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 complies with Health Insurance Portability and Accountability Act (HIPAA) and Americans with Disabilities Act regulations applicable to dental practices. HIPAA 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 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, 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 tool (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 Communication
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, 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 Guidance
Behavior guidance 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 is not feasible or effective, sedation or general anesthesia is the behavioral guidance armamentarium of choice. When in-office behavior guidance including sedation/general anesthesia is not feasible or effective, a hospital or outpatient surgical care facility is necessary 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 gel, mouth rinse, varnish, professional application during prophylaxis) may be indicated when caries risk is increased. Interim therapeutic restoration (ITR), 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.
Patients with oral involvement of conditions such as osteogenesis imperfecta, ectodermal dysplasia, and epidermolysis bullosa often present with unique financial barriers. Although the oral manifestations are intrinsic to the genetic and congenital disorders, medical health benefits often do not provide for related professional oral health care. The distinction made by third party payors 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.
