MANAGEMENT OF DISABLED

CHILDREN

CONTENTS
DEFINITIONS
SPECIAL DENTAL OPERATORY

PSYCHOBEHAVIORAL
DISORDERS
AUTISM
HYPERACTIVITY

PROGRAMS TO TEACH ORAL

HYGIENE

CONVULSIVE DISORDERS

PATIENT POSITIONS

HEARING IMPAIRED

IMMOBILIZATION AIDS

VISION IMPAIRED

DEVELOPMENTALLY
COMPROMISED

LEARNING DISABILITIES

MENTAL RETARDATION
DOWNS SYNDROME

CEREBRAL PALSY

NEUROMUSCULAR
DISORDERS
SPINA BIFIDA
MUSCULAR DYSTROPHY

DONT LET DISABILITY KEEP

DENTIST AWAY

DEFINITION

Handicapped child :
One who, over an appreciable time, is prevented by a
physical or mental condition from full participation in
the normal activities of his age group including those of
a social, recreational , educational and vocational nature
(WHO)

REASONS FOR LACK OF AVAILABILITY OF CARE

FOR HANDICAPPED PATIENTS :
Lack of knowledge
Dentists consider themselves inadequate to treat these patients
Other problems such as fear, anxiety and feelings regarding
the handicapped

SPECIAL DENTAL OPERATORY FOR SPECIAL

CHILD :
Doorway 4 wider than normal
Flooring flat, firm carpets
Wheel-chair turning space
Movable dental chair
Adjustable dental chair to match different wheel-chair
designs

Dental operatory design

PROGRAMS TO TEACH ORAL HYGIENE

Three groups (Bensberg):

SELF-CARE GROUP:
Easiest to deal with MINIMAL SUPERVISION
Children who can maintain excellent oral hygiene
Modification rheumatoid arthritis pts/chronic
joint damage
Modifications of toothbrush handles
Attend special academic schools

PARTIAL CARE GROUP:

Moderately disabled
Require CLOSE SUPERVISION
Motivation difficult
DO NOT EXPECT RAPID LEARNING
Break task into small and easy steps
Positive reinforcement

TOTAL-CARE GROUP:
Severely disabled confined to wheelchairs
Individual assistance needed
Power toothbrush

PATIENT POSITIONING:
PROPER POSITION OF CHILD AND
PERSON PERFORMING ORAL HYGIENE
IS CRUCIAL (JOHNSON AND ALBERTSON)
Standing position
Patient in wheel chair
On bed, sofa
For uncooperative patients
For patients unable/unwilling to
open mouth

TREATMENT IMMOBILIZATION:
Patient who requires treatment but cannot cooperate due to lack of
maturity
Cannot cooperate due to lack of mental or physical disability
Does not cooperate after all behavior management techniques have
failed
When the safety of patient and operator is at risk without the
protective use of immobilization

Immobilization aids

BODY
Papoose board
Triangular sheet( MINK)
Pedi wrap
Bean bag
Safety belt
Extra assistant

EXTREMITIES
Posey strap
Velcro strap
Towel tape
Extra assistant

HEAD
Forearm body support
Head positioner
Plastic bowl
Extra assistant

INTRAORAL
Padded tongue blades
Molt mouth props
Fergusson mouth props
Towel

CHANGING TRENDS

DEVELOPMENTAL DISABILITY

Mental retardation

MOST COMMON
DEFINITON: (AAMD)

significantly sub average general intellectual functioning

which originates during the developmental period and is
associated with impairment in adaptive behavior

Significantly Sub average General Intellectual Functioning:

(CAPUTE) :developmental or intelligence quotient (IQ) that is
below 70 and represents two or more standard deviations
Originates During The Developmental Period: is defined as
within the limit of 18 yrs of age
Adaptive Behavior: individuals effectiveness in adapting to
natural and social demands of environment ie maturation,
learning and social adjustment

DIAGNOSIS OF MR IS NOT BASED

ON IQ ALONE

TESTS USED TO DETERMINE IQ ARE:

CATTELL INFANT INTELLIGENCE SCALE
STANFORD-BINET INTELLIGENCE SCALE
WECHSLER INTELLIGENCE SCALE FOR CHILDREN
WECHSLER ADULT INTELLIGENCE SCALE

FORMULA FOR COMPUTING INTELLIGENCE

QUOTIENT (IQ) :
RATIO B/W MENTAL AGE (MA) AND CHRONOLOGICAL
AGE (CA)
IQ = (MA / CA) 100
= (3 / 6)100 = 50

CLASSIFICATION OF MENTAL
RETARDATION

ACC TO AAMD:
IQ
SCORES

FUNCTIONAL LEVEL

69-55

MILDLY/EDUCABLY RETARDED

54-40

MODERATELY/TRAINABLY RETARDED

39-25

SEVERELY RETARDED

BELOW 25 PROFOUNDLY RETARDED

DEGREE OF
MENTAL
DISABILITY
MILD

STANFORDBINET
INTELLIGENCE
SCALE
67-52

WECHSLERINTELLIGENCE
SCALE

COMMUNICATION

69-55

ABLE TO SPEAK FOR

MOST
COMMUNICATION

MODERATE

51-36

54-40

NEEDS
COMMUNICATE AT
BASIC LEVEL WITH
OTHERS

SEVERE/
PROFOUND

35 AND BELOW

39 AND BELOW

MUTE OR
COMMUNICATIONS
IN GRUNTS/LITTLE
OR NO COMM. SKILLS

ETIOLOGY
PRENATAL:
Genetic diseases
Maternal/fetal
infections
Kernicterus
Cretinism
Fetal alcohol syndrome

NATAL:
Birth injuries
Infection
Cerebral trauma
Hypoglycemia
Hypoxia

POST NATAL:
Cerebral infections
Cerebral trauma
Poisoning
Cerebral-vascular accidents
Malnutrition

Anomalies of dentition

Most common dental caries

In older children periodontal conditions
Hypo-calcification of teeth
Malocclusions
DIETARY COUNSELING

Dental considerations
Medical history
Short attention span, restlessness, hyperactivity
Brief tour of office
Be repetitve, speak slowly and in simple terms
Listen to patient
Alternative form of communication
ONE INSTRUCTION AT A TIME
Short appointments
Appointments in morning

Emphasis on good oral hygiene

Patience and sensitivity on part of dentist
Gentle firmness
BEHAVIOR MANAGEMENT:
TSD
Principles of classical conditioning
Principles of operant conditioning
IN SEVERE CASES:
Sedation
General anesthesia

DOWNS SYNDROME
MOST COMMON CHROMOSOMAL ABERRATION
First description of its characters given byEsquirol(1838)
CHROMOSOMAL ABNORMALITIES:
Trisomy 21/ extra Ch 21 (95%)
Translocation (3%)
Mosaicism/ partial trisomy (2%)
1 in 600 to 1000 live births
( with maternal age)

PHYSICAL FEATURES:
Head: Prominence of forehead
Flattening of occiput
Eyes: Hypoplasia of iris stroma
Brushfield spots
Face: Round flat face
Flat nasal bridge
Upward slanting palpebral fissures

Limbs: Short and broad

Clinodactyly of fifth finger
Wide space b/w first and second toe
Transverse palmar crease- SIMIAN CREASE

SYSTEMIC ANOMALIES:
Congenital cardiac anomalies (40%)
Increased susceptibility to infections
Greater risk of developing leukemia (ALL)
Increased laxity of transverse ligament b/w atlas and odontoid
processes of cervical vertebrae
Motor function delayed
Behavior : warmth, gentle, patience, tolerance and complete
honesty
Speech: expressive language is delayed

ORAL ANOMALIES:
STAIR PALATE
Hypotonia of perioral muscles- angle of mouth pulled down
Hypotonia of lower lip
Mouth appears open due to relatively enlarged
tongue
Tongue: scalloped or crenated
PSEUDO CLASS III MALOCCLUSION

DENTAL ANOMALIES:
Microdontia
Hypoplasia
Partial anodontia
TAURODONTISM
LOW PREVALENCE OF DENTAL CARIES
Bruxism
Delayed eruption of teeth
Rapid, generalized periodontal breakdown
Anterior/posterior cross bite

MANAGEMENT:
These children are generally cooperative dental procedures
can be provided without any compromise
Preventive dental care
HOME CARE ORAL HYGIENE
Sedation (difficult-obstructed nasal passage)
Immobilization
General anesthesia (severe cases)

CEREBRAL PALSY (CP)

Nelson et al : a group of non progressive disorders
resulting from malfunction of motor centers and
pathways of brain.
It may occur in conjunction with :
Speech defects (50-75%)
Mental retardation (45%)
Visual defects (20-50%)
Seizures (35-60%)
Deafness (10-30%)
Behavioral and emotional disorders

CAUSES:
ANY PROCESS THAT REDUCES SUPPLY OF OXYGEN TO
DEVELOPING BRAIN
Cord strangulation
Hemorrhage
Infections
Birth trauma

HIGH ASSOCIATION WITH PREMATURITY

CLASSIFICATION:
SPASTICITY (approx. 70% of cases)
ATHETOSIS (25%)
TREMORS (5%)
RIGIDITY (5%)
ATAXIA (10%)
MULTIPLE SYMPTOMS

SPASTICITY :
Lesion in cerebral cortex
Hypertonia of muscles- stiff and awkward movements
Hand and arm are flexed and held against trunk
Foot and leg rotated internally-limping gait
Head roll
Difficulty in maintaining posture
Impaired chewing and swallowing
Speech defects
Inability to control voluntary movements

ATHETOSIS/DYSKINETIC:
Lesion in basal ganglia
SLOW WRITHING INVOLUNTARY MOVEMENTS
(ATHETOSIS)
Quick jerky movements (choreoathetosis)
NO SPASTICITY OR WEAKNESS OF MUSCLE
Involvement of neck musculature- hypertonicity
Severe bruxism
Hypotonicity of perioral muscles-excessive drooling
Chewing, swallowing and speech difficulties
ALL FOUR EXTREMITIES INVOLVED

ATAXIA:
Lesion in cerebellum
Inability of involved muscles to contract completely
Difficulty in grasping objects
STUMBLING GAIT
Tremors may be present
NO MUSCULAR INVOLVEMENT

RIGIDITY:
Lesion in basal ganglion
STIFFNESS/CONSTANT RIGIDITY
Voluntary movement slow and stiff

TREMORS:
Repetitive, rhythmic involuntary contractions

MIXED:

THESE CAN AFFECT FOLLOWING

AREAS:
MONOPLEGIA- one extremity affected
DIPLEGIA- affecting both legs with minimal involvement of arms
PARAPLEGIA- involvement of both legs only
HEMIPLEGIA- involvement of one side of the body
QUADRIPLEGIA- all four limbs affected

ORO-DENTAL CHARACTERISTICS ASSOCIATED WITH CP

NO SPECIFIC ORAL DISEASE RELATED TO CP
SPASTIC :
Class II, Div 2 malocc
Crossbite, tongue thrust
SHUT DOWN/ INTROVERT, FEARFUL
Environment-devoid of excitements
Afraid of demonstration of affection
Slow to show anger
ATHETOID:
Class II, Div 1 malocc
Demonstrate little fear
Readily provoked to outbursts of anger
Enjoy company and engage in conversation

ATAXIA:
Ankyloglossia is seen in some cases
Have little fear
Anger is readily provoked
Make friends and seek affection

TRAUMA COMMON
PERIODONTAL DISEASE
POUCHING OF FOOD
RUMINATION
PICA

NEONATAL REFLEXES IN CP
ASYMMETRIC TONIC NECK REFLEX:
Head suddenly turned on one side, hand and leg of
that side extend and stiffen

TONIC LABYRINTHINE REFLEX:

If head suddenly falls backward while patient is in supine position,
back may assume position k/n as POSTURAL EXTENSION

STARTLE REFLEX:
Sudden, involuntary and forceful movements occurs when
patient surprised by stimuli or unexpected movements by other
people

DENTAL MANAGEMENT
Treat patient in wheel chair
Place and maintain patient in midline of chair
Keep back slightly elevated
Use of mouth props
Prevent abrupt movements
Introduce intra oral stimuli slowly
Minimize patient time in chair
Use of restraints

AUTISM
Incapacitating

disturbance

of

mental

and

emotional

development that causes problems in learning, communicating

and relating to others
SYNONYMS: Kanners syndrome, Early Infantile Autism,
Infantile Psychosis, Childhood Schizophrenia
IQ score below 50

ETIOLOGY:
BEHAVIORAL CHARACTERISTICS:
Extreme aloneness
Language disturbance
Mutism
Repetious speech - ECHOLALIC
Difficulty with concept of YES
Desire to maintain consistency

Intrigue with spinning

objects
Eating disturbances
Hyperactivity
Nystagmus
Mental retardation

DISPLAY ANGER/AFFECTION ON TOY

MANAGEMENT:
Several dental visits to acclimate to dental environment
Use of positive reinforcement
Patience and slow approach
Allow to bring some comfort items to clinic
Sedation and GA
Special education programs for family and family counseling

HYPERACTIVITY
SYNONYMS: Minimal Brain Dysfunction, Hyperkinetic
Syndrome
C/F:
Increased motor activity
Short attention span
Inability to concentrate
Difficulty in performing tasks
Lack of social integration

MANAGEMENT:
Delay in reception room to minimum
Treatment time should also be short
Methods of behavior modification

CONVULSIVE DISORDERS
Signs of abnormal brain function
Etiology:
Idiopathic
Symptomatic
Febrile seizures
Partial seizures
Generalized convulsions
Grand-mal
Petit-mal
Focal seizures
Self induced seizures

Prevention of seizures in dental office:

Reducing stress
Do not place light directly on face
Avoidance of seizure promoting drugs
Daily medication routine before dental treatment
Adequate preparation of patient
USE OF MOUTH PROPS

If child develops seizures in dental office:

Maintain patent airway
Dental instruments moved away from patient
Patient placed on floor/use of restraints
Post-ictal phase
Discontinue treatment

Hearing impairment

Bowley and Gardner have described 4 levels

of deafness:
Mild hearing loss (15-30 db) hard of hearing
Partial hearing loss hearing aid
Severe hearing loss (>70) difficulty in learning language
Profound hearing loss (>95) lip reading, sign language
and manual methods

Incidence: 1 in 600
Etiology:
Rubella and influenza
Ototoxic drugs
Birth injury
Erythroblastosis foetalis
Mumps, chicken pox, polio
Injuries

MANAGEMENT:
Minimal hearing loss- misunderstanding of instructions
Mode of communication
Use of chalk board or writing pads
Parent visible to child
Face patient and speak slowly
Watch for patients expressions
TELL-SHOW-FEEL-DO approach
Adjust hearing aid
NON-VERBAL COMMUNICATION
REASSURANCE

VISION IMPAIRMENT
NOT AN ALL OR NOTHING PHENOMENON
Visual Acuity less than 20/200
If > 20/200 visual field: less than 20 degree
CAUSES:
Optic atrophy
Cataracts
Syphilis
Rubella
HT
DM
Trauma

DENTAL PROBLEMS:
Prolonged immature swallowing
Prolonged use of bottle
Poor oral hygiene
Hypoplastic teeth
Traumatic injuries
Gingival inflammation

PARENTAL COUNSELING:

MANAGEMENT:
Duration of blindness
Guide him to dental operatory
Description- office, treatment, dentist, other office
personnel
Allow patient to ask questions
Let patient TOUCH-TASTE-SMELL
Use of audio cassettes and braille
Distractions and loud noises minimum
Patient should not be left alone

LEARNING DISABILITIES

Learning disability is applied to children who exhibit a

disorder in one or more of basic psychologic processes
involved in understanding or using spoken or written
language
Boys > girls
3 out of every 100

CAUSE:
Minimal brain injury
Damage to CNS
Genetic factor

C/F:
Delayed milestones
Behavioral disorders
Decreased logical thinking
Lack of language skills

Communicating with people who have Learning

Disabilities is difficult because:
Visual and hearing impaired
Poor memory
Difficulty in sustaining attention

ACCEPT DENTAL CARE

Patients preferred method of communicating:
Speech slow and clear
Patient should be given plenty of time to respond
Appropriate body posture and eye contact maintained

SPINA bifida
TWO FORMS:
Spina bifida occulta (closed)
Myelomeningocele / spina bifida aperta (open)

ORAL MANIFESTATIONS:
Caries risk
Poor nutritional intake
LATEX ALLERGY

INVESTIGATIONS:
Screening
Exposure to recurrent surgical procedures
Food allergies

MANAGEMENT:
Non latex substitutes
Do not handle non latex products while wearing gloves
Ideal time to schedule appointments

MILD IRRITANT REACTIONSYSTEMIC REACTIONS-

MUSCULAR DYSTROPHY
Affect neuromuscular and skeletal system
Skeletal muscle affected
M>F
ORAL MANIFESTATIONS:
Flaccid, weak perioral musculature
Expanded arches
Malocclusions
INABILITY TO ADJUST TO REMOVABLE PROSTHODONTIC
APPLIANCES
DRUGS THAT DEPRESS RESPIRATION AND GENERAL ANESTHETICS

CONCLUSION

REFERENCES:
DENTISTRY FOR CHILD AND ADOLESCENT McDonald
PEDIATRIC DENTISTRY: TOTAL PATIENT CARE Stephen Wei
TEXT-BOOK OF PEDIATRIC DENTISTRY Braham Morris
PEDIATRC DENTISTRY - Stewart
DENTISTRY FOR HANDICAPPED PATIENT Kenneth Wessels