BACKGROUND

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In 1997, the U.S. Census Bureau reported that nearly 20 percent of the U.S. population had some type of disability, with approximately 12 percent of the population considered severely disabled (that is, reliant on crutches or a wheelchair for mobility, having a mental or emotional condition that interfered with independent functioning or receiving federal benefits due to an inability to work).²

Not surprisingly, severe disability becomes more common with age; the 1997 Census Bureau report stated that nearly 38 percent of those aged 65 years and older reported having a severe disability.² Since the baby boomer generation has created a swell of aging Americans—experts predict that by 2030 one in five adults will be at least 65 years of age³—the coming years also may see an increase in the number of special-needs dental patients.

For a variety of reasons,⁴ the special-needs population has difficulty accessing dental care. In addition to the challenges a disability may present a patient in actually getting to a dental office, special-needs patients also often are unable to pay for dental care. More than 1.5 million mentally retarded or developmentally delayed adults rely on Medicaid for healthcare coverage, which does not include dental care.⁵ The effort to bring these adults with disabilities out of institutions and into communities also has created unintended barriers to dental care. Between 1967 and 1997, the number of such adults who live in institutions dropped by 75 percent.⁶ While living in smaller, community-based settings is invaluable in providing a normalized existence, it also decentralizes access to services such as dental care.

	ORAL CARE IN A STATE-RUN RESIDENTIAL FACILITY

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Lakeland Village Nursing Facility is a state-run institution for developmentally disabled adults in Medical Lake, Wash. The facility provides full-time services and habilitation for 269 residents, including training in activities of daily living, adult training and high school completion courses.

Population. The residents at our institution have a variety of physical diagnoses. About 30 to 40 percent have genetic conditions such as Down syndrome, cerebral palsy and phenylketonuria. Dual diagnoses, such as mental retardation and mental illness (schizophrenia, bipolar disorders and so forth), affect approximately 10 percent of the population. About half of the residents suffered disabling brain injuries at birth or later in life (anoxia, encephalitis, high fever, being physically dropped or shaken, or other head trauma). While a few clients function at a higher level mentally, they are socially disabled and therefore are unable to function in society or live independently.

Dental services. The dental staff at a state-run residential care facility such as ours may be modest or nonexistent. Our staff consists of a dentist, a dental hygienist and two dental assistants. Our primary concern is for the safety and health of the patient and the companion or facility staff member who accompanies them to the appointment. To that end, the dental team has been trained in dentistry for disabled people and in providing supportive care for such patients’ other needs. Since many special-needs patients have difficulty tolerating dental treatment on an emotional or behavioral level, I, as the dentist, am licensed in conscious sedation and analgesia techniques.

Treatment needs. Care provided for residential patients extends across the range of dental services. Often, these services need to be provided quickly and efficiently as the attention span of the patient and the duration of sedation may only allow a short treatment time (approximately 15 minutes).

Primarily, treatment revolves around tooth cleaning and periodontal care. Most of our patients have periodontal disease because their home-care abilities are limited. In addition to range-of-motion restrictions, these patients often have habits that may minimize their self-cleansing abilities (for example, pocketing food in the cheeks, habitual tongue movements, swallowing habits or mouth breathing). The residents are seen every three months for regular examinations and cleanings (including scaling and prophylaxis). Clients who are fed internally (via tube) tend to have increased levels of calculus and require more frequent calculus removal.

Caries management is the second most common dental treatment provided at our facility. Factors such as food impaction, regurgitation, xerostomia, and abrasion secondary to bruxing and grinding all affect the dentition and our ability to restore the teeth. We often treat patients who have lost restorations because tooth wear has resulted in loss of enamel support.

Other treatments are provided less frequently. For example, endodontic treatment occasionally is required and must be completed in stages. Crowns, bridges, and partial and complete dentures are made as needed based on the patient’s ability to tolerate the procedure or the prosthesis. In general, we try to help patients maintain their dentition as long as their teeth can remain healthy and are not painful. Unfortunately, extractions are needed at times; however, the inability of special-needs patients to tolerate replacement teeth can create a treatment planning challenge. Furthermore, oral or structural constraints or behaviors and such patients’ general intolerance of oral manipulation can limit the available treatment options.

Typical appointment. The typical dental visit for residential clients begins as they arrive at the oral care clinic. Some will arrive in a wheelchair, which is required if sedation is to be used. To help relax the patient, a dental staff member greets and welcomes him or her, escorting the patient into the treatment room. Vital signs are measured and recorded.

We make every effort to establish a relaxing atmosphere in the treatment area. Before the patient arrives, the dental chair is covered with a soft massage pad that has a plastic barrier in place over it. This full-length vibrating massage pad (Homedics, Commerce Township, Mich.) is used as a relaxation tool.

The operatory has soft illumination, and soft music plays quietly in the background. In addition, we have incorporated aromatherapy into the dental care setting, using essential oils that are intended to help people relax. Once the patient is situated in the dental chair, the chair is reclined and the massage pad is activated. Head and neck massage also may be given by the dental assistant, if he or she is trained in massage. Hand or foot massage, when appropriate, also may be given by the attendant counselor, or AC, from the residence who accompanies the patient and who also may be trained in massage techniques.

(A note about the use of massage: At our institution, the guardians of each client sign a general consent form each year that grants permission for the staff to provide treatment. There are licensed massage therapists on staff, but they usually work in areas other than the dental clinic. They are available to our clinic to train the dental staff and to provide massage services on an as-needed basis. Permission for the use of massage can be arranged with the guardian before the patient arrives at the dentist’s office. In general, consent forms provide permission for the doctor and other associates and assistants to provide whatever treatment is necessary.)

When necessary, sedating medication may be given orally before the patient comes to the appointment, or it can be given intramuscularly (in the deltoid or gluteus muscle) by a registered nurse trained in sedation once the patient is settled in the dental chair. The patient is not left alone once sedated. The dental assistant remains in the operatory and monitors the patient’s vital signs. The AC who accompanies the patient stays in the operatory while the sedative takes effect to maintain personal contact and provide reassurance.

Once the client is calm and drowsy, treatment is provided. Cleanings are done using an ultrasonic scaler to remove plaque, staining and calculus. The units used in our clinic have a separate water source that supplies the power scaler with a chlorhexidine oral rinse. The three-way syringe also dispenses this antimicrobial solution. The AC or the patient’s companion may hold the patient’s hand to provide reassurance and encouragement during the treatment.

The patient may require the use of a soft wrap with nylon fastners (Velcro, Velcro USA, Manchester, N.H.) across the lap or shoulders to prevent him or her from rising up or rolling from the chair during treatment. This provides a measure of safety for the client. Vital signs are monitored during the procedure and are recorded again at the end of the appointment. If sedation has been used, the client is transferred by wheelchair to the recovery room for postoperative follow-up with the nurse. The patient is released to his or her living quarters when he or she is responsive and the vital signs are stable.

	PROVIDING SPECIAL CARE IN THE GENERAL DENTISTRY PRACTICE

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Care for special-needs patients requires dental skills that are up to date. Services should be delivered with even more patience and empathy than are used with patients who are not developmentally disabled. The following tips illustrate that the practitioner needs special equipment less than compassion and tolerance.

Use your pediatric care training. General dentists who would like to begin treating special-needs patients might find it useful to recall their training in pediatric care and try some of those techniques for handling movements and behaviors in patients with developmental disabilities. Smiling and acting playful can make the provision of care seem less threatening.

Take your time. Perhaps the greatest consideration that should be recognized is that more time is required to provide simple services for special-needs patients than for nondisabled patients. To help yourself relax—which in turn will help the patient relax—schedule more time than typically is required for the procedure planned. Although you may be able to perform the dental procedure quickly, the behavior management of the patient often will require more of your time and patience. Talk to the patient’s care-giver ahead of time, if possible, so that you can become acquainted with the usual limits of the patient’s attention span. The average span for most patients in this population is about 15 to 20 minutes.

Do a little of the procedure at a time. For example, use the mirror and explorer to count (examine) a few teeth on one side, and then let the patient rest before counting on the other side. Also, allow the patient to get used to what you are doing and the sensation of having someone else’s fingers in his or her mouth. An adjustable mouth prop can help to maintain the mouth in an open position and prevent trauma to the fingers of the dentist or assistant. If you will be using a mouth prop, put it in place and allow the patient to become accustomed to it before opening it up and beginning to work. Clean a few teeth or prepare a tooth, then allow the patient to rest before finishing the procedure. Giving the patient time to adjust to the activity at hand allows for desensitization and for an easier appointment next time.

Speak the patient’s language. Communicating with a person who has special needs also often requires patience. The mental age of these patients may range from 6 months to 6 or 7 years in bodies that are 20 to 80 years of age, and it may be easy to forget that they do not communicate like other adults. The caregiver or guardian can help you get a feel for a patient’s level of functioning and can be helpful in addressing the patient’s individual communication needs. When possible, talk to the patient on his or her level of understanding. Simple sign-language skills are helpful when working with hearing-impaired or nonverbal clients.

Practice show, tell and do. Throughout the appointment, break the procedure down into small steps. At each step, show the patient what you plan to do as you tell him or her about this step; then perform the procedure in stages.

Establish a relaxed atmosphere. Communicating in a soft voice and using a gentle touch will go a long way toward helping the patient relax.

At our residential facility’s oral care clinic, we recently introduced massage therapy to help our patients relax and have had good results. Perhaps this could be considered for general dental practices for all apprehensive patients—not just those with developmental disabilities. A review of client management techniques had shown that many clients were agitated during simple dental procedures. These clients required presedation, sedation and manual restraint to undergo procedures safely. As a result of the review, we found that about 30 percent of our clients were receiving sedation for dental work. Additionally, there were others who routinely required mechanical positioning devices. A number of clients also required presedation to be calm enough to be cared for safely in conjunction with the sedation and positioning devices. We were looking for a way to reduce the use of chemical or mechanical restraints. Massage therapy seemed to provide a way to relieve anxiety and help calm the patient and decrease the amount of chemical or mechanical restraints used during the dental procedure.

As a result of using massage therapy during dental treatment, we have recorded a decrease in resistant behaviors and a more positive response to treatment. Presedations have been reduced to almost zero. The dosage for sedation has been reduced by one-third to one-half the amount used previously. Use of the mechanical positioning device also has been drastically reduced (again, to almost zero). Patients who are relaxed as a result of massage seem less resistant and more receptive to dental treatment. Recovery times for patients who do require sedation have been reduced as well.

Massage therapy can include head and neck massage as well as hand or foot massage by a massage therapist. The dental staff can be trained in simple massage techniques to assist the massage therapist. We also use aromatherapy in the dental clinic to help our patients feel more comfortable. Essential oils purported to have calming properties are diffused in the operatory for relaxation benefits, and oils with stimulating aromas are diffused in the recovery area to refresh the patients after dental treatment. A vendor custom-blends essential oils for us, keeping in mind the special needs and limitations of our clients.

Establish a comfortable work area. No specific equipment is required to treat special-needs patients. The room, however, should be big enough to accommodate a wheelchair and still provide space for the patient’s companion to sit and reassure him or her, and for the dentist and the assistant to move about and work above the patient.

In our operatory, we occasionally slide our regular dental chair to the side to allow access for wheelchair and gurney-type block chairs. This permits us to work with the client in his or her own chair.

I use a headlight in conjunction with an operatory light. Often, clients will turn their heads repeatedly, and the headlight allows me to have light wherever I’m looking. The headlight also is useful if I have to stand up and work over a wheelchair.

The techniques used for performing a dental procedure are the same as those used for dental patients who do not have developmental disabilities, but these special patients may require more stabilization of the head. At times, an additional assistant is needed to hold the patient’s head steady. Good finger rests and retraction of the cheeks and lips also are necessary to provide proper care.

Rinsing and suctioning by the dental assistant are essential. The clients may have enlarged tongues and/or swallowing difficulties, which may cause them to react unexpectedly when fluids are in the mouth. Some clients may not have gag reflexes and can be silent aspirators, which places them at risk of developing pneumonia after dental care. Other clients regurgitate on a regular basis or may self-induce emesis. In all these cases, responsive suctioning is critical to the provision of safe care.

	CONCLUSION

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As the U.S. population with special needs increases, more general dentists are likely to find that such patients require their services. While the prospect of accommodating the needs of patients with disabilities may seem daunting initially, such treatment actually can be incorporated into a general dental practice easily.