Dentistry for individuals with special needs

Dr. William J. Maloney provides guidance on modifications that may be needed in the treatment of special needs patients  

While providing dental care, dentists must take into consideration that each patient is a unique individual who may require modifications to treatment in order to allay their fears and provide safe, comfortable, and effective dental treatment. Special needs patients often require individualized treatment due to a disability or medical condition that affects their ability to function on a daily basis. These individuals may have chronic illnesses or emotional, physical, mental, or learning disabilities that require special care while receiving dental treatment. It is imperative that special needs patients receive quality dental care on a regular basis. Failure to receive proper dental treatment can cause pain, poor oral health, and exacerbate already existing conditions which the individual is challenged by on a daily basis. The dentist is a vital and integral part of the special needs patient’s healthcare team and, as such, must work collaboratively with the patient, caregivers, and family members as well as other healthcare providers.  

We, as dentists, must look at our facilities through the eyes of our special needs patients. Often, these individuals face various barriers while seeking dental treatment, including difficulty accessing dental treatment and higher associated costs.¹ When designing new dental facilities or renovating existing ones, it is highly advised to keep in mind the physical challenges these patients may encounter while seeking dental care in our facilities. Some of these considerations can include ramps for those who cannot use stairs and more spacious treatment areas which would help facilitate a more comfortable environment for the patients who need a wheelchair and their caregivers. 

In many instances, especially for youthful patients, it is helpful to have a family member or trusted friend in the treatment area in order to calm the special needs dental patient. Having someone the patient trusts in the treatment area can help allay the patient’s fears and anxiety and, in turn, allow the dentist to provide dental care in a safer and more effective manner. Also, the trusted friend or caregiver often has knowledge of the individual’s triggers and coping mechanisms which can be shared with the dental team.  

If the patient is an adult, different strategies may be helpful. Firstly, it is very important that the atmosphere of the dental setting is warm, calm, and relaxing.  

Gentle music can always set the proper tone. Communication between the clinician and the special needs adult patient and the caregiver is absolutely essential. Effective communication techniques build rapport and trust between the dental professional and the patient. This connection leads to more effective and efficient dental treatment. As such, active listening is very important. The dental staff should listen carefully to the patient’s fears and concerns. This allows the dental team to understand and address their concerns and anxieties. As is true with any patient, the essential element of building a strong and successful relationship is trust. If patients trust the dental team, they will be much less likely to be uncooperative as effective communication aids the dental team in addressing issues that may be potential triggers. 

Morning appointments can often be more suitable for both the adult and the pediatric special needs patient. This is true because the patient may be tired and more anxious in the afternoon. 

Also, allow the patient to take breaks during the procedure. This gives the patients a sense of control over their surroundings. Tell the patient to give the dentist a predetermined sign whenever a break is needed. Sometimes just stopping for half a minute or so can allow the patient to catch their breath or rinse out and avoid any sudden attempt by the patient to stop the dental treatment. 

Sedation options can be extremely helpful while treating both youthful and adult special needs patients. Nitrous oxide can calm the patient in a very efficient manner. Another benefit of sedation is it can help patients who may have a severe gag reflex. The appropriate form of sedation should be tailored to the individual’s specific conditions and in consultation with the special needs patient’s medical providers. 

Many times patients with special needs, especially children, have dietary issues such as restricted diets or sensory sensitivities.²  This can exacerbate existing oral challenges. In such cases, it is very important for the dentist to work with the caregiver and, if possible, a dietician in order for the caregiver to fully understand the effects of various food and beverages on the individual’s oral health. 

Obtaining informed consent is essential before providing treatment to any dental patient, but additional challenges may present when treating a special needs patient. Such patients may have dfficulty with various forms of communication. 

Visual aids and involving caregivers might be helpful in such circumstances. Also, some special needs patients, which obviously includes all minors, may not have the capacity to consent, which necessitates obtaining the consent from the patient’s legal guardian.³  

Excessive tooth grinding or bruxism is often present in children with cerebral palsy⁴  as well as others with neurological or developmental conditions. This can lead to exposed dentin and thermal sensitivity, sleep disturbances, temporomandibular joint disorders, and fractures of the teeth. Many times, an occlusal guard is recommended. It is essential for the dentist to work collaboratively with the caregiver and other healthcare professionals to determine the underlying cause of the excessive tooth grinding if not already known. 

Delayed eruption of both deciduous and permanent teeth in certain special needs children, such as those with Down syndrome, are often seen. In these children, delays in the normal eruption pattern may be up to 2 years.⁵  Some children with Down syndrome retain their deciduous teeth until up to 15 years of age.⁵  This commonly leads to both malocclusion and overcrowding.⁶  These orthodontic issues very frequently lead to serious dental concerns which the dentist must be both aware of and take actions to mitigate their effects. Such actions can include the use of fluoride therapies and an increased amount of time spent educating both the patient and caregiver on oral hygiene techniques.  

Special needs patients most likely will be taking multiple medications. Some of these medications may cause various dental side effects. Some of these medications include anticoagulants (gingival hyperplasia, xerostomia, stomatitis), anticholinergics (xerostomia, bruxism), and muscle relaxants (xerostomia).⁷  

There are many useful strategies and tips for making the dental visit successful for a special needs child. These tips include the following:^8,9  

1. Have a desensitization visit where the patient can become familiar with the environment. 
2. Ask the caregiver what time of day the patient is most calm and cooperative. 
3. Start the exam with fingers only. 
4. Keep light out of eyes. 
5. Praise good behavior. 
6. If possible, ignore inappropriate behavior. 
7. Utilize the same staff and dental chair at each visit. 
8. Minimize stimuli such as odors, sounds, and bright lights. 
9. Ask permission before starting any dental treatment. 
10. The patient might not give a verbal “OK” for you to start treatment. If they don’t try to stop you, consider that they have given you permission. 
11. Including your entire staff including front desk personnel and dental assistants in the dental visit will make the patient feel more comfortable. This will also allow the patient to develop trust for the staff which will help lessen the patient’s fears and anxieties. 
12. Make sure to ask if the patient has an allergy to latex before starting treatment as latex allergies are more common among individuals with developmental disabilities. 
13. Have the special needs patient bring certain comfort items, such as a pillow, a stuffed animal, or a blanket, to the dental appointment to provide reassurance during the dental visit. 

Special needs dental patients experience many obstacles to achieving ideal oral health. Some of these challenges include overcrowding, delayed eruption of teeth, and an increased incidence of dental caries. Homecare and oral hygiene are extremely important for everyone, but it is imperative for special needs patients that their oral hygiene and homecare are at a very high level. The importance of oral hygiene must be reinforced at every dental visit. Oral hygiene instructions must be regularly reviewed not only with the patient but, also with the patient’s caregiver. An electric toothbrush might be recommended for patients with manual dexterity difficulties. Home fluoride therapies also are recommended to combat their high incidence of dental decay. Also, working with an orthodontist may prove useful in order to correct overcrowding issues which can cause difficulty in keeping the teeth clean which can lead to dental decay. 

A follow-up telephone call the day after the procedure to check on the well-being of the patient is a great way to both address any questions or concerns which the patient or caregiver may have and also build and strengthen the all-important relationship between the patient and the dental team. 

At times, special needs patients may exhibit volatile behavior. In such instances it is essential to ensure the safety of both the patient and staff. De-escalation techniques should be initially employed by using non-threatening and calming verbage and body language. Calmly reinforce positive and cooperative behavior while clearly telling the individual which behaviors are unacceptable along with the possible consequences of continued unacceptable behavior. At this time, it would be wise to discreetly call for assistance and/or consider ending the appointment. If the behavior does not cease, or there is potential risk of bodily harm to the patient or others, law enforcement should be notified. After the incident has been resolved, the details of the incident should be discussed with the entire dental team. An analysis of what happened and what caused it to occur should be discussed. Future dental treatment should be discussed as to how to avoid another negative event in the future. A referral to a specialized center for patients with special needs might be the best option for some individuals with complex special needs and for those individuals who do not respond to in-offce techniques. 

Special needs dental patients often present with unique challenges. Some of these challenges might be more significant than others and require significant modifications to the usual course of dental care delivery. However, the key to treating all special needs individuals is patience — taking the time to let the patient become familiar with the dental environment and allowing the patient to become comfortable in their surroundings. As a profession, it is our duty, responsibility, and most profound privilege to champion the oral health of patients with special needs.