Dental Professionals Treating Children with Special Needs

Oral Health Guidance for Dental Professionals for Children with Special Health Care Needs & Their Caregivers

Children with Special Health Care Needs (CSHCN) are defined as “those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.” (HRSA Maternal and Child Health Bureau) Examples of conditions these children may have include: asthma, autism spectrum disorder, cancer, cerebral palsy, Down Syndrome, cleft lip and/or palate, cystic fibrosis, attention deficit hyperactivity disorder, prematurity, speech/language delay, sickle cell anemia, diabetes, juvenile arthritis, epilepsy, blindness, hearing loss, gross and/or fine motor delay. (Washington State Department of Health CSHCN Program)

The term “disability” means, with respect to an individual, a physical or mental impairment that substantially limits one or more major life activities of such individual; a record of such an impairment; or being regarded as having such an impairment. (Americans with Disabilities Act – ADA 1990)

Oral health needs vary considerably among children with special health care needs.

To provide the best care possible, dental professionals may need more information from parents or caregivers about a child’s specific needs. Oral health may not be a priority for families who are attending to the child’s other considerations. Keep in mind the following when working with families:

• 18% of children in Washington State have a special health condition.
• Be sensitive to the time constraints of Parents/Caregivers of CSHCN since they have to deal with the multiple needs of their child.
• Be culturally sensitive and responsive.
• Actively include parents in the decisions about their child’s care.
• Be flexible in scheduling appointments.
• Be aware of other resources in the community that may be helpful for the family.

Help parents understand the road to good oral health for their child by educating them on:

Oral environment

• Provide information about oral development, teething issues and specific oral issues related to their child’s special needs.
• Show parents how to look in their child’s mouth, become familiar with what are normal conditions so they can identify unusual conditions necessitating a professional visit.
• Provide information on the increased incidence of caries and periodontal disease in some children with special needs.

Home care

• Demonstrate appropriate brushing and flossing techniques for the child and parent/caregiver. Offer handouts whenever possible.
• Ask parents to demonstrate how they clean and inspect their child’s mouth, and discuss problems they encounter.
• Discuss use of power toothbrush and adaptive aids that may be helpful based on specific conditions. Caution parent when using a power toothbrush as it may be too stimulating for some children.
• Suggest caregivers establish a routine such as the use of the same positioning, timing and location for daily oral hygiene activities.
• Advise brushing the child’s teeth twice a day with fluoride toothpaste.
• Brainstorm with parents to arrive at realistic solutions.
•  Encourage parent/caregiver to find a toothpaste their child will tolerate. Try different toothpastes—both for taste and foaming action (Sodium Laurel Sulfate). Explain that toothpastes vary in taste and in amount of foam; and that Fluoride is the essential ingredient for decreasing caries.

Nutrition

• Remind parents to discourage the consumption of cariogenic foods and beverages. Limit frequent snacking unless medically necessary.
• Discuss inspecting the child’s mouth after eating or administering medication to prevent pouching. Rinse with water and sweep mouth with a finger wrapped in gauze to remove food.
• Discuss other feeding practices such as overuse of baby bottles and cariogenic foods as rewards. Contact the child’s feeding therapist if additional caregiver support is needed.

Dental care

• Obtain consent from the legal guardian and choose the least restrictive technique to treat child.
• Obtain the prior dental experiences of the parent and child. Clarify family’s expectations of treatment.
• Be clear about your own expectations. Decide if parent or caregiver can decrease child’s fear by being in the operatory.
• Review with parents the child’s exposure to fluoride sources to maximize prevention benefits.
• Recommend professionally applied preventive measures such as topical fluoride and sealants based on the child’s risk assessment.
• Prescribe additional disease prevention measures (e.g., chlorhexidine, xylitol) as appropriate.
• Provide written protocols for use post-dental trauma (e.g., seek immediate professional care and locate/ preserve missing tooth if avulsed).
• The American Dental Association, the American Academy of Pediatric Dentistry and the American Academy of Pediatrics recommend that children with special needs establish a dental home, that is a place to receive routine dental care, 6 months after the first tooth erupts or by 1 year of age (whichever comes first).

Other

• Communicate with primary care physician, nurse, feeding therapist for helpful information regarding the child’s special needs.
• Recommend that parent ask physician to prescribe sugar-free medications.
• Recommend rinsing with water thoroughly after taking each dose of medication containing sugar and suggest frequent water intake for children taking xerostomic medication.
• Advise rinsing mouth with plain water four times a day to mitigate effects of gastric acid in children with GERD.
• Discourage consumption of sugary snacks and drinks (juices, pop) and avoid using them as rewards. Ask caregiver to look at labels on food products for words ending in “ose” such as “fructose” and “sucrose” and limit their use.
• Advise parent/caregiver to not share utensils, cups and toothbrushes with the child to avoid transmitting bacteria causing dental disease. When using pacifiers, advise not dipping in honey or any sugary liquid. Clean it with water. Advise not serving juice in sip cups, just in open cups; if child goes to bed with a bottle,
  fill with water only.
• Recommend preventive measures such as fluoridated water, topical fluorides and sealants.
• Discuss safety measures such as the use of seat belts, stair gates, bike helmets, and mouth guards to prevent oral/facial trauma and injuries. • Appreciate the challenges that the family might face in obtaining dental care.
• Assist the dental office staff in understanding considerations and needs of children with special needs.
• Make dental office accessible and safe for all children who may have physical limitations.