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Complete Summary

GUIDELINE TITLE

Clinical guideline on management of persons with special health care needs.

BIBLIOGRAPHIC SOURCE(S)

  • American Academy of Pediatric Dentistry. Clinical guideline on management of persons with special health care needs. Chicago (IL): American Academy of Pediatric Dentistry; 2004. 4 p. [24 references]

GUIDELINE STATUS

This is the current release of the guideline.

COMPLETE SUMMARY CONTENT

 
SCOPE
 METHODOLOGY - including Rating Scheme and Cost Analysis
 RECOMMENDATIONS
 EVIDENCE SUPPORTING THE RECOMMENDATIONS
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS
 QUALIFYING STATEMENTS
 IMPLEMENTATION OF THE GUIDELINE
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES
 IDENTIFYING INFORMATION AND AVAILABILITY
 DISCLAIMER

SCOPE

DISEASE/CONDITION(S)

Oral diseases
Special health care needs (SHCN)

GUIDELINE CATEGORY

Counseling
Evaluation
Management
Treatment

CLINICAL SPECIALTY

Dentistry
Pediatrics

INTENDED USERS

Dentists

GUIDELINE OBJECTIVE(S)

To address the management of oral health care particular to persons with special health care needs (SHCN) rather than provide specific treatment recommendations for oral conditions

TARGET POPULATION

Pediatric patients with special health care needs (SHCN)

Note: The American Academy of Pediatric Dentistry (AAPD) defines persons with special health care needs as individuals who "have a 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 developmental or acquired and may cause limitations in performing daily self-maintenance activities or substantial limitations in a major life activity. Health care for special needs patients is beyond that considered routine and requires specialized knowledge, increased awareness and attention, and accommodation."

INTERVENTIONS AND PRACTICES CONSIDERED

  1. Scheduling appropriate length of appointment and complying with the Health Insurance Portability and Accountability Act (HIPAA) and the Americans with Disability Act (AwDA)
  2. Establishing a dental home
  3. Patient assessment
    • Obtaining medical history
    • Performing comprehensive head, neck and oral examination
      • Caries-risk assessment (CAT)
      • Recommending an individualized preventive program
    • Providing a summary of oral findings and specific treatment recommendations
  4. Consulting with physician when necessary
  5. Establishing good communication
  6. Obtaining informed consent
  7. Behavior management
    • Protective stabilization
    • Sedation or general anesthesia
    • Provision of care in a hospital or outpatient surgical care facility
  8. Preventive strategies
    • Education of parents/caregivers to ensure appropriate and regular supervision of daily oral hygiene
    • Demonstrating oral hygiene techniques
    • Stressing the need to use a fluoridated dentifrice daily and to brush and floss daily
    • Use of electric or modified toothbrushes and floss holders
    • Dietary counseling
    • Sealant application
    • Use of topical fluorides (e.g., brush-on gels, mouth rinses, fluoride varnish, professional application during prophylaxis)
    • Alternative restorative treatment (ART)
    • Use of chlorhexidine mouth rinse
    • Referral to periodontist when necessary
  9. Encouraging assistance from community-based resources
  10. Making appropriate referrals when the patient's needs are beyond the skills of the practitioner

MAJOR OUTCOMES CONSIDERED

Not stated

METHODOLOGY

METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

This guideline is based on a review of the current dental and medical literature related to special health care needs (SHCN) patients. A MEDLINE search was conducted using the terms "special needs", "disabled patients", "handicapped patients", "dentistry", and "oral health".

NUMBER OF SOURCE DOCUMENTS

Not stated

METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

METHODS USED TO ANALYZE THE EVIDENCE

Review

DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The oral health policies and clinical guidelines of the American Academy of Pediatric Dentistry (AAPD) are developed under the direction of the Board of Trustees, utilizing the resources and expertise of its membership operating through the Council on Clinical Affairs (CCA).

Proposals to develop or modify policies and guidelines may originate from 4 sources:

  1. the officers or trustees acting at any meeting of the Board of Trustees
  2. a council, committee, or task force in its report to the Board of Trustees
  3. any member of the AAPD acting through the Reference Committee hearing of the General Assembly at the Annual Session
  4. officers, trustees, council and committee chairs, or other participants at the AAPD's Annual Strategic Planning Session

Regardless of the source, proposals are considered carefully, and those deemed sufficiently meritorious by a majority vote of the Board of Trustees are referred to the CCA for development or review/revision.

Once a charge (directive from the Board of Trustees) for development or review/revision of an oral health policy or clinical guideline is sent to the CCA, it is assigned to 1 or more members of the CCA for completion. CCA members are instructed to follow the specified format for a policy or guideline. All oral health policies and clinical guidelines are based on 2 sources of evidence: (1) the scientific literature; and (2) experts in the field. Members may call upon any expert as a consultant to the council to provide expert opinion. The Council on Scientific Affairs provides input as to the scientific validity of a policy or guideline.

The CCA meets on an interim basis (midwinter) to discuss proposed oral health policies and clinical guidelines. Each new or reviewed/revised policy and guideline is reviewed, discussed, and confirmed by the entire council.

RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

COST ANALYSIS

A formal cost analysis was not performed and published cost analyses were not reviewed.

METHOD OF GUIDELINE VALIDATION

Peer Review

DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Once developed by the Council on Clinical Affairs (CCA), the proposed policy or guideline is submitted for the consideration of the Board of Trustees. While the board may request revision, in which case it is returned to the council for modification, once accepted by majority vote of the board, it is referred for Reference Committee hearing at the upcoming Annual Session. At the Reference Committee hearing, the membership may provide comment or suggestion for alteration of the document before presentation to the General Assembly. The final document then is presented for ratification by a majority vote of the membership present and voting at the General Assembly. If accepted by the General Assembly, either as proposed or as amended by that body, the document then becomes the official American Academy of Pediatric Dentistry (AAPD) oral health policy or clinical guideline for publication in the AAPD's Reference Manual and on the AAPD's Web site.

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

Scheduling Appointments

The parent's/patient's initial contact with the dental practice (usually via telephone) allows both parties an opportunity to address the child's primary oral health needs and to confirm the appropriateness of scheduling an appointment with that particular practitioner. Along with the child's name, age, and chief complaint, the receptionist should determine the presence and nature of any special health care needs (SHCN) and, when appropriate, the name(s) of the child's medical care provider(s). The office staff, under the guidance of the dentist, also should determine the need for an increased length of appointment and/or additional auxiliary staff in order to accommodate the patient in an effective and efficient manner. The need for a higher level of dentist and team time as well as customized services should be documented so the office staff is prepared to accommodate the patient's unique circumstances at each subsequent visit.

When scheduling patients with SHCN, it is imperative that the dentist be familiar and comply with Health Insurance Portability and Accountability Act (HIPAA) and Americans with Disabilities Act (AwDA) regulations applicable to dental practices. The Health Insurance Portability and Accountability Act ensures that the patient's privacy is protected and the Americans with Disabilities Act prevents discrimination on the basis of a disability.

Dental Home

Patients with SHCN who have a dental home are more likely to receive appropriate preventive and routine care. The dental home provides an opportunity to implement individualized preventive oral health practices and reduces the child's risk of preventable dental/oral disease. When SHCN patients reach adulthood, their oral health care needs may go beyond the scope of the pediatric dentist's training. It is important to educate and prepare the patient and parent/legal guardian on the value of transitioning to a dentist who is knowledgeable in adult oral health needs. At a time agreed upon by the patient, parent/legal guardian, and pediatric dentist, the patient should be transitioned to a dentist knowledgeable and comfortable with managing that patient's specific health care needs. In cases where this is not possible or desired, the dental home can remain with the pediatric dentist and appropriate referrals for specialized dental care should be recommended when needed.

Patient Assessment

Familiarity with the patient's medical history is essential to decreasing the risk of aggravating a medical condition while rendering dental care. An accurate, comprehensive, and up-to-date medical history is necessary for correct diagnosis and effective treatment planning. Information regarding the chief complaint, history of present illness, medical conditions and/or illnesses, medical care providers, hospitalizations/surgeries, anesthetic experiences, current medications, allergies/sensitivities, immunization status, review of systems, family and social histories, and thorough dental history should be obtained. If the patient/parent is unable to provide accurate information, consultation with the caregiver or with the patient's physician may be required. At each patient visit, the history should be consulted and updated. Recent medical attention for illness or injury, newly diagnosed medical conditions, and changes in medications should be documented. A written update should be obtained at each recall visit. Significant medical conditions should be identified in a conspicuous yet confidential manner in the patient's record.

Comprehensive head, neck, and oral examinations should be completed on all patients. A caries-risk assessment (CAT) should be performed. CAT provides a means of classifying caries risk at a point in time and, therefore, should be applied periodically to assess changes in an individual's risk status. An individualized preventive program, including a dental recall schedule, should be recommended after evaluation of the patient's caries risk, oral health needs, and abilities.

A summary of the oral findings and specific treatment recommendations should be provided to the patient and parent/caregiver. When appropriate, the patient's other health care providers should be informed.

Medical Consultations

The dentist should coordinate care via consultation with the patient's other care providers including physicians, nurses, and social workers. When appropriate, the physician should be consulted regarding medications, sedation, general anesthesia, and special restrictions or preparations that may be required to ensure the safe delivery of oral health care. The dentist and staff always should be prepared to manage a medical emergency.

Patient Communications

When treating patients with SHCN, an assessment of the patient's mental status or degree of intellectual functioning is critical in establishing good communication. Often, information provided by a parent or caregiver prior to the patient's visit can assist greatly in preparation for the appointment. An effort should be made to communicate directly with the patient during the provision of dental care. A patient who does not communicate verbally may communicate in a variety of non-traditional ways. At times, a parent, family member, or caretaker may need to be present to facilitate communication and/or provide information that the patient cannot. According to the requirements of the Americans with Disabilities Act (AwDA), if attempts to communicate with the SHCN patient/parent are unsuccessful because of a disability such as impaired hearing, the dentist must work with those individuals to establish an effective means of communications.

Informed Consent

All patients must be able to provide appropriate signed informed consent for dental treatment or have someone who legally can provide it for them. Informed consent/assent must comply with state laws and, when applicable, institutional requirements. Informed consent should be well documented in the dental record through a signed and witnessed form.

Behavior Management

Behavior management of the patient with SHCN can be challenging. Demanding and resistant behaviors may be seen in the person with mental retardation and even in those with purely physical disabilities and normal mental function. These behaviors can interfere with the safe delivery of dental treatment. With the parent/caregiver's assistance, most patients with physical and mental disabilities can be managed in the dental office. Protective stabilization can be helpful in patients for whom traditional behavior management techniques are not adequate. When protective stabilization alone will not allow delivery of comprehensive oral health care, appropriate sedation or general anesthesia is the behavioral management armamentarium of choice. When in-office behavior management including sedation/general anesthesia is not feasible, a hospital or outpatient surgical care facility may be the most appropriate setting to provide treatment.

Preventive Strategies

Individuals with SHCN are at increased risk for oral diseases; these diseases further jeopardize the patient's health. Education of parents/caregivers is critical for ensuring appropriate and regular supervision of daily oral hygiene. Dental professionals should demonstrate oral hygiene techniques, including the proper positioning of the person with a disability. They also should stress the need to use a fluoridated dentifrice daily to help prevent caries and to brush and floss daily to prevent gingivitis. Toothbrushes can be modified to enable individuals with physical disabilities to brush their own teeth. Electric toothbrushes may improve patient compliance. Floss holders may be beneficial when it is difficult to place hands into the mouth. Caregivers should provide the appropriate oral care when the patient is unable to do so adequately.

Dietary counseling should be discussed for long term prevention of dental disease. Dentists should encourage a non-cariogenic diet and advise patients/parents about the high cariogenic potential of oral pediatric medications rich in sucrose and dietary supplements rich in carbohydrates. As well, other oral side effects (e.g., xerostomia, gingival overgrowth) of medications should be reviewed.

Patients with SHCN may benefit from sealants. Sealants reduce the risk of caries in susceptible pits and fissures of primary and permanent teeth. Topical fluorides (e.g., brush-on gels, mouth rinses, fluoride varnish, professional application during prophylaxis) may be indicated when caries risk is increased. Alternative restorative treatment (ART), using materials such as glass ionomers that release fluoride, may be useful as both preventive and therapeutic approaches in patients with SHCN. In cases of gingivitis and periodontal disease, chlorhexidine mouth rinse may be useful. For patients who might swallow a rinse, a toothbrush can be used to apply the chlorhexidine. Patients having severe dental disease may need to be seen every 2 to 3 months or more often if indicated. Those patients with progressive periodontal disease should be referred to a periodontist for evaluation and treatment.

Barriers

Dentists should be familiar with community-based resources for patients with SHCN and encourage such assistance when appropriate. While local hospitals, public health facilities, rehabilitation services, or groups that advocate for those with SHCN can be valuable contacts to help the dentist/patient address language and cultural barriers, other community-based resources may offer support with financial or transportation considerations that prevent access to care.

Patients with Developmental or Acquired Orofacial Conditions

The oral health care needs of patients with developmental or acquired orofacial conditions necessitate special considerations. While these individuals usually do not require longer appointments or advanced behavior management techniques commonly associated with SHCN patients, management of their oral conditions presents other unique challenges. Developmental defects such as hereditary ectodermal dysplasia, where most teeth are missing or malformed, cause lifetime problems that can be devastating to children and adults. From the first contact with the child and family, every effort must be made to assist the family in adjusting to the anomaly, and the related oral needs. The dental practitioner must be sensitive to the psychosocial well-being of the patient, as well as the effects of the condition on growth, function, and appearance. Congenital oral conditions may entail therapeutic intervention of a protracted nature, timed to coincide with developmental milestones. Patients with conditions such as ectodermal dysplasia, epidermolysis bullosa, cleft lip/palate, and oral cancer frequently require an interdisciplinary team approach to their care. Coordinating delivery of services by the various health care providers can be crucial to successful treatment outcomes.

The distinction made by third party payers between congenital anomalies involving the orofacial complex and those involving other parts of the body is often arbitrary and unfair. For children with hereditary hypodontia, removable or fixed prostheses (including complete dentures or overdentures) and/or implants may be indicated. Dentists should work with the insurance industry to recognize the medical indication and justification for such treatment in these cases.

Referrals

A patient may suffer progression of his/her oral disease if treatment is not provided because of age, behavior, inability to cooperate, disability, or medical status. Postponement or denial of care can result in unnecessary pain, discomfort, increased treatment needs and costs, unfavorable treatment experiences, and diminished oral health outcomes. Dentists have an obligation to act in an ethical manner in the care of patients. When the patient's needs are beyond the skills of the practitioner, the dentist should make appropriate referrals in order to ensure the overall health of the patient.

CLINICAL ALGORITHM(S)

None provided

EVIDENCE SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

All oral health policies and clinical guidelines are based on 2 sources of evidence: (1) the scientific literature; and (2) experts in the field.

BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

POTENTIAL BENEFITS

Appropriate management of pediatric oral health needs in patients with special health care needs (SHCN)

POTENTIAL HARMS

Not stated

QUALIFYING STATEMENTS

QUALIFYING STATEMENTS

The American Academy of Pediatric Dentistry (AAPD) recognizes that persons with special health care needs (SHCN) are an integral part of the specialty of pediatric dentistry. The American Academy of Pediatric Dentistry values the unique qualities of each person and the need to ensure maximal health attainment for all, regardless of their development or other special health care needs. By developing these guidelines, the American Academy of Pediatric Dentistry accepts its responsibility to assist the dental profession in meeting the unique oral health care concerns of this patient population.

IMPLEMENTATION OF THE GUIDELINE

DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

IMPLEMENTATION TOOLS

Chart Documentation/Checklists/Forms
Resources

For information about availability, see the "Availability of Companion Documents" and "Patient Resources" fields below.

INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

IOM CARE NEED

Living with Illness
Staying Healthy

IOM DOMAIN

Effectiveness
Patient-centeredness

IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

  • American Academy of Pediatric Dentistry. Clinical guideline on management of persons with special health care needs. Chicago (IL): American Academy of Pediatric Dentistry; 2004. 4 p. [24 references]

ADAPTATION

Not applicable: The guideline was not adapted from another source.

DATE RELEASED

2004

GUIDELINE DEVELOPER(S)

American Academy of Pediatric Dentistry - Professional Association

SOURCE(S) OF FUNDING

American Academy of Pediatric Dentistry

GUIDELINE COMMITTEE

Council on Clinical Affairs

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Not stated

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

GUIDELINE STATUS

This is the current release of the guideline.

GUIDELINE AVAILABILITY

Electronic copies: Available from the American Academy of Pediatric Dentistry Web site.

Print copies: Available from the American Academy of Pediatric Dentistry, 211 East Chicago Avenue, Suite 700, Chicago, Illinois 60611

AVAILABILITY OF COMPANION DOCUMENTS

PATIENT RESOURCES

None available

NGC STATUS

This NGC summary was completed by ECRI on March 3, 2005. The information was verified by the guideline developer on April 18, 2005.

COPYRIGHT STATEMENT

This summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

DISCLAIMER

NGC DISCLAIMER

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