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, and/or use of specialized services or programs. (10) A significant gap in healthcare exists for this patient population, which can be due in part to limited appropriately trained and willing providers, challenges with insurance, and lack of resources required in certain settings to meet the needs of these patients. (11,12) When looking at how an office can accommodate patients with SHCNs, it is first important to consider the type of SHCN that the patient presents with, whether it is behavioral, congenital, developmental, or cognitive. (10)
The following will identify conditions, syndromes, and disorders organized into sections 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.
I. Behavioral
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)
• Scheduling patients in the morning will be ideal, as they have most likely taken their medications at this time and are the most attentive
• Keeping instructions brief and providing breaks as needed
• Use anxiolysis as needed to help with treatment
• Maintain consistency with the same practitioner, operatory, and appointment time if possible
• Quiet space void of any interruptions
• Avoid demonstration of dental equipment
Autism Spectrum Disorder (ASD): A developmental disorder that appears within the first 3 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. (13,15)
• First consult with caregiver on past dental experiences and tips for interactions that will ensure a positive experience
• Desensitization appointment: No treatment rendered- patient comes into the office to become familiar with the space and staff
• Work slow and use “Tell-Show-Do”
• Quiet space void of any interruptions
II. 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. (13,16)
• Schedule appointments early in the day
• Use caution when laying patient back- some patients may require extra protection around the spinal cord
• Maintain consistency with the same practitioner, operatory, and appointment time if possible
• Desensitization appointment
• Quiet space void of any interruptions
• Music may be comforting
• Complete or partial dentures NOT typically tolerated well
• Be mindful of swallowing or expectorating difficulties
Congenital Cardiac Disorder: 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
• Antibiotic premedication- consult with cardiologist
• High risk patients: prosthetic heart valves, history of infective endocarditis, congenital heart disease, repaired cardiac defect with prosthetic material
III. Developmental
Cerebral Palsy (CP): “Is a group of disorders that affect a person’s ability to move and maintain balance and posture. Cerebral, meaning having to do with the brain. Palsy, meaning weakness or problems with using the muscles.” (13,18)
• Be mindful of swallowing or expectorating difficulties
• Bite block with floss attached if tolerated
• Keep chin in downward position
• Introduce instruments slowly
• Quiet space void of any interruptions
• Let patient know before stimulus introduced
• Keep lights, sounds, or sudden movements to minimum
• Stay cognizant of items in the operatory that could get knocked over when providing care
• If patients are more comfortable in their wheelchair, lock and recline chair if possible. Utilize props to support head, neck, and back as needed
• Some patients with CP utilize a feeding tube. These patients will be low caries caries risk but accumulate calculus quickly
IV. Cognitive
Intellectual Disability (ID): The difference between intellectual disabilities and developmental disabilities is that developmental disabilities encompass both intellectual and physical disabilities. (12) Patients 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. (3)
• Maintain consistency with the same practitioner, operatory, and appointment time if possible
• Desensitization appointment
• Quiet space void of any interruptions
• Stay cognizant of items in the operatory that could get knocked over when providing care
• Determine who will be providing informed consent
• Music may be comforting
• Visual instructions are better understood 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 continually need to be overcome to achieve equal oral healthcare opportunities. However, 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 [Internet]. Silver Spring (MD): American Association on Intellectual and Developmental Disabilities; 2022 [cited 2022 Sept 24]. Available from: https://www.aaidd.org/intellectual-disability/faqs-on-intellectual-disability
2. U.S. Department of Health and Human Services [Internet]. NICHD. N.Eunice Kennedy Shriver National Institute of Child Health and Human Development; n.d. [cited 2023 July 29]. Available from: https://www.nichd.nih.gov/health/topics/factsheets/idds
3. Facts about intellectual disability [Internet]. Centers for Disease Control and Prevention; 2022 May 10 [cited 2023 Feb 11]. Available from: https://www.cdc.gov/ncbddd/developmentaldisabilities/facts-about-intellectual-disability.html
4. Defining criteria for intellectual disability [Internet]. American Association on Intellectual and Developmental Disabilities; n.d. [cited 29 July 2023]. Available from: 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 [Internet]. Centers for Disease Control and Prevention; 2019 Oct 15 [cited 2022 Sept 24]. Available from: https://www.cdc.gov/grand-rounds/pp/2019/20191015-intellectual-disabilities.html#:~:text=Approximately%206.5%20million%20people%20in,an%20intelintelle%20disability%20(ID)
6. University of Minnesota, RISP, Research and Training Center on Community Living. RISP infographics: People with IDD in the United States [Internet]. Institute on Community Integration Publications; n.d. [cited 2023 Feb 11]. Available from: https://publications.ici.umn.edu/risp/infographics/people-with-idd-in-the-united-states-and-the-proportion-who-receive-services#:~:text=There%20were%207.37%20million%20people%20with%20an%20intellectual,support%20or%20service%20in%20addition%20to%20case%20management.
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. American Academy of Pediatric Dentistry: Definition of special health care needs. The Reference Manual of Pediatric Dentistry. Chicago, IL: American Academy of Pediatric Dentistry; 2022:18.
11. Jones DM, Miller SR. Effectiveness of an Educational Module on Dental Hygiene Students' Attitudes Towards 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 [Internet]. University of Washington School of Dentistry; 2011 [cited 2023 Feb 11]. Available from: https://dental.washington.edu/dept-oral-med/special-needs/patients-with-special-needs/
14. Attention-Deficit/Hyperactivity Disorder [Internet]. National Institute of Mental Health; 2022 Sept [cited 2023 Feb 11]. Available from: https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd
15. What is Autism? [Internet]. Autism Research Institute; 2021 [cited 2023 Feb 11]. Available from: https://www.autism.org/what-is-autism/
16. Facts about Down Syndrome [Internet]. Centers for Disease Control and Prevention; 2022 Nov 18 [cited 2023 Feb 11]. Available from: https://www.cdc.gov/ncbddd/birthdefects/downsyndrome.html
17. Congenital heart defects (CHDs) [Internet]. Centers for Disease Control and Prevention; 2023 Feb 2 [cited 2023 Feb 11]. Available from: https://www.cdc.gov/ncbddd/heartdefects/index.html
18. What is Cerebral Palsy? [Internet]. Centers for Disease Control and Prevention; 2022 May 2 [cited 2023 Feb 11]. Available from: https://www.cdc.gov/ncbddd/cp/facts.html
