NURSING CARE OF PATIENTS

WITH SPECIAL HEALTH CARE

NEEDS
 INTRODUCTION
Individuals with special health care needs
are those who have physical, mental,sensory,
behavioural,cognitive,emotional and chronic
medical conditions which require health care
beyond that considered routine, and which
involves specialized knowledge, increased
awareness, attention and accommodation.
Their oral health condition may be influenced
by age, severity of impairment and living
conditions.
Intro Contd

Individuals with special needs may have

great limitations in oral hygiene
performance due to their potential
motor,sensory and intellectual
disabilities and so are prone to poor oral
health.
This group of individuals may also not
understand and assume responsibility
for or cooperate with preventive oral
health practices.
DEFINITIONS

Impairments: loss or physiological,

structural or anatomical function.
Disability: any restriction or lack of ability
to perform an activity in a manner or within
a range considered normal for human being.
Handicapped: the disadvantage for a given
individual resulting from an impairment or
disability which limits or prevents the
fulfilment of a role that is normal
depending on age,sex, social and cultural
factors for that individual.
CATEGORIES OF PATIENTS WITH SPECIAL
NEEDS

 Physical Disabilities:- Patients with mobility

impairments e.g cerebral palsy, poliomyelitis,
juvenile arthritis, spinal cord injuries and other
injuries due to RTA.
 Chromosomal Abnormalities:- e.g Down syndrome,
Noonan syndrome, Sturge-weber syndrome, Cridu
chat syndrome, Fragile X syndrome.
 Sensory Disabilities:- this relates mainly to sight
and hearing. e.g visual and learning impairment,
 Craniofacial Disorders:- e.g cleft lip and palate,
treacher collins syndrome, osteogenesis
imperfecta.
 Intellectual Disability:- It’s a broad concept that ranges
from mental retardation to cognitive deficits too mild or
too specific to qualify as mental retardation. Intellectual
disability may appear at any age such as mentally
retarded children and children with learning difficulty.
 Emotional or Behavioural Disorders:- This includes
children that are fearful, anxious, shy and aggressive. eg
autism, selective mutism, hyperactivity disorder,
schizophrenia.
 Other conditions that requires special care includes;
seizure disorders like epilepsy, chronic conditions like
HIV, cardiac and renal problems, asthma, malignant
problem like leukaemia.
PRESENTING ORAL PROBLEMS
 Dental caries; cerebral palsy
 Periodontal disease; (worse in children with low IQ,
the blind and those on phenytoin, down syndrome)
 Trauma to teeth; (high in convulsive child, initial
stages crutches and braces, blind, cerebral palsy)
 Malocclusion; (Down syndrome-class III, cerebral
palsy- classII div 1).
 Anodontia /hypodontia; (CLP and down syndrome)
 Attrition; (bruxism in mentally retarded, cerebral
palsy)
 Hypoplasia; (sensory disability, cerebral palsy)
 Tooth discolouration
 Candidiasis; (chronically ill, long term antibiotics)
 Poor oral hygiene; reduced manual
dexterity, joint laxity, lack of
comprehension of oral hygiene needs due to
mental difficulty (down syndrome), sensory
disabilities – related to learning disability.
 Gingival hyperplasia usually drug induced.
 Spontaneous tempomandibular joint
dislocation (cerebral palsy) .
 Dentofacial mutilation
Special need
Oral trauma attrition
Discoloured teeth malformed teeth
Gingival swelling malocclusion
GENERAL CONSIDERATIONS
 Dental office access: wheel chair ramps,
handicapped packing space, accessibility of dental
offices and operatories.
 Barrier free facilities to accommodate people
with varying kind of disabilites.
 More width doorway and wide corridors
 Clear floor surface with non skid surfaces
 Elevators in buildings with 2 or more floors
 Provision of wheel chair turning space.
 Operatory with moveable dental chair, instrument
control unit and suction.
 Adjustable dental chairs to match various wheel
chair designs.
Role Of The Dental Nurse

 scheduling the timing of treatment

session
 organising patient transport
 arranging access to treatment facilities
 moving and handling patients
 liaising with other health care
professionals
 support of the patient
 physical intervention for the patient
DENTAL/SPECIAL CONSIDERATIONS

MANAGEMENT OF BEHAVIOUR:
Behaviour guidiance of patients with special
needs can be challenging. Demanding and
resistant behaviours may be seen in
patients with mental retardation and
physical disabilities, hence the importance
of behavioural management.
1. Pharmacologic (conscious sedation or G.A)
2. Non Pharmacologic (tell-show-do, positive
reinforcement, modelling, desensitization
etc)
Non pharmacological method of behavioral
management

 Tell-show-do
 Modeling
 Positive reinforcement
 Parental presence/Absence
 Voice control
 Desentization
 Hand over mouth
 Restraint
Management Of Movement

Movement can be abnormal or due to

inability to understand instructions. The
use of immobilization is indicated in the
following situations;
1. A patient requires diagnosis or treatment
and cannot cooperate because of lack of
maturity, mental or physical disability.
2. In resistant and uncooperative children
especially if behaviour modification
techniques have failed.
3. When safety of child or clinician is at risk
without the use of restraints.
Contraindications
 Cooperative patient
 When underlying medical or systemic condition
makes it unsafe.
 Not to be used as punishments
 Not to be used just for convenience of the staff.
The following are commonly used for immobilization;
EXTREMITIES -Posey straps
-Velcro straps
-Towel and tape
-Extra assistant
HEAD; - Fore arm-body support
- Papoose board head positioner
- Plastic bowl
- Extra assistant
BODY; - Papoose board
- Triangular sheet
- Pedi -wrap
- Beanbag dental chair insert
- Safety belt
- Extra assistant
Papoose board pediwrap
Posey circumstraint bean bag
board strap
 Mouth props may also be necessary because
a disabled person may lack ability, or may
not want to keep their mouth open.
Use of a mouth prop not only provides
protection from the patient suddenly
closing their mouth but can improve access
and visibility for the dental team.
Types of mouth props includes:
 Rubber mouth props; with channels for
teeth to rest in and usually a dental floss
is tied onto it so that if it dislodges, it can
be pulled out quickly.
 Molt mouth prop; it’s a ratchet type device
inserted in between upper and lower teeth. It
slowly opens jaw more with a scissors motion.
 Open wide plus mouth prop; sturdy,
disposable, Fam matériel and dis Watergate.
It help keep the mouth open When Needed.
 Home made mouth props; which includes
several tongue depressors put together with
a large amount of tape wrapped around them
for bulk.
Radiographic Examination

Adequate radiographic records are often

necessary in planning dental treatment for
patients with special need. Better cooperation
may be elicited from such patients by
delaying radiography until the second visit.
For patients with limited ability to control
film position, intra oral film with bite wing
tabs are used for all bitewing and periapical
radiographs. An 18-inch length of floss is
attached through a hole made in the tab to
facilitate removal of the film if it falls
towards the pharynx.
PREVENTIVE MEASURES

Home care;
 Toothbrushing (horizontal scrub tech for children
with gross deformities)
 Brush with modified handles (custom fit acrylic,
bent toothbrush handles)
 Electric toothbrush for patients with poor fine
motor skills.
 Use of a fluoridated dentrifice daily to help
prevent caries.
 Brush and floss daily to prevent gingivitis.(floss
holders may be beneficial when it is difficult to
place hands in the mouth).
Diet and Nutrition;
 Dietary counselling should be discussed
with parents or care giver for long term
prevention of dental disease. Dentists
should encourage a non - cariogenic diet.
Fluoride supplementation; Topical fluorides
may be indicated when caries risk is
increased.
Fissure sealants; patients with special needs
benefits from this because sealants reduce
the risk of caries in susceptible pits and
fissures of primary and permanent teeth.
 Chlorhexidine mouth rinse; may be
useful in patients with gingivitis and
periodontitis. For patients who might
swallow a rinse, a tooth brush can be
used to apply the chlorhexidine.
 Care of prostheses
 Periodic regular dental examination;
should be done every 2 to 3 months.
 PROBLEMS ENCOUNTERED IN PROVIDING
CARE
 Structural barriers; willingness of caregivers to
bring patients, transportation, discriminatory
treatment, difficulty locating providers who treat
special needs patient for free.
 Physical barriers; buildings, staircase, provision of
wheel chair ramps, handicapped parking space.
 Attitudinal barriers; priorities and attitudes can
serve as impediments to oral care.
 Medical complications
 After care; cooperation with family, other health
care personnel
 Communication; learning disability, hearing / visual
impairment
CONCLUSION

Children with disabilities may present

challenges that require special
preparation before the dentist and
office staff can provide acceptable
care.
The role the Dental nurse is very
important. Children with special needs
should be treated with care and
compassion.
Making a difference in the oral health of
a person with a form of disability may
go slowly at first, but determination can
bring positive results and invaluable
rewards which i believe will make a
significant impact not only on the
patient’s oral health but on their quality
of life.
THANK YOU FOR LISTENING