Dental Care and the Special Needs Patient

Oral Health America Webinar Series

Dental Care for the Special Needs Patient

December 1, 2017

Connect with OHA! /Oral Health America

@Smile4Health

/Oral Health America

@Smile4Health

HOUSEKEEPING INFORMATION • •

Please remember to MUTE your phone.

Questions are welcome! We’ll allow 10-15 minutes after the presentation for questions.

• •

• •

Questions will be accepted in writing through the control panel on the upper right hand of your screen.

Submit questions at any time; we will address them at the end of the presentation.

Webinar is being recorded; for rebroadcast on OHA’s website – OralHealthAmerica.org Your feedback is important to us. Please take our brief webinar evaluation after this session; link will be sent via email.

CE Credit Available

*Now available for dental professionals, nursing professionals, and social workers!

ABOUT ORAL HEALTH AMERICA

America’s leading national oral health nonprofit focused on the nation’s oral and overall health for 63 years, with particular emphasis on children and youth, older adults and Americans whose voices are not well-represented in oral healthcare conversations. © 2017 Oral Health America

OHA employs strategic partnerships and communications to connect the dots between oral and overall health

SMILES ACROSS AMERICA®

CAMPAIGN FOR ORAL HEALTH EQUITY

WISDOM TOOTH PROJECT®

© 2017 Oral Health America

Early Childhood Caries Prevention Project

School-Based Prevention Programs

Human Centered Design Project

Product Donation

Technical Assistance

Š 2017 Oral Health America

toothwisdom.org

Advocacy

Health Education & Communications

Professional Symposia

Demonstration Projects

© 2017 Oral Health America

CAMPAIGN FOR ORAL HEALTH EQUITY Addresses oral health inequities in our society and identifies possibilities for closing the oral health divide in America.

The campaign strives to: Educate and engage the public, including policymakers, about the importance of oral health for overall health Emphasize the need to prioritize oral disease alongside other chronic health conditions

Lead, participate and observe on legislative issues impacting oral health policies critical to OHA, our programs and stakeholders

Š 2017 Oral Health America

Tracye Moore, RDH, MS, EdD Chair of the Department of Dental Hygiene at Northern Arizona University

Dental Care for the Special Needs Patient Tracye A. Moore, RDH, MS, EdD Chair, Department of Dental Hygiene

Northern Arizona University December 1, 2017

Objectives

 Define the patient with special needs.  Identify barriers to dental care for the special needs population.  Define the role of the dental hygienist in providing care for the special needs patient.  List oral hygiene techniques/modifications specific for the special needs patient.

Special Needs Definition  In 2010, there were 56.7 million people in the United States with a disability 1,2,3,4,5,6  The Americans with Disabilities Act (ADA) of 1990 defines a disability as a “physical or mental impairment that substantially limits one or more major life activities” which can include: hearing, seeing, communicating, mobility around the home, performing manual tasks, caring for oneself, and many other activities of daily living. 1,7,8,9,10, 11,12  A patient with a disability is considered a special needs patient (SNP) in the dental milieu due to the condition of the patient which requires a modification of the usual or customary treatment plan in order to provide appropriate dental treatment for that patient.

Types of Special Needs  The term SNP encompasses patients who are disabled due to:  Physical limitations (congenital, traumatic, and/or physiological),  Medical complications (systemic, acquired, and/ or hereditary), developmental (congenital and/or acquired), and  Cognitive (mental, sensory, emotional, and/or behavioral) constraints.8, 9,10,11,12

Special Needs Specifics  Physical  Pregnancy, broken or amputated limbs, sensory impairment, and wheelchair use

 Medical  Cancer, diabetes, respiratory disease stroke, cardiovascular disease, kidney disease, Parkinson’s disease, and multiple sclerosis

 Developmental  Down Syndrome, epilepsy, cerebral palsy, and muscular dystrophy

 Cognitive  Autism spectrum disorder (ASD), Alzheimer’s disease, attention deficit hyperactivity disorder (ADHD), dementia, and other mental disorders. 8, 10,11,14

Obstacles to Dental Care

ď‚š Oral diseases can have a direct impact on the health and quality of life of those with disabilities and SNPs have disproportionate amounts of oral disease and problems with access to oral health care services compared to the rest of the population.3,6,8,9,10 ď‚š Financial barriers remain the primary obstacle to obtaining oral healthcare services for persons with disabilities.4, 6, 9, 10, 11 ď‚š Dental coverage is considered by most heath care plans as an unnecessary medical service.8,9,10,11,12

Obstacles to Dental Care  Language (non-effective communication for hearing impaired, English as a second language (ESL), or visually impaired patients;  Psychosocial (negative attitude toward oral health by SNPs, social norms and past dental experience of the caregiver, lack of understanding about the oral/systemic health connection, or negative attitudes of health care providers toward patients with disabilities);  Accessibility (SNPs may have lack of access to transportation);  Structural (buildings that do not comply with ADA mandates); and  Cultural barriers (inadequate training and skills of health service providers in the treatment of individuals with disabilities).6,9,10,11

Addressing Obstacles to Care

 An interdisciplinary and interprofessional approach to traditional health care delivery model should be embraced by the health care team in order to comprehensively treat SNPs.  Mid level providers  Legislative reform of private oral health

insurance/Medicaid/Medicare reimbursement system is needed to provide payment for the extra time needed to treat SNPs.11,12

Addressing Obstacles to Care  Special Care Dentistry Association (SCD)  http://www.scdaonline.org

 National Foundation of Dentistry for the Handicapped (NFDH)  Dental Lifeline Network  http://dentallifeline.org/

 Dental Education in the Care of Persons with Disabilities (DECOD)  https://dental.washington.edu/decod/

Pre-Treatment Modalities  Schedule an initial desensitizing appointment  Acclimates patient to office, staff, and

equipment

 Talk with the patient and/or caregiver to:  Review patient medical history  Determine the patient’s communication style

 Establish respect and rapport  Obtain informed consent

https://www.nidcr.nih.gov/OralHealth/Topics/DevelopmentalDisabilities/

Treatment Modalities  Wheelchair Transfer (if necessary)  Determine the need  Prepare the dental operatory  Prepare the wheelchair  Perform the two-person transfer  Position the patient after the transfer  Transfer from the dental chair to the wheelchair

https://www.nidcr.nih.gov/OralHealth/Topics/DevelopmentalDisabilities/

Treatment Modalities  Praise and reinforce good behavior periodically throughout the appointment  Use a “tell-show-do” approach to providing care  Listen actively and use simple, concrete instructions  Minimize distractions (sounds, sights, odors, and other stimuli)  Calm and supportive environment

https://www.nidcr.nih.gov/OralHealth/Topics/DevelopmentalDisabilities/

Treatment Modalities  Allow parents or caregivers in the treatment room to assist with communication  Schedule treatment appointments early in the day  Short as possible

 Take frequent breaks

 Maintain a clear path for movement throughout the treatment setting  Use immobilization techniques only when absolutely necessary

Treatment Modifications  Stabilization of the patient’s head can be accomplished through the use of pillows, rolled blankets, or towels and it is important for the patient’s head to be raised slightly to avoid respiratory compromise. 8,10,11,22  During treatment, oral stabilization via mouth props can be achieved by the following methods: rubber bite blocks (with floss tied through one end to prevent patient aspiration), disposable bite sticks (made of tongue depressors and gauze), cotton rolls, rolled gauze, or Styrofoam bite blocks.8,10,11,22

Oral Care Modifications

ď‚š Because poor oral hygiene, dental decay, and periodontal disease may be more prevalent in SNPs due to their oral condition, neglect, and/or the effects of medications on the oral flora (xerostomia),10,11,22modifications in selfcare oral devices may need to be created and/or fashioned to maintain oral health.

Oral Conditions of SNP Patients Necrotizing Ulcerative Perio

Denture stomatitis

Candidiasis

Root caries

Angular cheilitis

Periodontal Disease

Oral Care Modifications ď‚š For SNPs who have difficulty grasping certain dental devices, the use of a wide handled power toothbrush is recommended and/or the use of household items (bicycle grips, tennis balls, or soft plastic to make the handle of the toothbrush bulkier and easy to hold. The use of an extender (rulers, rods, or wooden spoon) can be taped to the handle of a toothbrush to add length to the toothbrush for patients who have limited range of motion.10,11,22

Conclusions

ď‚š Dental hygiene treatment of SNPs requires a multidisciplinary approach to care. ď‚š Each patient necessitates pre-treatment planning and proper assessment which includes appropriate time scheduled for the appointment, a thorough medical/dental history in consultation with the physician, social worker, caretaker/legal guardian, and appropriate communication with the patient.

Conclusions

ď‚š The entire dental team should be educated about how to interact with SNPs so that the initial impression of the staff is inviting and body language does not send unintended messages. ď‚š Informed consent and proper documentation are essential prior to the start of any treatment.

Conclusions ď‚š The various treatment modifications for intraoral care can range from pillows and mouth props to toothbrush modifications and stand-up dental treatment. ď‚š The caregiver/legal guardian as well as the patient should be educated about nutrition and preventive oral care for both to maintain optimal oral health.

References 1. U.S. Census Bureau: Americans with Disabilities Act: population distribution. U.S. Census website. https://www.census.gov/newsroom/facts-for-features/2015/cb15ff10.html

Accessed December 12, 2015.

2. Brault MW. Americans with disabilities: 2010. Washington D.C: Health & Disability Statistics Branch. U.S. Dept. of Commerce, 2012. https://www.census.gov/newsroom/cspan/disability/20120726_cspan_disability_slides.pdf Accessed November 5, 2015.

3. Dehaitem MJ, Ridley K, Kerschbaum WE, Inglehart MR, habil, p. Dental hygiene education about patients with special needs: A survey of U.S. programs. J Den Ed. 2008; 72(9): 1010-1019. http://www.jdentaled.org/content/72/9/1010.full.pdf+html Accessed November 5, 2015.

4. Lee HS, Jung HI, Kim SM, Kim J, Doh RE, Lee JH. Attitudes of Korean dental students toward individuals with special health care needs. J Den Ed. 2015; 79(9): 1024-1030.

5. Stoddard S. 2014 Disability statistics annual report. Durham, NH: University of New Hampshire. http://www.disabilitycompendium.org/docs/default-source/2014compendium/annual-report.pdf Accessed December 12, 2015.

6. World Health Organization summary report on disability 2011. WHO website. http://apps.who.int/iris/bitstream/10665/70670/1/WHO_NMH_VIP_11.01_eng.pdf Accessed December 12, 2015.

7. Americans with Disabilities Act (ADA) 1990. Definition of a disability. ADA website http://www.ada.gov/pubs/adastatute08.htm#12102 Accessed December 12, 2015.

8. Jaccarino J. The patient with special needs: General treatment considerations. DentalCare CE. http://www.dentalcare.com/media/enUS/education/ce384/ce384.pdf Accessed November 5, 2015.

9. American Association of Pediatric Dentistry (AAPD) Reference Manual: Guideline on management of dental patients with special health care needs. Pediatr Dent.

2012; 37 (6): 166-171. http://www.aapd.org/media/policies_guidelines/g_shcn.pdf Accessed November 5, 2015.

10. Muzzin K. Persons with disabilities. In Darby ML & Walsh MM. Dental hygiene theory and practice. 4th ed. St. Louis, MO: Elsevier Saunders; 2015: 786-804.

11. Wilkins EM. Section VIII: Patients with special needs. In Clinical practice of the dental hygienist. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013: 742-1056.

12. DiMatteo AM. Serving patients with special needs. In Dent. 2009; 5(2) https://www.dentalaegis.com/id/2009/02/serving-patients-with-special-needs Accessed November 5, 2015.

References 13. Commission on Dental Accreditation (CODA): Accreditation standards for dental hygiene education programs. American Dental association website http://www.ada.org/~/media/CODA/Files/2016_dh.ashx Accessed November 5, 2015.

14. Szarejko MJ. Dental care for special needs patients. NetCE. 2013. http://www.netce.com/coursecontent.php?courseid=1316&scrollTo=BEGIN. Accessed November 5, 2015.

15. Special Care Dentistry Association (SCD): Definition. SCD website. http://www.scdaonline.org/ Accessed December 12, 2015.

16. National Foundation of Dentistry for the Handicapped (NFDH): Definition. NFHD website. http://www.1800dentist.com/national-foundation-of-dentistry-forhandicapped/ Accessed December 12, 2015.

17. Dental Education in Care of Persons with Disabilities (DECOD). Definition. DECOD website http://www.astdd.org/bestpractices/DES54005WAspecialneedsdecod.pdf Accessed December 12, 2015.

18. Dental Lifeline Network. Definition. Dental Lifeline website. https://dentallifeline.org/about-us/our-programs/ Accessed December 12, 2015.

19. Bridge Campaign of Concern. Definition. Bridge of Campaign Concern website http://dentallifeline.org/about-us/our-programs/#HouseCalls Accessed December 12, 2015.

20. Kibbler B. Are my directions user-friendly? Access August 2015; 41-47.

21. American Association of Pediatric Dentistry (AAPD) Reference Manual. Guideline on behavior guidance for the pediatric dental patient. Pediatr Dent. 2011;36(6): 179191 http://www.wuft.org/news/files/2015/06/Guidline-on-Bahavior-Pediatric-Dental-Patient.pdf Accessed December 12, 2015.

22. Jaccarino J. Helping the special needs patient maintain oral health. DentalCare CE http://media.dentalcare.com/media/en-US/education/ce393/ce393.pdf Accessed November 5, 2015.

Question and Answer Session • Questions are welcome! This session may last for 10-15 minutes.

• Write your questions in your control panel on the upper right hand of your screen.

• Submit questions at any time.

CE Credit Available

*Now available for dental professionals, nursing professionals, and social workers!

Contact Information • Tracye Moore • tracye.moore@nau.edu

• Eamari Bell • eamari.bell@oralhealthamerica.org