THERAPEUTIC APPROACH TO

CHILDREN AND
ADOLESCENTS WITH
SPECIFIC NEEDS
 Course plan
1. Disability - definition, classification.

2. Types of disabilities (particularities of the

therapeutic approach)

3. First consultation

4. Prophylactic treatment

5. Oral-dental pathology

6. Patient approach to the dentist. Anxiety.

Psycho-behavioral approach

7. Sedation
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 Disability

• Physical or mental imbalance that

substantially limits one or more
important vital functions or
activities.

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 Defining Disability/Disability Based on the
Disease's Consequences:
The Wood Sequence

• Deficiencies: Loss of substance, alteration of a psychological /

physiological / anatomical structure or function (eg paraplegia)

• Handicap/Inability: Difficulties or inability to perform basic actions

(physical or mental) or more complex

• Disability: Permanent/Temporary,Reversible,
Stable / Progressive

• Disadvantages: Difficulties or Impacts that a person has in

fulfilling the social roles aspired or which society expects from it. It
results from the interaction between persons with deficiencies or
disabilities and the environment (eg: access to the cabinet)
5
 Classification of Disability
Depending on the extension
• Light: Autonomy
• Moderate: Long-term support, rehabilitation
and social assistance
• Heavy: complete absence of autonomy,
polyhandicap
• Over-handicap: It may occur in those with
a congenital disability that overlaps with a
mental disability.
• Ex: Deafness can cause behavioral
disturbances.
 Classification of Disability
Depending on the Origin
1. Mental Disability:
1.1 Mental Retard
1.2 Chronic Invalidating Psychiatric
Disease
1.3 Psycho-emotional disorders
1.4 Psycho-intellectual disorders
1.5 Behavioral Disorder
2. Motor (cerebral or non-cerebral)
3. Sensitive (Deafness)
4. Somatic or Visceral
5. Aesthetic

Displazie ectodermală
 The main types of disability
1. Mental Retard(USA)/Learning Disability (EU)

2. Down syndrome = Trisomy 21

3. Spectrum Autist

4. ADHD

5. Cerebral palsy = Cerebral motor failure (IMC)

6. Muscular dystrophy

8
7. Sensory deficits
1. MENTAL RETARD(USA)/LEARNING
DISABILITY (EU)
= Deficiency in theoretical intelligence and
social function, acquired before adulthood
IQ <70 (IQ <50 = Severe mental retard)

• Intellectual deficiency
• Adaptation deficiency
• Etiology: genetic factors or acquired at young
age
• Ex .: Sdr. Down, Sdr. X fragile
9
 Syndrome
= a disease or disorder involving a certain
group of signs and symptoms
Eg:
• Trisomy 21 (Down Syndrome),
• Ectodermal dysplasia,
• Sdr. Apert, Crouzon,
• Sdr. Pierre-Robin,
• Sdr. Klinefelter etc.
10
 2. DOWN SYNDROME
= Trisomy 21

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 Down Syndrome
• It is a genetic disorder characterized by
an excess of genetic material due to an
extra copy of chromosome 21, with a
total of 47 chromosomes (46 should be
normal)

• It is the most common chromosomal

disorder
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 Risk factors

• In principle, at any pregnancy there is

a risk of having a baby with Down
syndrome or other genetic disorders.

• However, with increasing maternal

age, the risk increases.
.

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 Other factors that can contribute can also be:

• father's age
• radiation
• alcohol abuse
• excessive smoking
• using oral contraceptives
• viral infection at the time of conception.
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 The facial appearance

- Brahicephaly, short neck, round and flat face

- The eyes are oblique, with delicate folds at the inner corner
of the eye (epicantus) and prominent ocular globe
- White spots on the iris in babies that disappear in the adult
- The base of the nose is flat and wide
- The mouth is always open
- - Macroglossy (Tongue is too big) and often comes out of the
mouth
- Narrow palace and deep palatine bolt
- Small and round ears

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 Mental Retard
• Children with Down syndrome have difficulty learning
to speak, because of hearing loss. Their language is
sometimes difficult to understand.
• In many cases, they need more time to understand
new situations. They have delayed motor
development.
• The limited intellectual capacity, most of the time,
has the intelligence below average.
• In Down's syndrome, the intellectual development of
the child is not dependent only on genetic
inheritance, but also depends on the environment as
well as the intensity of intellectual stimulation.
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13:27 18
 • Approximately 50% of all children born with Down
syndrome are also born with a congenital heart
defect.

• Children with Down syndrome may be affected by a

wide variety of cardiac defects.

• Many of these conditions will require surgery, while

some of the lighter heart conditions may self-
resolve as the baby grows and may only need to be
monitored through regular checks.

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 Compared to children without Down syndrome, children
with DS have a higher risk of:

• Lose Hearing (up to 75%)

• Obstructive sleep apnea, a condition in which a person's
breath stops temporarily during sleep (between 50-75%)
• Ear infections (50-70% may be affected)
• Eyes, such as cataracts (up to 60%)
• Eye problems requiring glasses (50%)
• Cardiac defects present at birth (50%)
• Intestinal blockage at birth - requires surgery (12%)
• Congenital Hip Replacement (6%)
• Diseases of the thyroid (4-18%)

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 Down Syndrome
Considerations for treatment
• The degree of cooperation is dependent
on each individual.
• There are patients who cooperate
selectively only in simple labor (eg
sealing, topical fluoridation), but there
are also patients who cooperate with
the labor complex (eg endodontic
treatment, application of orthodontic
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fixation, etc.). 21
• Associated pathologies are accentuated
over time (eg cataracts) and make it
difficult to read instructions or brush
correctly

• Chronic use of some sweet or

hypoactive drugs predisposes to dental
caries

• Associated immune deficiency favors

periodontal forms more frequently
22
located in inferior incisors.
 Indications
• Dispensarisation from the early age
• Insisting on prophylactic measures
• Dietary counseling
• Brushing instruction, plate revelators,
additional hygiene means
• Regular checks
➔Decreased incidence of caries and
slowing progression of periodontal
disease
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 3. Spectrum Autist

• 3.1. Autism

• 3.2. Asperger's Syndrome

• 3.3. Fragile X syndrome

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 3.1. Autism

• Incidence-6/1000, more common in men

• Emotional imbalance and intellectual problems,

communication and socialization issues.

• Repetitive stereotypes related to behavior,

interest, imagination

• It is manifest in the first 3 years of life

25
 3.1. Autism

• +/- hyperactivity, sleep problems

• About 50% fail to use the spoken

language

• Epilepsy Risk

26
 3.2. Aspeger’s Syndrome

• It belongs to the whole autistic spectrum,

just as IQ = normal or> normal

• Social deficiencies, concerns and

specific interests

27
 3.3. X fragil Syndrome

= a genetic disease that causes a number of

developmental problems, including learning
disabilities, communication, behavioral problems
and cognitive disorders.

Dg. is determined by blood tests. Most people

suffering from fragile X syndrome have autism.

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 4. ADHD
Attention Deficit
Hyperactivity Disorder
1. Attention Deficit

2. Motor hyperactivity

3. Impulsive behavior

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 4. ADHD
Attention Deficit Hyperactivity
Disorder
• Affects 3-7% of children and adolescents

• Boys are diagnosed more frequently

• Etiology: genetic field, affection of the

frontal lobe and neurotransmitters
dopamine + epinephrine
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 ADHD Therapy

• Psycho-educational strategies
(educational programs for parents and
teachers)

• Medication: methylphenidate,
amphetamine

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 ADHD - oro-dental health
• Major Goal = PREVENTION

• + Encouraging A Positive Attitude +

Accepting Odontal Treatments
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 Treatment strategies
• Concentration Deficit => We help focus by
lowering visual and auditory stimuli (no radio,
no movies, the cabin door closed)

• Instructions directly and on the subject:

• We say "sit in the chair" instead of "Would you

please sit in your chair“

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• Encouragement 33
 5. CEREBRAL PARALYSIS =
Cerebral motor failure (BMI)

Brain damage that causes motor activity.

Cause: prenatal or perinatal, often prematurity

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 IMC

• Etiology:
- cerebral anoxia
- physical trauma
- birth weight <2500 g

• Different clinical forms.

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Variable neurological forms:

• -Ataxic (Balance, Coordination)

• -Hypotonic (Postura)
• -Atetotics (Involuntary Cockpit)
• -Spastics (Muscle Load)
• Mixed forms.
• They often accompany RETARD +/-
EPILEPSY.
 Oral-dental particularities

• Uncontrolled muscle movements =>

• 1. Involuntary trauma

• 2. Malocclusions

• 3. Drain the saliva out of the mouth

• (hypotonia, low head position control)
 • Saliva leakage is sometimes solved by
behavioral therapy, medication, oral
motor therapy, or surgical therapy for
redirection of submandibular gland
ducts to oropharynx => Increases
caries risk!!!
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4. Dental Abrasion

5. Gastro-esophageal reflux erosions

The dentist is frequently the first to

point out a possible reflux, observing
erosions in the palatal faces of the
superior fronts and the occlusal and
vestibular faces of the lower molars
 • Sometimes gastro-oesophageal reflux
is controlled by Percutaneous
Endoscopic Gastrostomy (PEG) but
due to the non-use of the oral cavity
for food, it also results in favoring
dental plaque deposits

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• Sometimes there are self-injuries due to
the pain and discomfort the child can not
communicate

Thermoformed tray to prevent future self-mutilation

(! Lower lip/Left)
!!!Tartar due to exclusive feeding through PEG
(gastrostomy)
Specialized offices that:

• Allow wheelchair access

• Have devices to move the patient out
of the chair into the dental chair
• Dental chairs with special support
pillows
• Units that allow the patient to be
treated in his wheelchair 42
 6. Muscular dystrophy
• Genetic disorder caused by a mutation of
the gene that controls the distrophin
protein => progressive muscle weakness
• It mainly affects the striated muscles but
can also affect the smooth muscles (eg the
intestine)
• The most common: DM Duchenne, DM
Becker, DM facial capuchulum.
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 Oro-dental considerations
• It presents wide arches with tremors
and diastemas due to muscle
hypotony

• Low incision force

• Difficult dental hygiene due to the

decrease in the force of the muscles of
the hand
•Malocclusions due to disruption of the
balance of dental lane forces =>

•Anatomically open bite occlusions

•Mandibular lateralgate with crossed

bite occlusions

•Gingivite due to dental plaque and

posture with open mouth
 • RISKS

• Breathing difficulties !! Risk of aspiration

of water during dental treatment

• Low tolerance for local anesthesia !!!

Use it with caution

• High sensitivity to anesthetic gases to

be avoided!
 7. Sensory deficits
• 7.1 HEAT DEFICIENCIES
• For communication:
• expressiveness,
• Using an interpreter in sign
language
• Tell-Show-Feel-Do
 7. Sensory deficits
7.2. DEFICIENCES OF VISION

Avoiding unexpected noises

Explain all steps

Soothing, refreshing words

 Difficult
Collaboration

Frequent Cause: ANXIETY

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 Anxiety
May lead to:
• Addressing dental treatment only in
emergency situations when pain becomes
unbearable;

• The painful patient is in an uncomfortable

situation that exacerbates anxiety;

• The doctor has to start communicating for

treatment from an already tense situation.
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 Criteria for assessing subjective
anxiety
and
behavior:
Patient Assessment? maturity, fear,
cooperation

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 Family assessment? motivation, willingness to
cooperate, understanding of explanations

Parents arrive with their fears, past

experiences, their history. They often
project these experiences on the child.

Anxiety Contagious !!
Sometimes the parent exerts pressure on
the doctor about how to apply the treatment
plan.

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 Anxiety manifestations:
• - In young children: - Shouts
- Tears
- Gems
- Gestural manifestations
- Somatic manifestations
• - For older children
- The posture: the heels of the feet, the hands tied
- Attitude: Silence (mutism),
- Concern, Worry, Impatience, “Ready?”
- Determined not to cooperate "I will not open my mouth
- Aggressive (turn your head to the opposite side, push
the instruments, etc.)
- 12-13 years, he does not cry, he does not fight, but he
13:27 plays with the words, he answers acid, defies the doctor 54
 Premize pt. Pacient dificil- context
- A very young child (0-5 years old). (Ą5 years, the child is more
accessible to communication)
- A child with policemen, bottle nurseries (the childhood caries)
- Numerous treatment sessions, cooperation has reached exhaustion.
- A child who is afraid, anxiety, phobias, even without previous
experience
- Parents anxious
- A child with mental disabilities, difficult communication
- Psychological immaturity, education without limits / restrictions
- Difficult social and family context (placement centers, abused
children)
- A child suffering
- A tired child
 STAGES OF TREATMENT
1. Consent of Consumers

2. Pediatrician's opinion

3. Reduce infectious risk

4. Reduce pain

5. Restorative treatment

6. Means of prevention / prophylaxis

7. Collaboration of the medical team

 FIRST CONSULTATION

1. Obtain informed consent from the

claimants

2. Medical history and information from

the attending physician

3. Preliminary assessment of the patient

(11 points)
1. Assessment of mental abilities and patient communication
• We talk to the accompanying person
• The patient should always be treated with respect

2. Behavioral Disorders often related to Fear and Anxiety

• Fear of dental treatments:
• Fear of pain.
• Fear of betrayal.
• Fear of the unknown (practitioner, situation).
• Fear of losing control.
• Fear of intrusion into the oral cavity.
• Anxiety: the result of a long process, unresolved fears, can be the
result of a medical, dental, family history.
Behavioral approach
3. Mobility Disorders
• We inform about posture requirements.
• Whether or not it can be transferred from the
wheelchair to the dental chair.

4. Neuromuscular disorders
• Reflection: anxiety-related nausea => Behavioral
management approach, morning consultation.
• Dysphagia: Position as vertical as possible.

5. Uncontrolled movements of the body, often

reproduced exactly, steriotomy;
• Instruments should be placed outside the patient's area
of action.
• Quiet and soothing environment.
6. Cardiac diseases
• Prophylaxis with antibiotics according to protocols.

7. Gastroesophageal reflux, common in the case of

cerebral palsy => dental sensitivity due to erosion
• It is recommended to rinse with fluoridated solutions
4 times / day

8. Epilepsy - assesses the frequency and extent of

seizures, the treatment of the background
• If the trigger factors are known, for example,
avoiding them (stress ?!)
• If a crisis occurs, interrupting dental treatment and
positioning the patient in lateral safety.
• 9. Deficiency of sight and blindness, addressing
other senses, especially touch and hearing
• 10. Loss of hearing and deafness
• Rotating instruments may interfere with hearing
aids
• Remove the mask if the patient reads on the lips
Continuously maintains visual contact
• The presence of an interpreter for sign language
• 11. Allergies or latex sensitivity
• Frequently patients who have had multiple
surgeries
• Latex-free materials and gloves,
• Early morning consultation, because allergens are
less in the air, possibly on a Monday
 • Need for treatment
• Postpone treatment-progressive
progression to worsening!
• Impact on quality of life
• Influences on patient's
psychosocial sentiment
• Very Important Prevention!
• Follow-up of maxillo-facial growth
and development
• SEALING all cuspid teeth + incisors
to the cingulum
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 PROFILACTIC TREATMENT
1. Oral hygiene

2. Proper diet

3. Topical applications with fluorine/fluoride

systemic

4. Sealing

5. Auxiliary toiletries
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6. Periodic checks
1. Recommendation of topical fluoridation every 3 months
(Ex Duraphat®).

2. Sealing the ditches and fossils of all cuspid + incisive

teeth to the cingulum.

3. Warning parents and caregivers on medicines containing

sugar or reducing salivary flow, indicates rinsing with
water after each use.

4. Offering alternatives to food and cariogenic drinks !!!

5. Suggestion of non-food rewards.

6. !!! Attention to nocturnal feeding with the bottle, for

prolonged breastfeeding (increased risk for nipple
feeding or feeding bottle> 1 year old)
7. Encourage the independence in everyday oral
hygiene, possibly, someone to finish and control the
brush initiated by the patient. If the patient is unable,
you should instruct the caregivrs..
8. Highlighting the importance of repetitive technique
and ritual.
9. If is necessary, adjust the toothbrush, "foam
handle", electric toothbrush
 Oral-dental pathology
1- Dental caries
•Often common in patients with disabilities due to
problems associated with diet, medication, hygiene or
"difficult" child, refractory to treatment
2- Periodontal disease also occurs in young people
with disabilities.
Predisposing factors:
•poor oral hygiene,
•bad oral habits,
•retard, physical disability,
•gingival hyperplasia caused by certain anti-epileptic,
immunosuppressive drugs
3. Malocclusions

•Dental eruption disorders

•Facial musculoskeletal abnormalities and chewers

•Insufficient development of the jaw

•Mastication and speech can be difficult

•Increased risk of trauma, caries, and periodontal

disease

•Orthodontic treatments are not always feasible

according to common criteria, compromise solutions
• 4. Bad oral habits such as bruxism,
lingual parafunctions, lower lip
aspiration, etc. They are favored,
especially the pro-alveolo-denties and
open bite.

• Voluntary or involuntary self-mutilation

(A POSITIONER/Essix- polishing of
the cusps or composite covering,
injection of botulinum toxin)
Acrylic/silicone vestibular
shield + ring for toning
orbicular muscles
Dr. Bendsen Face Former
• 5. Labial incompetence, favors dental caries and
gingivitis

• 6. Tooth eruption may be delayed, the eruption

sequence is not always respected, possibly
asymmetric eruptions.

• 7.Trauma
They often occur especially in patients with epilepsy
and motor disorders.

• 8. For dental prosthesis patients => Tips for them

and caregivers regarding the hygiene and daily
maintenance of dentures.