Virgen Milagrosa University Foundation Dr. Martin Posadas Ave., San Carlos City, Pangasinan

COLLEGE OF DENTISTRY

Sy. 2015-2016

ORTHOPEDO SEMINAR 1 REPORT

PRESENTED BY: Ma. Hermie Culeen F. Barapon

PRESENTED TO: Dr. Ma. Mildred L. De Vera

MANAGEMENT OF THE HANDICAPPED CHILDREN

I. FIRST DENTAL VISIT

a. Schedule patient at designated time (early in the day)

b. Allow sufficient time to talk with the parents and patient before initiating

treatment

II. RADIOGRAPHIC EXAMINATION

a. Occasionally, assistance from the parent and dental auxiliaries and the

use of immobilization devices may be necessary to obtain the films

b. Better cooperation may be elicited on second visit

c. For patient with limited ability to control film position, intraoral films with

bite-wing tabs are used

d. Patient should be wear lead apron with thyroid shield

III. PREVENTIVE DENTISTRY

A. HOME DENTAL CARE

a. The dentist is responsible for the consulting with the caregiver of the

child with disabilities

b. Home dental care should begin in infancy

c. Some of the positions most commonly used for children requiring

oral assistance

d. Electronic toothbrushes

B. DIET AND NUTRITION

a. Influence caries by affecting the type and virulence of

microorganism in dental plaque, the resistance of teeth and

supporting structures, and properties of saliva in the oral cavity

b. Conditions with difficulty in swallowing (cerebral palsy) – pureed

diet

Dental Management Of Handicapped children

c. Metabolic disturbance – diets restricting total caloric consumption

d. Discontinuation of nursing bottle – 12months

e. Cessation of breastfeeding – after teeth begin to erupt

C. FLUORIDE EXPOSURE

a. Patient with disabilities who has poor oral hygiene – daily rinsing of

0.05% NaF 0.4% Stannous fluoride brush on gel at night

D. PREVENTIVE RESTORATION

a. Sealants are appropriate for patient with disabilities

b. Deep occlusal pits and fissures should be restored with long

wearing composites to prevent further breakdown and decay

c. Patient with bruxism and interproximal decay – restore with stainless

steel crowns

E. REGULAR PROFESSIONAL SUPERVISION

a. Although most patient are seen semiannually for professional

prophylaxis, examination and topical fluoride application, certain

patient can benefit from recall examinations every 2, 3 or 4 months.

IV. MANAGEMENT OF A CHILD WITH DISABILITIES DURING DENTAL TREATMENT

A. TREATMENT IMMOBILIZATION

o INDICATIONS:

Patient requires diagnosis or treatment and cannot cooperate

because of lack of maturity

Patient requires diagnosis or treatment and cannot cooperate

because of mental and physical disabilities

Patient requires diagnosis or treatment and does not cooperate

after other behavior management techniques have failed

The safety of the patient/practitioner would be at risk without the

use of protective immobilization

o CONTRAINDICATIONS:

Cooperative patient

Patient who cannot be safely immobilized because of underlying

medical or systemic conditions

o PHYSICAL AIDS TO KEEP MOUTH OPEN:

Wrapped tongue blades

Open wide disposable mouth props

Molt mouth props

Rubber bite blocks

BODY EXTEMETIES HEAD

Papoose board Posey straps Forearm-body support

Triangular sheet Velcro straps Head positioner

Pedi-wrap Towel and tape Plastic bowl

Beambag dental chair

inself

Extra assistant Extra assistant

Safety belt

Rainbow stabilizing system

B. NITROUS OXIDE ANALGESIA

With the handicapped child, inhalation analgesia with nitrous oxide can

be a safeand effective method of decreasing apprehension or resistance to

dental treatment. Except for children who have severe mental retardation or

emotional disturbance, there are few contraindications to its use.

C. GENERAL ANESTHESIA

Indications for general anesthesia:

1. The uncooperative child who resists treatment after all conventional

management procedures have been tried.

2. The child with a hemostasis disorder who needs extensive dental service.

3. The mentally retarded child so severely handicapped that dentist-patient

communication is impossible.

4. The child suffering from central nervous disorders manifested by extreme

involuntary movements.

5. The child with severe CHD who is considered incapable of tolerating the

excitement and fatigue of extensive dental service.

I. MENTAL DISABILITY

General term used when an individual’s intellectual development is

significantly lower than average and ability to adopt to the environment is

consequently limited

o SEVERE SUBNORMALITY (IDIOT) – IQ OF 0 - 19

o MODERATE SUBNORMALITY (IMBECILE) – IQ OF 20 – 49

o MILD SUBNORMALITY (MORON) – IQ OF 50 – 69

CLASSIFICATION OF MENTAL RETARDATION

o DENTAL TREATMENT OF PERSON WITH MENTAL DISABILITY

1) Give family brief tour of the office before attempting treatment

2) Be repetitive; speak slowly and in simple terms

3) Give only 1 instruction at a time. Reward the patient with

compliments

4) Actively listen to the patient

5) Invite the parent into operatory for assistance and to aid in

communication with patient

6) Keep appointments short

7) Schedule the patients’ visit early in the day.

A. DOWN SYNDROME

Best known chromosomal disorder and is caused by presence of three copies

of chromosome 21.

Have underdeveloped midface creating a prognathic occlusal relationship

Medical conditions occurring include cardiac defects, leukemia and upper

respiratory infections.

Oral findings include mouth breathing, open bite, macroglossia, fissured lips

and tongue, angular cheilitis, delayed eruption times, missing and malformed

teeth, oligodontia, small roots, microdontia, crowding and low level of caries

Children with down syndrome experience a high incidence of rapid

destructive periodontal disease

B. LEARNING DISABILITIES

Applied to children who exhibit a disorder in one or more of the basic

psychologic processes involved in understanding or using spoken or written

language.

May be manifested in disorders of listening, thinking, talking, reading, writing,

spelling or arithmetic

Includes condition that have been referred to as perceptual handicaps,

brain injury, minimal brain dysfunction, dyslexia, and developmental aphasia

C. FRAGILE X SYNDROME

Common inherited form of mental disability and autism

The defect is an abnormal gene on the terminal portion of the long arm of an

X chromosome

A history of developmental delay and hyperactivity, and physical features

such as prominent ears, long face, prominent jaw, high arched palate,

flattened nasal bridge, hyperex tensible joints, flat feet, cardiac murmur,

simian creases of the palms, post adolescent macroorchidism in males.

Behavior features such as hand slapping, hand biting and poor eye contact

Dental treatment depends on level of developmental delay , cognitive ability

and, degree of hyperactivity

Mild cases may be treated by scheduling short appointments and using

immobilization/ conscious sedation

Severely affected (generalized anesthesia)

D. FETAL ALCOHOLIC SYNDROME

Consumption of 1-3 drinks a day during the first 2 months of pregnancy.

Physical findings include microcephaly, bilateral ptosis, short depressed

midface, flat nasal bridge, short philtrum and thin upper lip

Most of the dental problems associated with fetal alcohol syndrome in

children are related to high incidence of dental and skeletal malocclusions

E. AUTISM

An incapacitating disturbance of mental and emotional development that

causes problems in learning, communicating and relating to others

Manifest during the first 3 years of life

Have poor muscle tone, poor coordination, drooling, hyperactive knee jerk,

strabismus and epilepsy

Children prefer soft and sweetened foods

Because of their tendency to adhere to routines, children with autism may

require several dental visits to acclimate to the dental environment

Use papoose board or pedi- wrap and preappointment conscious sedation

F. CEREBRAL PALSY

One of the primary handicapping conditions of childhood; most severely

handicapping problem affecting newborn

1) SPASTIC

a. Hyperirritability of involved muscles

b. Tense, contracted muscles

c. Limited control of neck muscles

d. Lack of control of muscles supporting the trunk

e. Lack of coordination of intraoral, perioral and masticatory muscles

2) DYSKENETIC

a. Constant and uncontrolled motion of involved muscles

b. Athetosis and choreoathetosis

c. Frequent involvement of neck muscles (excessive movement of

head)

d. Possibility of frequent uncontrolled jaw movement

e. Frequent hypotonicity of perioral musculature

f. Facial grimacing

g. Speech problems

3) ATAXIC

a. Combination

4) MIXED

a. Muscle are flaccid

5) RIGIDITY

a. Muscle are in a constant state of contraction

Neonatal reflexes may persist long after the age at which they normally

disappear. Three of the most common reactions which a dentist should

recognize are the ff:

1) Asymmetric tonic neck reflex

2) Tonic labyrinthine reflex

3) Startle reflex

Manifestations of Cerebral Palsy

1) Mental retardation

2) Seizures disorders

3) Sensory deficits/dysfunction (strabismus : most common visual defects)

4) Speech disorders

5) Joint contracture

Intraoral anomalies more common in patients with cerebral palsy

1) Periodontal diseases

2) Dental caries

3) Malocclusion

4) Bruxism ( common in athetoid CP)

5) Trauma

G. SPINA BIFIDA AND LATEX ALLERGY

TWO TYPES:

1) SPINA BIFIDA OCCULTA

Presents with skin covering an area where tissue protrudes through a bony

cleft in the vertebral column

These children may develop foot weakness or bowel and bladder sphincter

disturbances

2) MYELOMENIGOCELE (SPINA BIFIDA APERTA)

Most sever because spinal cord, spinal fluid, and membranes protrude in a

sac through the defect

Can suffer from hydrocephalus, paralysis, orthopedic deformities and

genitourinary abnormalities

Taking folic acid during 6 weeks of pregnancy can prevent 50% of neural tube

defects

Children with neural tube defects are at high risk for caries secondary to poor

oral hygiene , poor nutritional intake and long term therapy

Ideal time – beginning of a working session such as in the morning or after a

vacation when the office has been closed or after the office has been

professionally vacuumed and cleaned to remove latex – tainted cornstarch

H. EPILEPSY

Various disorders may cause abnormal neuronal discharge in the brain that

may induce a seizure.

If these seizures are recurrent, the condition is termed epilepsy, and may

affect a person by a change in the state of consciousness, an abnormal

sensory experience, tonic or clonic muscular contractions, or a disturbance in

behavioral contractions.

A dental problem peculiar to this condition is fibrous hyperplasia of the

gingiva produced by the anticonvulsant drug Dilantin.

1. PETIT MAL SEIZURE

Characterized by episodes of abrupt, momentary loss of consciousness.

The child has a blank expression and discontinues any voluntary activities

he is engaged in at that time. Duration is approx. 10 secs.

2. GRAND MAL SEIZURE

Has a much more violent nature. Typically the eyes roll up, the pupils

dilate, and the face becomes flushed or pale. Consciousness is lost and

the body is seized by atonic spasm followed by violent muscle

contractions. The dentist is primarily concerned with preventing the child

from injuring himself.

II. RESPIRATORY DISEASES

A. ASTHMA (Reactive Airway Disease)

Very common childhood diseases

Chronic airway disease characterized by inflammation and bronchial

constriction

Diffuse obstructive disease of the airway caused by edema of the mucous

membranes, increase mucous secretions and spasm of smooth muscle

Symptoms: coughing, wheezing, chest tightness, and dyspnea

Patient with taking systemic corticosteroids and those who were hospitalized

or in emergency dept. in the last year should be treated with caution

because they are at higher risk of mobility and mortality

Patient who use bronchodilators should take a dose before their

appointment, and they should bring their inhalers/nebulizers

Hydroxyzine HCl and diazepam may be used to alleviate anxiety

Contraindications: barbiturates, narcotics, aspirin and NSAID’s

Position the child with mild asthmatic symptoms in an upright/ semi – upright

position

Emergency treatment: discontinuing dental procedure, reassuring patient

and opening airway

Administer 100% oxygen while placing patient in upright/ comfortable

position

Keep the airway open, administer patient B2 agonist with inhaler/nebulizer

If no improvement, administer subcutaneous epinephrine

B. BRONCHOPULMONARY DYSPLASIA

Chronic lung disease usually resulting from occurrence during infancy of

respiratory distress syndrome that requires prolonged ventilation with a high

concentration of inspired oxygen

More likely in the premature infant

Some children develop right ventricular hypertrophy (cor pulmonale)

Major causes of death include cor pulmonale, respiratory infections, and

sudden death

If the patient is taking O2 continuously via a nasal cannula, short

appointment with frequent breaks are necessary to prevent pulmonary

vasoconstriction

C. CYSTIC FIBROSIS

Autosomal recessive disorder

Most common lethal genetic disorder affecting whites

The defective gene products cause abnormal H2O and electrolyte transport

across epithelial cells, which results in a chronic disease of the respiratory and

GI system, elevated levels of electrolytes in sweat, and impaired reproduction

function

In the lungs, retention of mucous occurs which causes obstructive lung

disease and increased frequency of infections

Symptoms: increase chest diameter, clubbing fingers and toes, decrease

exercise tolerance and chronic productive cough

Children with cystic fibrosis have a high incidence of tooth discoloration,

mouth breathing, and open bite malocclusion

Incidence of dental caries is low

They prefer to be treated in a upright position and avoid sedative agents

III. HEARING LOSS

The following should be considered when treating a hearing impaired patient

1. Prepare the parent and the patient before the visit a welcome letter

2. Let the patient and parent determine how the patient desires to communicate

3. Assess speech, long ability and degree of impairment

4. Enhance visibility for communication

5. Reassure the patient with physical contact

6. Employ the tell-show-do approach

7. Display confidence

8. Avoid blocking the patient visual field

9. Adjust the hearing aid

10. Make sure the parent/patient understands explanations of diagnosis treatment

IV. VISUAL IMPAIRMENT

Dentists should realize that congenitally visually impaired children need a

greater display of affection and love early in life and that they differ

intellectually from children who are not congenitally visually impaired

Explanation is accomplished through touching and hearing, smelling and

tasting

Hypoplastic teeth and trauma to ant. Teeth are common also gingival

inflammation

DENTAL TREATMENT

1. Determine the degree of visual impairment

2. Find out if companion is an interpreter

3. Establish rapport

4. In guiding the patient to the operatory, ask if the patient desires assistance

5. Paint a picture in the mind of visually impaired child

6. Introduced other office personnel very informally

7. When making physical contact, do so reassuringly

8. Allow patient to ask questions about the course of treatment and answer them

9. Allow a patient who wear glasses to keep them on

10. Invite the patient to touch, taste, or smell rather than tell-show-feel-do

11. Describe in detail instruments and objects to be placed in the patient mouth

12. Because strong taste may be rejected, use smaller quantities

13. Some patient may be photophobic

14. Explain the procedures of oral hygiene and then place the patient’s hand over

yours

15. Use audio cassette tapes and Braille dental pamphlets

16. Announce exits and entrance to the dental operatory cheerfully

17. Limit providers of the patients’ dental care to one dentist whenever possible

18. Maintain a relaxed atmosphere

V. HEART DISEASE

A. CONGENITAL HEART DISEASE

Divided into two groups:

1. ACYANOTIC CHD

Characterized by minimal or no cyanosis, and has 2 major groups:

a. (Ventricular and atrial septal defect) Left to right shunting of blood

within the heart – CM: CHF, pulmonary congestion, heart murmur,

labored breathing and cardiomegaly

b. (Aortic stenosis and coarction of aorta) obstruction – CM: labored

breathing and CHF

2. CYANOTIC

Characterized by right to left shunting of blood within the heart

Cyanosis is often observed even during minor exertion ( tetralogy of

fallot, transposition of the great vessels, pulmonary stensis and

tricuspid atresia)

B. ACQUIRED HEART DISEASE

1. RHEUMATIC FEVER

A serious inflammatory disease that occurs as a delayed sequel to

pharyngeal infection with group A streptococci

Commonly diagnosed cause of acquired heart disease in patient

under 40 years old

Appears most commonly in 6-15 years old

Cardiac involvement is the most significant pathologic sequela of

rheumatic fever and can be fatal or can lead to chronic RHD as a

result of scarring and deformity of heart valves

2. INFECTIVE BACTERIAL ENDOCARDITIS

One of the most serious infections of humans

Characterized by microbial infection of the heart valves or

endocardium in proximity to congenital or acquired heart defects

a) ACUTE

Fulminating disease that usually occurs when microorganisms of high

pathogenicity attack a normal heart, causing erosive destruction of

valves

Caused by staphylococcus, grp. A streptococcus and Pneumococcus

b) SUBACUTE (SBE)

Usually develops in persons with pre existing congenital cardiac

disease or rheumatic valvular lesions

Also caused by surgical placement of prosthetic heart valves

Commonly caused by viridians streptococci, microorganism common

to the oral flora

Embolization is a characteristic feature of infective endocarditis

Symptoms: low irregular fever( afternoon or evening peaks) with

sweating, malaise, anorexia, weight loss and arthralgia, painful fingers

and toes and skin lesions

DENTAL MANAGEMENT

Behavior management techniques are useful and conscious sedation and

nitrous oxide – oxygen analgesia have been proven beneficial in reducing

anxiety in such patient

Cardiopulmonary resuscitation equipment should be readily available

during the appointment

If gen. anesthesia is indicated, the dental procedures should be

completed in a hospital setting

ENDOCARDITIS PROPHYLAXIS

VI. HEMOPHILIA

Collection of several inborn abnormalities of metabolism which manifest

themselves as hemostasis disorders

The most common hemophilic condition is the disorder caused by deficiency

of factor VIII (antihemophilic globulin)

Bleeding may occur from any site, but is most common in the muscles, kidneys,

mouth and joints.

Dental Treatment:

During most routine dental treatment, the dentist must exercise extreme

caution to prevent tissue lacerations.

The use of local anesthesia is contraindicated for these children except when

pain is extreme and then it should be used with caution.

Mandibular block should be avoided.

Tooth extraction should be considered only as a last resort.

VII. CLEFT LIP AND PALATE

CLASSIFICATION:

GROUP I – clefts lying anterior to the incisive foramen

GROUP II – clefts lying posterior to the incisive foramen

GROUP III – combination of clefts of primary and secondary palate

Surgical Treatment: Surgical closure is performed between 2-12 weeks of age

Dental Treatment: Initial visit should be between 2-3 years old. Many of the

patients are mouth breathers, has dental enamel hypoplasia and orthodontic

problems.

Special prosthetic appliances, speech appliances and overlay denture are

useful for these patients.

REFERENCES:

o Avery, David R., et al. Dentistry for the Child and Adolescent 8th ed. Elsevier, 2006.

pg. 526-555.

o Finn, Sidney B. Clinical Pedodontics 4th ed. W.B. Saunders Company, 1973.

Pg.562-589.