Pediatric patients with special needs: one hygienist's perspective.
Providing treatment to pediatric patients with special needs requires particular attention. Breaking the barriers to the provision of oral health care for the pediatric patient with special needs is critical in the goal of optimizing oral health care for this patient population. Various disabilities, along with their associated effects on overall health and function, make the appointment with the client with special needs more challenging, not only for the patient and family, but for the dental hygienist as well. This article will discuss my perspective, as a dental hygienist with 30 years of experience with patients who have special needs, on how to better care for this population. The time of day appointments are scheduled, the age at which the disability is identified, maintenance of regular scheduled appointments, and other considerations will be discussed, with the goal being provision of high-quality dental hygiene care for the patient with special needs.
My personal clinical experience has shown that scheduling appointments with pediatric patients with special needs early in the day is beneficial because both the patient and the dental hygienist are more rested. I recommend performing the prophylaxis for these patients as quickly as possible. My own personal experience, with which many other dental hygienists agree, is that the "in-and-out quickly" method works very well for these patients, and usually the overall appointment time should be an hour. In many cases, the "prophy" turns out to be a cleaning using only a toothbrush. This can be an effective method for many patients.
Panoramic films are usually the best for all patients with special needs, as they prevent the difficulty of trying to place X-ray film intraorally. An Emesis basin or a cup can be helpful for the patient to expectorate into, especially if they appear to be afraid of the suction.
As soon as a disability is identified in an infant, home oral health care options should be recommended to the parents, who should be educated on the importance of instituting home care early to prevent disease. This can be accomplished by cleaning the infant's gums with a clean, damp cloth or small-head, soft manual toothbrush and plain water after each feeding and also before bedtime. Later, young adolescents, as directed by their dentists, can benefit from the use of Xylitol swabs and lozenges, chlorhexidine varnishes, fluoride varnishes and fluoride mouth rinses, gels or vitamins. Electric toothbrushes with a small head, such as the Oral-B Braun, can do a thorough job for optimal oral health. As a plus, this brush usually has very good patient acceptance.
Also, regular dental appointments should start at six months or at the eruption of the first tooth. Maintaining regular professional appointments will ultimately form good habits early in the child's development. (1) Try to motivate and interest children, and their parents, in good dental health and in your practice environment. During dental hygiene appointments with pedodontics patients who have special needs, positive reinforcement is of utmost importance. The dental hygienist needs to make the appointment as fun as possible. I have used "Tell, Show and Do" successfully with this population over the course of my career. The use of puppets, such as a friendly alligator or a floppy-eared dog with over-sized teeth, can show the pediatric patient with a disability that there is nothing to be afraid of. Most of the time, when they see these fun animal puppets, they are much calmer, and their fears subside.
These aids really facilitate the dental hygiene examination, and a pleasant, nonthreatening voice can make the appointment much less intimidating. Playing happy music and using bright colors, such as orange, green and purple, along with pleasant aromas, can help make the appointment a positive and fun experience. Small, inexpensive gifts can also be given to show young patients that their positive behaviors will bring positive results. These rewards can be stickers, small toys, or sugarless gum or candy (especially those sweetened with Xylitol).
If a child won't open his or her mouth, use the puppet as an example and show the child how wide the alligator or dog can open its mouth. Then place a sugarless candy near the child's mouth to get it open. Continue to use positive reinforcement. Never use negative reinforcement, such as holding the patient down or strapping the child into the dental chair, as this can cause a lifetime of fearing dentistry. Playing games, such as riding up and down in the dental chair, perhaps starting in the parent's lap first, then by themselves, can be a real icebreaker. Tell them it's their own "dental space rocket," and then watch them go!
I have found that music really works with all children, and I actually like it too. Make a variety of music available for these children. One song in particular, which is available through the American Dental Hygienists' Association, is called the "Brush-Along Song" (LearnAlong, Gotha, Fla.). In my experience, this song really makes kids of all ages want to brush their teeth. Also, the CD called "Wacky Favorites Crazy Hits" by Time Life Music, which features "The Monster Mash" and "The Purple People Eater," is great for children with special needs, as they love upbeat, happy music. The laughter that these songs generate can make for a great first appointment.
The Talking Toothbrush Holder by FUN-DAMEMTAL TOO LTD is also an excellent tool, because the children can learn when they push the button on the device's base and it reminds them in a booming voice "Hey! Don't forget to brush your teeth!" This has been a very popular tool virtually everywhere I have taken it.
Prospec MI Paste, manufactured by GC Corporation (Tokyo, Japan), is an excellent prophylaxis paste with bio-available calcium and phosphate. It removes stains while also helping to remineralize teeth in patients with poor saliva flow. Dental sealants are very important for protecting teeth from decay and should be applied as soon as the teeth are erupted; they can last for many years.
Often, pediatric patients with autism have trouble relating to their environment, and sometimes appear immature or mentally impaired, even though they may have a high IQ and/or level of understanding. They have a tendency to want to rock back and forth, and respond chiefly to their inner thoughts. (2) As the dental hygiene provider, it can be beneficial to slowly rock with them. One autistic boy I worked with was very intelligent, and was also a very good speller. I selected words for him to spell that were part of the dental visit. For example, when I asked him to spell "gums," he would say "g-u-m." Next was "teeth," and he responded by spelling "t-e-e-t-h." I quickly discovered that he was a better speller than I was! I would prepare dental-themed words in advance, and he was delighted to spell them for me. As he spelled, I performed the prophylaxis and an examination.
I found that games are very effective in getting children, especially those with special needs, to open up and lose their fear of the dental office. Dental puzzles and pictures with hidden objects, such as toothbrushes, work well and hold the child's attention.
Children with bipolar disorder may have extreme fluctuations in mood and behavior. It may be beneficial to discuss the best time for an appointment with the child's parents. My experience has been that the majority of these children seem to perform better for the exam if their disease is well controlled. Working with the child in the "high" or manic state is easier than in the "low" or depressed state. In the manic state, they seem to respond well to upbeat, happy, fun stimuli, such as bright colors and toys. Talking puppets or big-teeth models work particularly well. I find it helpful if every step that will be undertaken is slowly explained. If the patient with bipolar disorder arrives in a depressed state, I often found that it is better to give the child some toys and a new toothbrush and to reschedule the patient at a later time when their mood may be better.
Children with intellectual disabilities may represent a challenging visit for the dental hygienist because of their behavior difficulties and limited ability to follow commands. Before the actual oral exam, it is necessary to slowly explain every step and articulate every word, perhaps demonstrating on a large tooth model every step you will be performing. You can also offer a selection of prophylaxis paste flavors. In some situations, the dental hygienist must simply strive for no tears. With all patients who have intellectual challenges, if tears arise, immediately stop and use whatever it takes to have a happy child. This will help prevent development of a fear to return for the next appointment. I also wear many different uniforms decorated with characters such as Sponge Bob, Dora, Barbie, Scooby-Doo, etc., to bring a smile to the patients' faces. All patients seem to relate to these types of characters.
Pediatric patients with muscular dystrophy present unique circumstances that affect oral health treatment. Since muscular dystrophy is a hereditary disease characterized by progressive muscle atrophy, many of these patients are in wheelchairs. I always try to perform the prophylaxis in the wheelchair, if possible. This may be difficult due to the poor ergonomics for the RDH, but can often be best for the child. The chair should be positioned for the patient's comfort and security. Increasing the amount of time and attention you provide during the appointment is beneficial to this particular patient population. Also, as dental hygienists, we need to encourage an interest in the child's own health by discussing the relationship of oral hygiene and personal appearance. Avoid mentioning the patient's disease and symptoms if this may be troubling to them. In my experience, the best approach is praise for small achievements the patient makes during the exam. Positive reinforcement seems to work best. Again, maintain a cheerful atmosphere and stress-free environment, as these contribute to the child's happiness and a great dental hygiene appointment.
The child with Down syndrome has impaired intelligence, so effective communication is important. A short appointment usually works best, as distinct from the normal hour-long appointment. The RDH needs to look the child in the eye and talk slowly. These patients can be prone to gagging, due to the enlarged tongue and Class III prognathic jaw. My experience shows that the Down syndrome patient does not like loud noises, so the Titan Ultrasonic Scaler works best. The dental hygienist should flush out the pockets with minimal hand scaling, along with selective polishing, to reduce noise. It should be taken into account that the patient with Down syndrome may have a higher rate of periodontal disease and lower caries rate.
For all children with special needs, it is very important to stress proper dental hygiene care at home, and the caregiver will need to brush their teeth after the child has attempted to brush first. The daily cleaning and removal of plaque and food debris is crucial to good oral health. Also, a diet low in sugar and fermentable carbohydrates should be followed, as these can lodge on the teeth, causing the formation of acid and potentiating tooth decay. Patients with special needs have enough problems without the addition of tooth decay, which is completely preventable.
Considerations for providing the pediatric patient with special needs with a more positive experience in your dental office have been reviewed, and suggestions for a more positive, upbeat dental appointment have been made. Many patients with special needs require additional time, patience and dedication by the dental hygienist. A positive experience leads to better outcomes. Dedication to providing the best possible quality care for every patient with special needs is of utmost importance to providing appropriate oral health care to this population, and can be very rewarding for the dental hygienist.
(1.) Casamassimo P, Hold K (eds.). Bright futures in practice: oral health (pocket guide). Washington, D.C.: National Maternal and Child Oral Health Resource Center, Georgetown University; 2004. p. 26.
(2.) Daniels P et al. Body, the complete human. Washington, D.C.: National Geographic Society; 2007. p. 245.
Victoria M. Guerra, RDH, BA, attended the Ohio State University (Columbus, Ohio) in pre-dental hygiene and graduated with an associate's degree in Dental Hygiene Science from Shawnee State Community College (now University of Ohio) in Portsmouth, Ohio in 1979. She earned her Bachelor of Arts in General Studies, with emphasis in dental hygiene in 2000 from SUNY (State University of New York in Marcy, N.Y.). She has worked as a registered dental hygienist since graduating in 1979, working in pediatric and general practice for much of her career. She also spent nine years as director of dental services at a 300-bed nursing home facility, with one floor of young patients with disabilities. She has been a member of ADHA since 1979.
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|Title Annotation:||clinical future|
|Author:||Guerra, Victoria M.|
|Date:||Jan 1, 2011|
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