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 Table of Contents  
REVIEW ARTICLE
Year : 2018  |  Volume : 32  |  Issue : 1  |  Page : 1-6

Management of children with special health care needs (SHCN) in the dental office


Department of Paediatric and Preventive Dentistry, Dental College, Regional Institute of Medical Sciences, Imphal, Manipur, India

Date of Web Publication18-Jun-2018

Correspondence Address:
Dr. Charan Kamal Kaur Dharmani
Department of Paediatric and Preventive Dentistry, Dental College, Regional Institute of Medical Sciences, Imphal - 795 004, Manipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jms.jms_115_16

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  Abstract 

Children represent the future of our society and ensuring their healthy growth and development ought to be a prime concern of all. The dental condition of children with special health care needs (SHCN) may be directly or indirectly related to their disabilities. Children with SHCN relatively have poor oral hygiene and increased prevalence of gingival diseases and dental caries. Unfortunately, the importance of dental care for these children has often been overlooked by the health planners. Parents of disabled children usually do not seek dental treatment as they also have the burden of medical treatment. In the past, the emphasis was based on providing basic dental care, but in recent years, the dental profession has shown increased concern in providing complete oral health care to the mentally- or physically-challenged children. The specialty of pediatric dentistry provides both primary and comprehensive, preventive and therapeutic oral health care to children with SHCN. These special children are entitled to the opportunity to achieve appropriate rehabilitation, to enable them to realize their maximal level of functioning, and to assist them in not only “normalizing” their lives but also lengthening their life span.

Keywords: Dental caries, fluoride varnishes, special health care needs


How to cite this article:
Dharmani CK. Management of children with special health care needs (SHCN) in the dental office. J Med Soc 2018;32:1-6

How to cite this URL:
Dharmani CK. Management of children with special health care needs (SHCN) in the dental office. J Med Soc [serial online] 2018 [cited 2018 Nov 17];32:1-6. Available from: http://www.jmedsoc.org/text.asp?2018/32/1/1/214731


  Introduction Top


Children with special needs are those who have certain disability that restricts them in performing daily life activities. American Academy of Pediatric Dentistry (AAPD) defines special health care needs (SHCN) 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. The condition may be congenital, developmental, or acquired through disease, trauma, or environmental cause and may pose limitations in performing daily self-maintenance activities or substantial limitations in a major life activity. Health care for individuals with special needs requires specialized knowledge acquired by additional training, as well as increased awareness and attention, adaptation and accommodative measures beyond what are considered routine.”[1]

India has 12 million children living with disabilities, and only 1% of them have access to school.[2] About 80% of children with disabilities do not survive past age 40. Many conditions such as mental retardation, developmental disabilities, cerebral palsy, craniofacial abnormalities, and seizure disorders can impact a child's oral health. Children with SHCN generally have increased prevalence of poor oral hygiene, compromised gingival and periodontal health, and increased prevalence of dental caries than the general population. Dental diseases and its treatment present several problems in this group of patients. These children may not understand or assume responsibility for preventive oral health practices. Many caregivers do not practice appropriate oral hygiene or choose a proper diet. Their parents also have the burden of medical treatment. They usually do not seek dental treatment. Moreover, the importance of dental care for these children has often been overlooked by the health planners.

This paper reviews commonly seen oro-dental problems in children with special needs and causes of their increased prevalence, various barriers to accessing dental care, and management of oral diseases in this population of children. By understanding potential barriers to oral health care and consequences of poor oral health in children with SHCN, health professionals can identify at-risk patients early, provide anticipatory guidance, and refer to pediatric dentists.


  Oro-Dental Problems in Children with Special Health Care Needs Top


The dental condition of children with SHCN may be directly or indirectly related to their disabilities. Growth abnormalities and medical conditions may adversely affect oral health. Oral diseases may also have a direct and devastating impact on the general health of special children.[3] Following are the commonly seen oral problems in children with special needs.

Dental caries

Generally, children with SHCN have increased prevalence of dental caries [Figure 1] due to following reasons:
Figure 1: Severe early childhood caries in a child with Down syndrome

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  1. Uncoordinated chewing in certain conditions such as cerebral palsy may leave more food in the mouth. A weak, uncoordinated tongue may not be able to adequately clean all oral surfaces [4]
  2. There is difficulty in performing proper toothbrushing due to limited manual dexterity. Furthermore, there may be gagging on the toothbrush, paste, or saliva which may inhibit complete brushing of all surfaces. An inability to spit may result in the swallowing of toothpaste
  3. Diet (fermentable carbohydrates): children who reside at home are pampered by their parents with cariogenic snacks and other unhealthy eating habits
  4. Xerostomia caused by certain medications
  5. Gastroesophageal reflux disease and vomiting
  6. Gingival hyperplasia and crowding of the teeth are the risk factors
  7. Intake of medications containing sugar like flavored syrups.


Enamel hypoplasia and enamel demineralization

Children with low birth weight, developmental delays, or certain genetic syndromes may be at increased risk for enamel hypoplasia - a predisposing factor for dental caries, especially in the maxillary incisors and primary molars [Figure 2]a.[5]
Figure 2: (a) Molar Incisor Hypomineralization. (b) Oligodontia

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Hypoplasia usually appears on the middle or occlusal third of the teeth, whereas demineralization from poor oral hygiene and an acidic oral environment occurs most often near the gingival line. Demineralization often is characterized by white spot lesions that are best seen by “lifting the lip.”

Tooth eruption

Tooth eruption may be delayed, normal, or advanced in children with SHCN. Delayed eruption is more common in children with Down syndrome and hypothyroidism [Figure 2]b.[6]

Dental anomalies

Teeth may vary in shape, size, or number [Figure 3]a. Teeth with anomalies are usually of cosmetic concern and may increase the risk for caries.
Figure 3: (a) Supernumerary tooth (mesiodens). (b) Anterior open bite

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Malocclusion and crowded teeth

Malocclusion and crowded teeth occur more often in children with abnormal muscle tone (cerebral palsy), mental retardation, and craniofacial abnormalities. Malocclusion is the result of disharmonious relationship between extraoral and intraoral musculature, for example, in the spastic type of cerebral palsy, there is hypertonicity of facial muscles which results in the constriction of maxillary and mandibular arches resulting in anterior open bite [Figure 3]b and posterior crossbite. Whereas in athetosis type of cerebral palsy, the facial musculature is hypotonic and there is flaring or spacing between teeth.[7]

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

Gingival hyperplasia

Gingival hyperplasia usually occurs in children taking antiepileptic medications for seizures, especially phenytoin [Figure 4]a. Other medications such as calcium channel blockers (nifedipine) and cyclosporine A may also cause gingival hyperplasia. Chronic gingivitis from poor hygiene can also trigger or exacerbate medication-induced gingival overgrowth.
Figure 4: (a) Phenytoin-induced gingival overgrowth. (b) A child presenting with subluxation of 61.62 and swollen lower lip

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In addition to cosmetic concern, gingival hyperplasia may result in impaired tooth eruption, difficulty in chewing, and severe gingivitis.

Trauma

Trauma to the face and mouth occurs more frequently in children with seizures, developmental delays, poor muscle coordination, and abnormal protective reflexes [Figure 4]b. Some children with special needs exhibit self-injurious behavior which may damage oral structures.

Bruxism

It is more common and often more severe in children with cerebral palsy or severe mental retardation, those who have oral motor habits. Bruxism can lead to enamel loss and difficulty with chewing or tooth sensitivity. It can lead to wear on the teeth, flat tooth surfaces, headaches, pain, and gingival disease.


  Management of Dental Problems in Children with Special Needs Top


It is carried out in three phases:

  1. Relief of pain and control of infections
  2. Treatment or elimination of existing untreated disease
  3. Planning for prevention of further disease.


Treatment of dental diseases in special children is the same as carried out in other children except that they may require sedation even for routine cleanings, restorative procedures, and minimal oral surgery. If there is concern about a child's cooperation or ability to tolerate oral manipulation, he/she should be considered for referral to a pediatric dentist or a specialist with training in sedation.


  Preventive Dentistry for Children with Special Health Care Needs Top


Daily preventive care

Daily home preventive dental care may have to be tailored to meet the specific needs of the child. This is often best addressed by the dental and other health professionals involved in caring for the child. Patients with SHCN who have a dental home are more likely to receive appropriate preventive and routine care.

  • TootXhbrushing: If there are concerns about swallowing toothpaste, families should minimize the amount of toothpaste used (a smear, less than a pea-sized amount) or use a nonfluoridated toothpaste [Figure 5]. If gagging is triggered by toothpaste, the teeth can be brushed with fluoride mouthrinse
  • Fluoridated toothpaste: A smear for infants and children under age 3 and a pea-size amount for children aged 3 through 6 are recommended. It is important to prevent ingestion of toothpaste. For children aged 3–6 who cannot spit, let them drool into a cup. If the child persists in swallowing the toothpaste, a nonfluoridated toothpaste should be used [8],[9]
  • Fluoride rinses: Should be used only for children who can swish for 1 min and spit. Many children with oral motor dysfunction tend to swallow the rinse, so it can be applied with a cotton swab, or other form of fluoride should be used. Alcohol-free rinses should be used.
Figure 5: Amount of toothpaste

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Professionally applied fluoride gel or foam

This is especially beneficial for children who are unable to use home oral rinses with fluoride or who are at high risk for dental caries [Figure 6]a.
Figure 6: (a) Topical fluoride application in disposable trays. (b) Application of fluoride varnish

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Adaptations may be needed for children who have oral motor dysfunction (e.g., abnormal reflexes or muscle control) or oral hypersensitivity (e.g., overreaction to touch, taste, or smell). Gel or foam applied in trays requires frequent use of suction to prevent choking, excessive drooling, or aspiration. Trays may trigger hyperactive gag reflexes; brushing on the gel or foam for the same amount of time while using suction may be more effective.

Professionally applied fluoride varnish

Fluoride varnish may be the best type of professionally applied fluoride for children with SHCN [Figure 6]b. It should be applied every 3–6 months in children who are at increased risk for dental caries.

Antimicrobials

Antimicrobials are especially recommended for children with chronic diseases or disorders such as leukemia, kidney failure, immune deficiencies, or Down syndrome, in conditions where there is moderate to severe gingivitis or periodontitis at an early age or more fungal infections or other opportunistic infections.[10] Antimicrobial rinses should be used only in children who can swish and spit.

  • Chlorhexidine (CHX): Prevent dental caries and periodontal diseases. It is effective against Streptococcus mutans in children at high risk for dental caries. CHX is available in the form of gels, gum, varnishes, and rinses, and in various concentrations. Varnishes and gels would be more appropriate than rinses for many children with SHCN. Rinses can be applied with a cotton swab twice a day
  • Xylitol: A low-calorie sugar substitute used in certain chewing gums. Short-term exposure to xylitol has been shown to decrease S. mutans levels in saliva and plaque. It has additive dental caries preventive effect with fluoride. Children over age 3 can use xylitol if they are able to chew gum without choking. Xylitol should be used for 3–5 min per se ssion, three to five times per day.


Dental sealants

Children cooperate with dental sealant application since its application does not require an injection or the placement of a rubber dam [Figure 7]. Children who severely brux their teeth (e.g., because of cognitive disabilities, cerebral palsy, or autism) may not be candidates for dental sealants because of the flattened occlusal surfaces. Wet bond dental sealants can chemically bond to moist teeth and do not require dry field for application process. However, isolating the working field may be difficult with some children who have oral motor dysfunction. Efficient and effective suctioning is essential for successful application of dental sealants.
Figure 7: Pit and fissure sealants

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Oral prophylaxis

Some children with SHCN develop excessive calculus caused by mouth breathing, inadequate salivary flow, metabolic disorders, kidney failure, tube feedings, oral motor dysfunction, or inadequate oral hygiene. Hand scaling may be done.


  Pediatric Office Screening Top


The oral examination of a child with special needs is similar to the routine child oral examination. Oral defensiveness, increased gag reflex, and oral motor hypotonicity may make the examination more difficult and should be documented. The primary care physician should make increased efforts to complete an examination checklist. Practitioners should examine the following areas and document abnormalities: Oral-facial anomalies, teeth, gingiva, and palate. Early referral to a pediatric dentist will ensure complete examination of all oral structures.


  Barriers to Access to Dental Care in Children with Special Health Care Needs Top


Dental care is the most common unmet need among the special needs population. McIver has described following barriers to access dental care:[11]

  1. Primary medical care system: Since the child has more urgent health care needs, oral health is given less priority. Moreover, dental treatment may become more difficult with the child's existing medical condition
  2. Child's parents: The child's parents consider that their child has milk teeth which will fall off on their own which further complicates oral condition of their child. Parents also find it difficult to find a dentist who can see children with SHCN. Furthermore, dental treatment of children with special needs is more time consuming
  3. Child himself: The child himself may pose various problems to get dental treatment such as inability to understand the importance of dental procedure and cannot behave cooperatively
  4. The dentist: Inadequate knowledge and clinical experience of dentist are the reasons for hindrance to deliver dental treatment to special children. Other noneducational factors such as special arrangements to provide dental treatment to these children also affect the delivery of proper dental care
  5. Payment for dental care: Multiple visits and costly dental treatment add to the financial burden on parents.



  Referrals Top


  • AAPD Guidelines recommend that all children should be referred to a dentist 6 months after the first tooth erupts or by age 12 months (whichever comes first) for establishment of a dental home
  • All children with SHCN fall into a high-risk category and should be referred to a dentist by 1 year of age
  • Children with SHCN may need to visit a pediatric dentist every 2–3 months for professional preventive care, depending on risk factors
  • Any child with evidence of caries, gingival, or eruption anomalies should be immediately referred to a pediatric dentist.



  Conclusion Top


General health and oral health go hand in hand. Children with SHCN are at increased risk for various oral diseases which can adversely affect their quality of life. Dental care for these children has been given less attention by their families and health professionals. Let us all join hands and be aware of our responsibilities and services for these “God's forgotten children” as they certainly deserve the best that medical and dentistry has to offer as an important part to their total habilitation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
American Academy of Pediatric Dentistry. Definition of special health care needs. Pediatr Dent 2013;34:16.  Back to cited text no. 1
    
2.
Available from: http://www.childlineindia.org.in. [Last accessed on 2016 Nov 28].  Back to cited text no. 2
    
3.
American Academy of Pediatric Dentistry. Reference Manual. Guidelines on management of dental patients with special health care needs. Pediatr Dent 2008;37:166-71.  Back to cited text no. 3
    
4.
Rodrigues dos Santos MT, Masiero D, Novo NF, Simionato MR. Oral conditions in children with cerebral palsy. J Dent Child (Chic) 2003;70:40-6.  Back to cited text no. 4
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5.
Nelson S, Albert JM, Geng C, Curtan S, Lang K, Miadich S, et al. Increased enamel hypoplasia and very low birthweight infants. J Dent Res 2013;92:788-94.  Back to cited text no. 5
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6.
Rahul VK, Mathew C, Jose S, Thomas G, Noushad MC, Feroz TP. Oral manifestation in mentally challenged children. J Int Oral Health 2015;7:37-41.  Back to cited text no. 6
    
7.
Miamoto CB, Ramos-Jorge ML, Pereira LJ, Paiva SM, Pordeus IA, Marques LS. Severity of malocclusion in patients with cerebral palsy: Determinant factors. Am J Orthod Dentofacial Orthop 2010;138:394.e1-5.  Back to cited text no. 7
    
8.
Barzel R, Holt K, Isman B. Special Care: An Oral Health Professional's Guide to Serving Young Children with Special Health Care Needs. Available from: http://www.mchoralhealth.org/SpecialCare. [Last accessed on 2016 Nov 28].  Back to cited text no. 8
    
9.
Lewis CW. Dental care and children with special health care needs: A population-based perspective. Acad Pediatr 2009;9:420-6.  Back to cited text no. 9
[PUBMED]    
10.
Little JW, Falace DA. Dental Management of the Medically Compromised Patient. 2nd ed. The C.V. Mosby Company; 1984.  Back to cited text no. 10
    
11.
McIver FT. Access to care: A clinical perspective. In: Mouradian W, editor. Proceedings: Promoting Oral Health of children with Neurodevelopmental Disabilities and Other Special Health Care Needs: A Meeting to Develop Training and Research Agendas, Center on Human Development and Disability. Seattle, Washington: University of Washington; 2001. p. 167-71.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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Abstract
Introduction
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