special needs patients
Did you know that children with special
needs have a higher risk of dental disease?
Children with special needs present higher caries and gum disease rates due to a series of individual and environmental factors. This factors
turns them into a susceptible group
with a high need for dental care
from an early age. However,
preventive oral healthcare
strategies in these children is
usually not a priority…
What is a patient with special needs?
A Special needs patient is any child who has a physical, mental, sensorial or behavioral limitation that requires a differentiated sanitary attention or whose condition has negative implications in his / her oral health. Special needs patients are those who have development problems (autism, cerebral palsy, Down syndrome) as well as children with an hyperactivity disorder or asthma.
As we mentioned above, children with special needs present higher incidence of oral pathologies due to a series of physical and/or environmental factors (diet, medication, etc). This turns them into a risk factor group with a high need for dental care from an early age. However, these children usually have poor oral health, since oral health generally receives little care because the disorder / illness takes up all the attention or there is a limited access to specialized dental services.
Oral health is a very important component of general health; it contributes to the child's well being, avoids the pain and discomfort and promotes a good quality of life. Also, good oral health maximizes the probabilities of an adequate nutrition, language and appearance, so important for a child in a developing stage, especially if the child has physical or mental limitations.
Common oral pathologies in this group are:
Caries: children with physical and/or mental disabilities have a greater risk of developing caries due to various factors such as:
Lack of manual skills to perform a proper oral hygiene.
Muscle tone alterations, which prevent an adequate bite and cause food to accumulate in the mouth.
Physical alterations that interfere with collaboration during tooth brushing.
Soft consistency diets, rich in carbohydrates.
Constant medication with a high content of sugars or corticosteroids, which reduce the flow of saliva and alter the mouth’s self-cleaning system.
Dental malformations, malocclusions and parafunctional habits, which encourage food impaction and dental plaque.
Enamel defects that cause the tooth to be more susceptible to caries.
Periodontal disease: special needs patients have a greater risk of gum disease due to the same risk factors as caries, added to:
Anticonvulsive medication that causes gingival swelling.
Open mouth postures (breathing through the mouth) predispose dry gums which bleed easily.
Malocclusion (incorrect bite): there is a higher malocclusion rate in children with cerebral palsy or other motility dysfunctions which alter the movements of the jaw, lips and tongue; which in turn contribute to respiratory alterations and abnormal jaw postures. Also, children with Down syndrome have a greater risk of developing skeletal malocclusions.
Traumatisms and dental fractures: the risk of suffering from traumatisms is higher in children with cerebral palsy, epilepsy or hyperactivity. Also, the presence of protruded front teeth (that stick out from the upper lip), predispose them to fracture.
Children with mental limitations require extra help at home and at their schools in order to accomplish and maintain a good oral health. Sometimes, the help of several professionals is needed to perform tooth brushing.
At the dentist, the attention given to a child with special needs is closely related to his / her pathology and behavior. The ability to communicate with the child is crucial to accomplish a successful dental treatment. For example, a hearing impaired child could read lips; a blind child will need verbal descriptions of the procedures and a child with mental retardation may need modifications in the level of communication. Even when many children with special needs do not require a particular handling of behavior, some of them need more specialized techniques, including general anesthesia, in some cases.
The prevention of oral diseases in children with special needs is based on these main pillars:
- Performance of oral hygiene from the eruption of the first teeth, twice a day. Parents and/or tutors must be capable of routinely performing it.
- Training of parents, teachers, monitors and other professionals in contact with the child and raising awareness on the impact of sugars on the child's oral health.
- Reducing cariogenic foods (link nutrition andcaries) as much as possible between meals. We strongly advice not to feed these children refined sugars (e.g. candies, chocolates, ice creams), pastries, sodas or canned juices.
- Asking the child's pediatrician to prescribe medicines with the lowest content of sugar possible. Also, try to give children their medicine with meals, not in between them.
- In the case of inhaled corticosteroids (for asthmatic children) we strongly advice to asses the benefits of fluoride mouthwashes after their use.
- Visit the pediatric dentist (link first visit to the paediatric dentist) during the child's first year of life to perform an oral health risk assessment based on his / her individual risk of caries and periodontal disease.
- Enroll the child in an early prevention program: frequent visits to the paediatric dentist for risk assessment; fluoride mouthwashes to strengthen the enamel, antibacterial rinses as well as fissure sealant application (link fluoride and sealants) in dental surfaces susceptible to caries (enamel hypoplasia, deep pits and fissures), etc.
- Always have the pediatric dentist emergency phone number in case a dental trauma occurs (link dental traumatisms).
The importance of oral hygiene
Tooth brushing is the main tool to avoid oral diseases in children with special health care needs. However, oral hygiene can turn into a difficult task when a child's capacity of performing basic tasks such as eating, getting dressed, communicating, etc. is limited. On the other hand, without an adequate oral health, a child is vulnerable to caries and gum diseases (gingivitis), complicating the general health status.
Positions for tooth brushing
Wheel chair: place yourself behind the wheel chair, holding the child's head, pressing it gently against your body or against the wheelchair. You can also sit behind the wheelchair, lock the break and lean it against your lap.
Sitting on the floor: place yourself behind the child on the floor and lean his/ her face against your knees. If the child does not cooperate, you can sit with your legs stretched out and put them around the child's arms, to immobilize them.
Lying on the floor: place a pillow under the head of the child laying on his/ her back, kneel behind him / her and hold it.
Sobre una cama: coloca al niño acostado con la cabeza sobre tu regazo, sujétasela. Si el niño no coopera, otra persona puede sujetar sus brazos y piernas.
Oral hygiene technique
Place the brush's bristles in a 45° angle with the gum. Press moderately and perform small circle movements on the gum, like a massage. Place the toothbrush vertically again and brush upper teeth downwards and lower teeth upwards, in a sweeping movement; include both the outer and the inner sides. Finish with the biting surfaces, 10 times per area. Finally, brush the tongue.
For children who do not cooperate, you may open their mouth with the help of a mouth prop made out of a flexible material, such as silicone
Usually, creative adaptation of oral hygiene tools allows the child to participate in this task. There are various ways of adapting a brush to improve the brushing technique, as well as to encourage the child's participation in case he /she is willing to collaborate.
Holding the brush to the child's hand with a rubber band.
Bending the handle of the brush (by pouring hot water from the tap on the handle).
For children who cannot lift their hands or arms, the handle of the brush can be lengthened with a ruler or a wooden spoon.
For children with limitations in holding the brush, put a rubber ball or sponge at the middle of the handle, to help them hold it.
Toothbrushes do not reach the areas between teeth, so it is important to use a dental floss, especially for children with motor skill limitations. This task is easier to perform using floss holders or flossers. These must be placed between molars, and gently pushed down to the gum, always leaning on the tooth. Ideally, this should be done every single night after dinner and before brushing, so the child can sleep with a clean mouth and reduce the risk of bacterial attack.