Treatment accommodations for dental patients with special needs

In 2019, the National Health Interview Survey (NHIS) identified 7.39 million people in the US who live with an intellectual or developmental disability (IDD), which equates to about 1 in 10 people.^1-4 These individuals face numerous barriers to daily life, and access to adequate oral health care is one of them.^5,6

To provide a personalized level of care to these patients, oral health-care providers must understand the complexities of IDDs and the heightened oral manifestations that can result.^7-9 Dental hygienists are in a critical position as care providers for these patients due to their role in education and prevention. There are aspects of a dental hygiene visit that can be tailored specifically for special needs individuals. Caregiver education, oral hygiene aids, and dental office considerations also play a role.

Office space considerations and treatment accommodations are critical to ensure an optimal dental appointment for those with specialized health-care needs (SHCN). A SHCN is defined as any physical, developmental, mental, sensory, behavioral, cognitive, or emotional impairment or limiting condition that requires medical management, health-care intervention, or use of specialized services or programs.¹⁰

A significant gap in health care exists for this patient population, due in part to limited trained providers, challenges with insurance, and lack of resources in some settings to meet the needs of these patients.^11,12 When looking at how an office can accommodate patients with SHCNs, consider the type of SHCN the patient presents with, whether behavioral, congenital, developmental, or cognitive.¹⁰

Here are conditions, syndromes, and disorders based on the type of SHCN. This is not a complete list, but briefly identifies patients that may present with specific needs in your office.

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Behavioral disorders

Attention-deficit hyperactivity disorder (ADHD): ADHD is a disorder marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with function or development.^13,14

• Schedule patients in the morning as they have most likely taken their medications early and are attentive.
• Keep instructions brief and provide breaks as needed.
• Use anxiolysis as needed to help with treatment.
• Maintain consistency with the same practitioner, operatory, and appointment time if possible.
• Provide a quiet space void of interruptions.
• Avoid demonstration of dental equipment.

Autism spectrum disorder (ASD): This is a developmental disorder that appears within the first three years of life and has different forms with varying severity. The two main symptom areas of ASD are deficits in social communication and interaction, and restricted, repetitive behaviors, interests, or activities.^13,15

• Consult with the person’s caregiver about past dental experiences and tips for interactions that will ensure a positive experience.
• Have a desensitization appointment with no treatment rendered. The patient will come into the office to become familiar with the space and staff.
• Work slowly and use “tell-show-do.”
• Offer a quiet space void of interruptions.
  
  

Congenital conditions

Down syndrome: This is a condition where an individual has an extra copy of chromosome 21, often referred to as Trisomy 21. This results in an intellectual disability and specific physical features. Most patients with Down syndrome can be treated comfortably in a dental office.^13,16

• Schedule their appointments early in the day.
• Use caution when laying the patient back. Some patients may require extra protection around the spinal cord.
• Maintain consistency with the same practitioner, operatory, and appointment time if possible.
• Schedule a desensitization appointment.
• Provide a quiet space void of interruptions.
• It may be comforting to the patient if you play music.
• These patients typically do not tolerate complete or partial dentures.
• Be mindful if a patient has swallowing or expectorating difficulties.

Congenital cardiac disorder: These are conditions present at birth that can affect the structure of an infant’s heart and the way it functions.^13,17

• Use anxiolysis as needed to help with treatment.
• Use antibiotic premedication, but first consult with a cardiologist.
• High-risk patients may have prosthetic heart valves, a history of infective endocarditis, congenital heart disease, or a repaired cardiac defect with prosthetic material.
  
  

Developmental disorders

Cerebral Palsy (CP): This is a group of disorders that affect a person’s ability to move and maintain balance and posture. The names comes from cerebral, meaning having to do with the brain, and palsy, meaning weakness or problems with using the muscles.^13,18

• Be mindful of swallowing or expectorating difficulties.
• Use a bite block with floss attached if it can be tolerated.
• Keep the chin in a downward position.
• Introduce instruments slowly.
• Offer a quiet space void of interruptions.
• Let the patient know before stimulus is introduced.
• Keep lights, sounds, or sudden movements to a minimum.
• Stay cognizant of items in the operatory that could get knocked over when you’re providing care.
• If patients are more comfortable in their wheelchair, lock and recline their chair if possible. Use props to support their head, neck, and back as needed.
• Some patients with CP use a feeding tube. These patients will be low caries risk, but they accumulate calculus quickly.
  
  

Cognitive disorders

Intellectual disabilities (IDs): The difference between IDs and developmental disabilities is that developmental disabilities encompass both intellectual and physical disabilities.¹² Patients with an ID typically rely on caregivers to assist them with their primary care and may have a hard time communicating their wants and needs.³

• Maintain consistency with the same practitioner, operatory, and appointment time if possible.
• Schedule a desensitization appointment.
• Offer a quiet space void of interruptions.
• Stay cognizant of items in the operatory that could get knocked over when you’re providing care.
• Determine who will be providing informed consent.
• Music may be comforting for these patients.
• These patients understand visual instructions better than verbal alone.
• Count during short segments of a procedure to allow the patient to anticipate a break.

Improving access to care for this vulnerable patient population will take time and barriers will often need to be overcome to achieve equal oral health-care opportunities. Equipping dental hygienists with the necessary knowledge and resources specific to these patients could help move general dentist offices toward providing care to more patients with SHCNs.

References

1. FAQs on intellectual disability. American Association on Intellectual and Developmental Disabilities. 2024. https://www.aaidd.org/intellectual-disability/faqs-on-intellectual-disability
2. Itellectual and developmental disabilities. U.S. Department of Health and Human Services. NICHD. https://www.nichd.nih.gov/health/topics/factsheets/idds
3. Facts about intellectual disability. Centers for Disease Control and Prevention. May 10, 2022. https://www.cdc.gov/ncbddd/developmentaldisabilities/facts-about-intellectual-disability.html
4. Defining criteria for intellectual disability. American Association on Intellectual and Developmental Disabilities. https://www.aaidd.org/intellectual-disability/definition
5. Peacock G, Havercamp S, Weintraub L, Shriver T. Addressing gaps in health care for individuals with intellectual disabilities. Centers for Disease Control and Prevention. October 15, 2019. https://www.cdc.gov/grand-rounds/pp/2019/20191015-intellectual-disabilities.html
6. People with IDD in the United States. Institute on Community Integration Publications. https://publications.ici.umn.edu/risp/infographics/people-with-idd-in-the-united-states-and-the-proportion-who-receive-services
7. Freudenthal JJ, Boyd LD, Tivis R. Assessing change in health professions volunteers' perceptions after participating in Special Olympics healthy athlete events. J Dent Educ. 2010;74(9):970-979.
8. Mabry CC, Mosca NG. Interprofessional educational partnerships in school health for children with special oral health needs. J Dent Educ. 2006;70(8):844-850.
9. Perusini DJ, Llacuachaqui M, Sigal MJ, et al. Dental students' clinical expectations and experiences treating persons with disabilities. J Dent Educ. 2016;80(3):301-310.
10. Definition of special health care needs. American Academy of Pediatric Dentistry. https://www.aapd.org/research/oral-health-policies--recommendations/special-health-care-needs/
11. Jones DM, Miller SR. Effectiveness of an educational module on dental hygiene students' attitudes toward persons with disabilities. J Dent Hyg. 2018;92(4):27-34.
12. Miller SR. A curriculum focused on informed empathy improves attitudes toward persons with disabilities. Perspect Med Educ. 2013;2(3):114-125.
13. Patients with special needs. University of Washington School of Dentistry. https://dental.washington.edu/dept-oral-med/special-needs/patients-with-special-needs/
14. Attention-Deficit/Hyperactivity Disorder. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd
15. What is Autism? Autism Research Institute. https://www.autism.org/what-is-autism/
16. Facts about Down Syndrome. Centers for Disease Control and Prevention.November 18, 2022. https://www.cdc.gov/ncbddd/birthdefects/downsyndrome.html
17. Congenital heart defects (CHDs). Centers for Disease Control and Prevention. February 2, 2023. https://www.cdc.gov/ncbddd/heartdefects/index.html
18. What is Cerebral Palsy? Centers for Disease Control and Prevention. May 2, 2022. https://www.cdc.gov/ncbddd/cp/facts.html

Annie Walters, MSDH, RDH, attended Northern Arizona University, where she spent time caring for individuals in Guatemala and Indian Health Service. She has a special interest in advancing access to care for individuals with specialized health-care needs. She’s a member of ADHA, and received her MS from the University of New Mexico, where she developed a chairside resource for RDHs to use for patients with specialized needs. She practices in Flagstaff, Arizona, and serves as part-time faculty at her alma mater. Contact her at [email protected].