeding, dressing and mobility should take precedence over the seemingly superficial importance of having "straight teeth." However, if one looks beyond the vanity factor fostered by our society's valuation of the beautiful smile, the importance of overall orthodontic health for the special needs population becomes apparent.

The incidence of malocclusion (unaligned or "bad" bite) in people with developmental disabilities is markedly higher than in the rest of the population, as has been shown in several studies done in Europe and the United States. This increased frequency of orthodontic problems is certainly multifactorial, ranging from inherent growth and development anomalies common to many syndromes, such as cross-bites in people with Down syndrome, to malocclusions. These may develop as a result of dental neglect and lack of professional supervision; for example, premature loss of primary (baby) teeth can lead to drifting and crowding of permanent teeth. Therefore, an orthodontic examination and assessment should be considered an integral aspect of dental care for every person with special needs.

Early orthodontic care, often termed preventive or interceptive treatment, is generally intended to avoid and/or minimize potentially harmful patterns. Such an approach of early intervention is particularly important for a person with a developmental disability who may not be able to tolerate braces or similar traditional orthodontic treatment. An important aspect of preventive orthodontics includes good restorative care of both primary and permanent teeth since space loss, crowding and even tooth impaction can result from dental decay and its consequences.

Another aspect of interceptive orthodontics is the timely removal of primary teeth so that they do not block or deflect the underlying permanent teeth from their proper eruptive paths. When these baby teeth are overretained--when they are not shed on schedule--the result can be harmful cross-bite positions or impactions, which can become difficult orthodontic therapeutic challenges in a person with special needs.

Correction of functional asymmetries by early treatment intervention is also important to the orthodontic health of people with special needs. The promotion of symmetrical jaw growth in the young child is often essential in minimizing future orthodontic problems. Treatment may range from selected extractions of either primary or permanent teeth to rather complex orthodontic/orthopedic appliances designed to stimulate and/or favorably redirect bone growth. In many cases, especially with people exhibiting dentofacial anomalies (see the December 2001 and February 2002 issues of EXCEPTIONAL PARENT for descriptions), a team approach is used, with disciplines ranging from plastic surgery to oral surgery to orthodontics involved in the overall treatment. Therapy may be staged over many years; for example, corrective treatment for people with cleft lip/cleft palate may begin shortly after birth and can often continue into early adulthood.

As a dual-trained pediatric dentist and orthodontist, it has been my basic philosophy to offer all aspects of treatment--from preventive to restorative to orthodontic treatment--to everyone I see in my practice. It is our office's goal to provide every person with optimal-dental health, functionally and cosmetically, irrespective of any disability. However, this philosophical idealism must be tempered with certain realities, as I have learned over the past twenty-four years. Nowhere else do these realities make themselves more apparent than in the orthodontic realm.

The decision to initiate orthodontic therapy on a person with special needs is based on the same parameters as it would be for any other person. Severity of the malocclusion, tooth eruption patterns, oral hygiene level, periodontal (gum tissue) status, decay activity and functional and esthetic issues are all considered before beginning active treatment. The issues of cooperation and risk/benefit, however, may take precedence in the decision-making process.

People with mild to moderate disabilities may often prove to be quite cooperative and compliant with the requirements of fixed orthodontic appliance therapy. Parental assistance with some aspects of treatment, such as headgear wear, expansion appliance adjustments and elastic wear, can be of great benefit in creating a successful therapeutic outcome. Of prime importance is the need to educate parents and direct support professionals (DSPs) about the necessity of maintaining good oral hygiene throughout the orthodontic process and how to accomplish that goal. This increased awareness about dental issues helps to avoid periodontal flare-ups and decay activity, which could interfere with treatment. Malting parents and DSPs active participants in the therapy regimen provides another line of defense against the pitfalls of cooperation that seem to plague every orthodontic practice. Ironically, a good attitude on the part of parents and DSPs can make orthodontic treatment easier for a person with special needs than comparable therapy for a child without any special needs.

More severe disabilities, whether emotional, mental or physical, may preclude the use of traditional fixed orthodontic appliances. Practical considerations of cooperation, oral hygiene levels and safety must all be evaluated and explained to the parents and DSPs, who often have unrealistic expectations of what can be accomplished. Other treatment plans--whether in the form of an abbreviated, simplified course of therapy, or in the timely removal of primary or permanent teeth in order to alleviate crowding--may need to be presented and discussed. Risk/benefit is the concept that should be kept in the forefront when considering orthodontics for people with more severe special needs. Regardless, every person with developmental disabilities should be considered individually and given care, if at all possible. With patience and understanding, surprising and gratifying treatment victories may be achieved!

When all is said and done, orthodontic treatment is an elective procedure in the majority of cases, regardless of its functional and esthetic benefits. As applied to the population of people with special needs, orthodontics may be considered super-elective, especially for people with more severe disabilities. The overall needs of each individual person should be evaluated. If approached in this light, orthodontic therapy for the person with special needs can be highly rewarding for the orthodontist, parents, family members, DSPs and the person receiving the therapy.

Michael B. Koidin, DDS, MScD, is Assistant Clinical Professor of Pediatric Dentistry at The Boston University School of Dental Medicine. Dr. Koidin is trained in both pediatric dentistry and orthodontics and is in private practice in Lynn, MA.