A visit to the dentist can potentially be a difficult experience for any child. For a child with special needs, however, a dental visit can present unique challenges. Children with special needs often present to the dentist a background of multiple previous hospital or doctor visits and are therefore especially apprehensive. Extra time and discussion with the patient and the parents are necessary to determine the proper way to go about treating a special needs child.
A parent looking for a dentist who treats children or adults with special needs should first ask his or her own dentist for a recommendation, or look for a local pediatric dentist. All pediatric dental residencies include extensive training in treating children and adults with special needs. These residency programs include clinical and didactic training in pediatric medicine and surgery. Programs associated with hospitals generally treat a large number of special needs children and adults that cannot be treated in the typical office setting. Additionally, some general dentists specialize in treating special needs patients. When calling the office to make an appointment, a parent should tell the receptionist that their child is special needs, and relay the important details. In most offices, more time is allotted to treat special needs patients, or the dentist may want to meet with the parents and the patient first to discuss the expectations for the first visit.
Parents are often unsure whether they need to inform the dentist that their child has a certain diagnosis. There should be no uncertainty with this issue; all health history is relevant and any diagnosis, whether it is physical or developmental, should be included in the health history reported to the dentist. Not only do many conditions have significant impacts on oral health, but some require an antibiotic prophylaxis before a visit. A dentist should be aware of developmental or learning disabilities as such conditions would impact the dentist’s behavioral methods and expectations, as well as the expectations of compliance with oral hygiene routines. There are a large number of developmental, behavioral and physiologic disorders that are seen in children. Some of the most common childhood disorders and disabilities are Attention Deficit Hyperactivity Disorder (ADHD), Cerebral Palsy, Down Syndrome and Autism Spectrum Disorder (ASD).
ADHD is one of the most common childhood disorders and can continue through adolescence and adulthood. The cause is unknown, and though studies have showed a genetic link, ADHD probably results from a combination of factors. Symptoms include difficulty staying focused and paying attention, difficulty controlling behavior, and hyperactivity. Since children with ADHD can have difficulty focusing on one task, as well as following instructions and processing information, a dentist will require either a longer visit or multiple visits for an initial exam and cleaning. A patient with ADHD may have difficulty sitting in the dental chair for the time needed to do a proper exam and may want to touch and hold the instruments. In addition, many of the medications that children with ADHD take have significant pharmacological effects that the dentist should know about before treatment. These include xerostomia, sinusitis, inflammation of the salivary glands and the mucous membranes, gingivitis, glossitis (inflammation of the tongue) and elevated blood pressure. A dentist with experience treating children with ADHD will not misinterpret a patient’s inattention or hyperactivity as a sign of defiance but rather as a manifestation of the disorder.
About one in every 200 babies are born with Cerebral Palsy (CP), which is actually a collection of disabling disorders that impair control of movement caused by damage to the developing brain. There are many types of CP, and they are distinguished based on the extent of the neuromuscular dysfunction. Between 35 percent and 50 percent of all children with CP will have an accompanying seizure disorder and some level of mental retardation. Additionally, learning disabilities and vision, speech, hearing, or language deficiencies are common in children with CP. There are no specific dental or oral conditions unique to Cerebral Palsy, however, some conditions are more common in this patient population than in the general population. These include periodontal disease (due to poor oral hygiene or as a side effect of anti-seizure medication), dental decay, malocclusion and bruxism. Since a patient with CP has involuntary head and limb movements, a dentist may need the parent or an assistant to help stabilize or immobilize the child during a dental visit. If a child with CP is in a wheelchair, very often the dentist will examine the child in the chair. Since the muscular dysfunctions associated with Cerebral Palsy include difficulty swallowing, a dentist will never fully recline a child with CP. A parent should be aware that some sort of mouth prop will always be used when treating a child with CP so as to avoid involuntary jaw movements. The dentist will also introduce new stimuli, such as the overhead light and suction, slowly so as to avoid startle reactions.
In the United States, about 6,000 babies are born with Down syndrome every year. It is one of the most common genetic birth defects, and children with this condition have some degree of mental retardation as well as characteristic physical features. There are associated health problems with Down syndrome that include cardiac defects, leukemia and upper respiratory infections. Children with Down syndrome generally have a lower rate of dental decay but have a high incidence of periodontal disease, as well as delayed eruption of teeth, missing or malformed teeth, fissured lips and tongues, and malocclusion. Parents of a child with Down syndrome should tell the dentist about their child beforehand, including giving the dentist a sense of their general nature and level of cooperation. Many children with Down syndrome are affectionate and cooperative, and an office experienced in treating patients with Down Syndrome will not be surprised if the patient gives each of the staff a hug when coming in and leaving. As with other special needs patients, the dentist will likely dedicate a longer than normal appointment time to see a Down syndrome patient. In general, the emphasis will be on preventative care, possibly with frequent recall and cleaning visits to monitor oral hygiene. For Down syndrome patients who are severely anxious and uncooperative, general anesthesia may be required.
Autism Spectrum Disorder (ASD) is currently one of the most common developmental disorders in children. The CDC estimates that one in 110 children under the age of eight have an ASD. Children with ASD do not generally have unique dental presentations or problems. They do, however, have a higher risk of dental decay since behavioral difficulties make oral hygiene difficult at home. Depending on the patient, some common dental problems associated with ASD are bruxism (grinding), erosion, xerostomia (reduced salivary flow), tongue thrusting, and an increased gag reflex.
A dental visit for a child with ASD may be especially difficult since patients with ASD typically have difficulty with sensory stimuli and communicating their feelings and needs. Since the fear of the unknown elevates the patient’s level of anxiety, a good solution is for the parents and the child to meet with the dentist in the office before the scheduled check up. Since every ASD patient is unique, parents should discuss with the dentist what particular behavioral strategies they have found to be successful with their child. There may be a particular song or television show that relaxes the child, a favorite toy or blanket that can ease anxiety, and in some cases the feeling of being wrapped in the papoose can help calm an autistic patient. During the initial visit the parents and the dentist should walk the patient around the office to familiarize the patient with the new surroundings. The patient should also be allowed to touch the chair and some of the instruments. The initial visit and the subsequent visits should be scheduled during a time of the day when the office is relatively empty, so as to avoid unpleasant stimuli such as crowded rooms and crying children. The visits should be kept as short as possible; the dentist may have to use multiple visits as a desensitization technique to build up to using real dental instruments, so the first visit or two may include brushing teeth with a toothbrush or counting the teeth with a finger.
In general, preparation and good communication between the parents and the dentist are the key factors in ensuring a successful dental visit for a patient with any special needs. It is natural for parents of a child with special needs to have concerns about a dental visit, but it is important to relay those concerns to the dentist and to have an open and frank discussion about what the visit may involve. Working together, the dentist and parents can set realistic goals and expectations for any child’s dental visit.
Talya Gluck earned her BA from Barnard College in 2004. She attended dental school at University of Medicine and Dentistry of New Jersey and went on to complete a two-year Pediatric Dentistry residency in 2011. She is a board-eligible pediatric dentist and her research has been published in dental journals. She lives in NJ with her husband and three children.
By Dr. Talya Gluck, Montville Pediatric Dentistry
