Patients with specialized health-care needs: Oral manifestations and common medications

Read Annie’s first article about patients with SHCNs

Patients with specialized health-care needs (SHCNs) face numerous barriers in their lives, and access to adequate oral health care is one of them.^1,2 These individuals rely on family members or caregivers to assist them with their primary care and establish them with health-care providers who understand their specialized needs and offer supportive modifications.^3,4

Patients with SHCNs present with complex oral health-care needs that vary in severity. Due to systemic health conditions and difficulty maintaining personal oral hygiene, they’re at high risk for periodontal disease and dental caries.^5,6 To provide personalized care for these patients, oral health-care providers must understand the complexities of intellectual and developmental disabilities (IDD) and the heightened oral manifestations that can result.^6,7

Dental hygienists are in a critical position for these patients because of the role they play in health education and disease prevention. If disease is prevented, systemic health has the potential to improve, and less advanced therapy will need to be used regarding restorative treatment or periodontal therapy.^5,8

Here are oral manifestations and common medications that may present based on a patient’s SHCN. This is critical to consider when providing care to this patient population.

Behavioral

Attention-Deficit/Hyperactivity Disorder (ADHD): ADHD is marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with function or development.^9,10

Oral manifestations: High risk for caries and periodontal disease, and bruxism

Common medications: Stimulants: Amphetamines: Adderall, Dexedrine, Vyvanse; Methylphenidate: Concerta, Ritalin; and Dexmethylphenidate: Focalin. Nonstimulants: Strattera and Intuniv.

Autism Spectrum Disorder (ASD): A developmental disorder that appears within the first three years of life and appears in different forms with varying severity levels. The two main symptom areas of ASD include deficits in social communication and interaction, or restricted, repetitive behaviors, interests, or activities.^9,11

Oral manifestations: High risk for caries and periodontal disease, bruxism, tongue-thrust, nonnutritive chewing, erosion.

Common medications: Risperidone (Risperdal); Aripiprazole (Abilify); Sertraline (Zoloft)

Congenital

Down syndrome: 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.^9,12

Oral manifestations: Early onset periodontal disease; low caries risk; bruxism; tongue-thrust; short conical roots; chewing and swallowing difficulty due to hypotonia; congenitally missing teeth—third molars, lateral incisors, mandibular second premolars are most common; retained primary teeth until age 14 or 15; malocclusion; mouth breathing; hyper-sensitive gag reflex; prolonged wound healing; aphthous ulcers; oral candida infections; acute necrotizing ulcerative gingivitis (NUG); altered immunologic response to infectious and inflammatory disease; xerostomia.

Common medications: Seizure: Carbamezapine (Tegretol); Phenytoin (Dilantin); and Gabapentin (Neurontin). Muscle relaxer: Baclofen (Lioresal); Diazepam (Valium)

Congenital cardiac disorder: Conditions present at birth that can affect the structure of an infant’s heart and the way it functions.^9,13

Oral manifestations: Risk for infective endocarditis after dental treatment; risk for post-operative bleeding

Common medications: ACE inhibitor: Benazepril (Lotensin); Lisinopril (Prinivil). Antiarrhythmic: Amiodarone (Cordarone); Sotalol (Betapace). Anticoagulants: Warfarin (Coumadin). Angiotensin receptor blockers (ARBs): Valsartan (Diovan); Losartan (Cozaar). Beta blockers: Propranolol (Inderal); Metoprolol (Toprol XL). Calcium channel blockers: Amlodipine (Norvasc); Nifedipine (Cardene). Inotropes/Pressers: Digoxin (Lanoxin). Diuretics: Furosemide (Lasix); Thiazide hydrochlorothiazide.

Developmental

Cerebral Palsy (CP): This is a group of disorders affects a person’s ability to move and maintain balance and posture. Cerebral means having to do with the brain, and Palsy means weakness or problems with using the muscles.^9,14

Oral manifestations: High risk for caries and periodontal disease; bruxism; tongue-thrust; erosion; gingival enlargement; congenitally missing teeth; malocclusion, class II division I; high risk for oral trauma and injury to orofacial structures; mouth breathing; hypersensitive gag reflex; oral hypersensitivity—temperature, touch, taste, smell; excessive saliva production; swallowing difficulties/drooling; enamel hypoplasia.

Common medications: Movement disorder: Benztropine mesylate; Carbidopa-levodopa (Sinemet). Anticonvulsants: Gabapentin (Neurotonin); Lamotrigine (Lamictal); Topiramate (Topomax). Antidepressants: Citalopram (Celexa); Escitalopram (Lexapro); Fluoxetine (Prozac). Antispastic: Baclofen (Botulinum toxin/Botox); Diazepam (Valium); Flexeril. Anti-inflammatories: Aspirin; Corticosteroids; NSAIDs.

Cognitive

Intellectual Disability (ID): The difference between intellectual disabilities and developmental disabilities is that developmental disabilities encompass both intellectual and physical disabilities.¹⁵Patients with an ID typically rely on family members or caregivers to assist them with their primary care and may have a hard time communicating their wants and needs.¹⁶

Oral manifestations: High risk for periodontal disease; high risk for caries, specifically root caries and class V lesions; bruxism; tongue-thrust; enamel hypoplasia; missing permanent teeth and delayed eruption of permanent teeth; malocclusion; mouth breathing.

Common medications: There are no medications specific to ID, but patients may be taking medications for underlying or coexisting conditions, such as seizures, anxiety, and muscle relaxers.

Treating patients with SHCNs

Having an awareness of oral manifestations that may present can help guide our treatment recommendations for patients with SHCNs. You must also consider how medications can influence various conditions in addition to how you can better support your patients and their caregivers.

Just as the patient’s medical providers make changes based on systemic health needs, dental hygienists should be informing patients’ primary care providers on any oral health concerns. Dental hygienists’ role in the prevention, diagnosis, and maintenance of their patients’ oral health condition is critical to achieving optimal oral systemic health. In my next article, I’ll discuss various oral hygiene aids tailored specifically to the patient and caregiver.

References

1. 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

2. 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

3. Christensen LB, Hede B, Petersen PE. Public dental health care program for persons with disability. Acta Odontol Scand. 2005;63(5):278-283.

4. Keselyak NT, Simmer-Beck M, Bray KK, et al. Evaluation of an academic service-learning course on special needs patients for dental hygiene students: a qualitative study. J Dent Educ. 2007;71(3):378-392.

5. FAQs on intellectual disability. American Association on Intellectual and Developmental Disabilities; 2022. https://www.aaidd.org/intellectual-disability/faqs-on-intellectual-disability

6. 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.

7. 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.

8. 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.

9. Patients with special needs. University of Washington School of Dentistry. https://dental.washington.edu/dept-oral-med/special-needs/patients-with-special-needs/

10. Attention-Deficit/Hyperactivity Disorder. National Institute of Mental Health. September 2022. https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd

11. What is autism? Autism Research Institute. 2021 https://www.autism.org/what-is-autism/

12. Facts about Down Syndrome. Centers for Disease Control and Prevention; November 18, 2022. https://www.cdc.gov/ncbddd/birthdefects/downsyndrome.html

13. Congenital heart defects (CHDs). Centers for Disease Control and Prevention; February 2, 2023. https://www.cdc.gov/ncbddd/heartdefects/index.html

14. What is Cerebral Palsy? Centers for Disease Control and Prevention; May 2, 2022. https://www.cdc.gov/ncbddd/cp/facts.html

15. Miller SR. A curriculum focused on informed empathy improves attitudes toward persons with disabilities. Perspect Med Educ. 2013;2(3):114-125.

16. Facts about intellectual disability. Centers for Disease Control and Prevention; May 10, 2022. https://www.cdc.gov/ncbddd/developmentaldisabilities/facts-about-intellectual-disability.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].