GOOD MORNING

MANAGEMENT OF
SPECIAL CHILD

PRESENTED BY
NAZREEN AYUB. K
2018 MDS
PEDIATRIC & PREVENTIVE DENTISTRY
 INTRODUCTION
• Providing care to children with disabilities is a cornerstone of pediatric dentistry
(American Academy of Pediatric Dentistry includes children with special needs in
its definition of the profession).

• Pediatric dentists are uniquely trained to care for all children, including those with
complex dental needs, those who are the most vulnerable, and those who require
behavioral strategies.
• World Health Organization has defined a handicapped person as “one who,
over an appreciable period, is prevented by physical or mental conditions
from full participation in the normal activities of their age groups including
those of a social, recreational, educational and vocational nature”.

• ‘Children with Special Health Care Needs (CSHCN)’.

• Retardation  ‘Challenged’
Mentally retarded & physically handicapped  mentally challenged &
physically challenged.
 DEFINITIONS
• The American Academy of Pediatric Dentistry defines
individuals with special health care needs (SHCN) as those
with “any physical, developmental, mental, sensory,
behavioral, cognitive, or emotional impairment or limiting
condition that requires medical management, health care
intervention, and/or use of specialized services or
programs.”

American academy of pediatric dentistry. Definition of Special Health Care Needs. 2016;40(6):18-19.
• WHO

• A disabled child is one who has a mental, physical, medical or social condition that
prevents the child from achieving full potential when compared to other children
of the same age. Disabled includes all handicapping conditions or combinations
there of that a health professional might encounter.
-Weddell (McDonald and Avery)

• A person should be considered to have a dental disability, if pain, infection or lack

of functional dentition leads to restriction of nutritional intake adequate for growth
and energy needs, delays or otherwise alters growth and development, inhibits
participation in life activities and diminishes quality of life.
- American Academy of Pediatric Dentistry (2014-15)
• A child who cannot, within limits, play, learn, work or do things other children of his
age can do; he is hindered in achieving his full physical, mental and social
potentialities.
- American Public Health Association

• Social Security Disability Insurance Program Defines disability as individuals who

are “unable to engage in substantial gainful activity”.

• An individual is disabled if he:

 Has a physical or mental impairment that substantially limits one or more major
life activities.
 Has a record of such an impairment.
 Is regarded as having such an impairment.
- Americans Disabilities Act of 1990
 CLASSIFICATION
• SHCN children have been classified as:

1. Frank & Winter (1974)

2. Agerholm (1975)
3. Nowak’s classification (1976)
4. Damle (2000)
FRANK AND WINTER (1974)

 Blind or partially sighted

 Deaf or partially deaf
 Educationally subnormal
 Epileptic
 Maladjusted
 Physically handicapped
 Defective of speech
 Senile.
AGERHOLM (1975)

Intrinsic : An intrinsic handicap is one from which the person cannot be separated.

Extrinsic : Extrinsic handicap is one from which the person can be removed.
e.g:- social deprivation
 NOWAK (1976)

 Physically handicapped (poliomyelitis, scoliosis)

 Mentally handicapped (mental retardation)
 Congenital defects (cleft palate, congenital heart disease)
 Convulsive disorders (epilepsy)
 Communication disorders (deafness, blindness)
 Systemic disorders (hypothyroidism, hemophilia)
 Metabolic disorders (juvenile diabetes)
 Osseous disorders (rickets, osteopetrosis)
 Malignant disorders (leukemia)
 DAMLE (2000)
I. According to disability
 Physical handicap, e.g. monoplegia, paraplegia
 Mental handicap, e.g. Down syndrome
 Sensory handicap, e.g. deafness, blindness
 Medically compromised, e.g. hemophilia, leukemia
 Multihandicap: Multiple handicapping conditions.

II. Related to Dentistry as:

 Handicapped for dentistry - children who fall into the above mentioned
categories.
 Dentally handicapped—with oral abnormality, e.g. cleft lip and palate
 BENBERG et al
• Self-care group
• Partial-care group
• Total-care group
Considering the variations in the types of treatment modalities for
handicapped children and for the convenience of management, they can
be categorized as:

 Developmentally disabled child

 Medically compromised patients.
 PREVALENCE
• No:of disabilities increases with the advancement of age.
• In India, around 6.6 million (24.5%) children are having SHCN
• In the United State of America (USA), the proportion of children with
SHCN is estimated to be 12.5 million or 18% of the child population.

• 6–10% of children in India are born disabled and that possibly one-third
of the total disabled population is comprised of children.

• Only 1% of them have access to school.

• About 80% of children with disabilities do not survive past age 40.
 ORO‑DENTAL PROBLEMS IN CHILDREN WITH
SPECIAL HEALTH CARE NEEDS
• Growth abnormalities and medical conditions may adversely
affect oral health.

• Oral diseases may also have a direct and devastating impact on

the general health of special children.
 Dental Caries

• Uncoordinated chewing, weak & uncoordinated tongue

• Difficulty in performing proper toothbrushing due to limited manual
dexterity
• Diet
• Xerostomia caused by certain medications
• GERD and vomiting
• Gingival hyperplasia and crowding of the teeth are the
risk factors
• Intake of medications containing sugar like flavored
syrups.
Enamel hypoplasia and enamel demineralization
• Hypoplasia usually appears on the middle or occlusal third of the teeth.

• Demineralization from poor oral hygiene and an acidic oral environment occurs
most often near the gingival line.

• Demineralization often is characterized by white spot lesions that are best seen
by “lifting the lip.”
 Tooth Eruption

• Tooth eruption may be delayed, normal, or advanced in

children with SHCN.

• Delayed eruption is more common in children with Down

syndrome and hypothyroidism
 Dental anomalies

• Teeth may vary in shape, size, or number.

• People with Down syndrome, oral clefts, ectodermal dysplasias, or other

conditions may experience congenitally missing, extra, or malformed teeth.

• Teeth with anomalies are usually of cosmetic concern and may increase the
risk for caries.
 Malocclusion and crowded teeth

• More often in children with abnormal muscle tone (cerebral palsy), mental
retardation, and craniofacial abnormalities.

• Malocclusion is the result of disharmonious relationship between extraoral

and intraoral musculature.

• Crowded teeth are more difficult to clean, thereby increasing the risk of
dental caries and periodontal disease.
 Gingival hyperplasia
• In children taking antiepileptic medications for seizures, especially phenytoin.

• Other medications : calcium channel blockers (nifedipine)

& cyclosporine-A.

• Chronic gingivitis from poor hygiene can also trigger or exacerbate

medication‑induced gingival overgrowth.

• Superimposed infection

• Cosmetic concern + impaired tooth eruption + difficulty in chewing +

severe gingivitis.
 Trauma
• More frequently in children with seizures, developmental delays,
poor muscle coordination, and abnormal protective reflexes.

• Some children with special needs exhibit self‑injurious behavior

which may damage oral structures.

• People receiving restorative dental care should be observed closely to

prevent chewing on anesthetized areas.
 Bruxism
• More common and severe in children with cerebral palsy or severe mental
retardation, those who have oral motor habits.

• Lead to enamel loss & difficulty with chewing or tooth sensitivity.

• Wear on the teeth, flat tooth surfaces, headaches, pain, and gingival
disease.
 Early, severe periodontal disease

• In children with impaired immune systems or connective tissue

disorders and inadequate oral hygiene.

• Simple gingivitis results from an accumulation of bacterial plaque

and presents as red, swollen gums that bleed easily.

• Periodontitis is more severe and leads to tooth loss if not treated.

 MANAGEMENT OF DENTAL PROBLEMS IN
CHILDREN WITH SPECIAL NEEDS

It is carried out in three phases:

1. Relief of pain and control of infections

2. Treatment or elimination of existing untreated disease

3. Planning for prevention of further disease.

 GENERAL CONSIDERATIONS
1. Dental Office Access
2. Scheduling appointments
3. Dental home
4. Patient assessment
5. Medical consultation
6. Patient communication
7. Planning dental treatment
8. Informed consent
9. Behaviour guidance
10. Preventive strategies
11. Oral motor function
12. Barriers
 Dental Office Access
• Barrier-free facilities

• More width of doorways (should be 32 inch wider than normal).

• Provision of wheelchair turning space.

• Operatory specifically designed with moveable dental chair,

instrument control unit and suction system.

• Dental chairs should be adjustable to match different wheelchair

designs, etc.
• Parking lot • Elevator 5 inch × 5 inch

• Walk away • Space for wheelchair and

transportation
• Entrance door steps/ground
level • Telephone

• Slope 1:20 • Rest room

• Railing 1:12 • Space in the operatory

• Floor of the entrance (non- • Mobile units

slipping)
• Mobile dental services.
• Entrance calling bell
Figure 25-1 An accessible dental operatory floor
plan designed for either a straight or side
access doorway. (From Bill DJ, Weddell JA:
Dental office access for patients with disabling
conditions, Spec Care Dentist 6:246-252, 1986.)
 Scheduling Appointments
1. Child’s name, age, and chief complaint

2. Nature of SHCN

3. The name(s) of the child’s medical care provider(s)

4. Length of appointment

5. The need for additional auxiliary staff in order to accommodate the

patient
 Dental Home
• Defined as the ongoing relationship between the dentist and the patient, inclusive
of all aspects of oral health care delivered in a comprehensive, continuously
accessible, coordinated, and family-centered way.

- AAPD

• The dental home provides an opportunity to implement individualized preventive

oral health practices and reduces the risk of preventable dental/oral disease
 Patient Assessment
• Chief complaint; h/o presenting illness, which should be updated at each child visit;
family and social histories and a thorough dental history.

• At each patient visit, the history should be consulted and updated.

• Recent medical attention for illness or injury, newly diagnosed medical conditions,
and changes in medications should be documented.
• Comprehensive head, neck, and oral examinations

• Caries-risk assessment

• Individualized preventive program, including a dental recall schedule.

• A summary of the oral findings and specific treatment recommendations

 Medical Consultations
• Medications, sedation, general anesthesia (GA), and special
restrictions or preparations that may be required to ensure the safe
delivery of oral health care.

• Manage a medical emergency

 Patient Communication
• Developmentally-appropriate communication is critical.

• Communicate directly with the patient – acc.to pts level of

perception.

• A parent, family member, or caretaker must be present.

HomeFirst Makaton book for dental procedures (
www.makaton.org)
 Planning Dental Treatment
• Progresses through several steps.
 Informed Consent
• All patients and their legal representatives must be able to provide
informed consent prior to dental treatment.

• This should be documented in the dental record through a signed

and witnessed form.
 Behavior Guidance
• Dental anxiety or a lack of understanding of dental care  may exhibit
resistant behaviors.

• Simple behavior management techniques such as Tell, Show, Do (TSD)

• Protective stabilization, use of mouth props and blocks - helpful in some

patients.

• SHCN with severe behavioral problems  sedation or general anesthesia.

• Marshall et al.  children with autism spectrum disorders (ASD), cooperation for
dental appointments was predicted by parental report of toilet training,
toothbrushing, haircuts, academic achievement, and language.

• Communicative behavior guidance techniques - with short, one-step instructions for

patients with intellectual disabilities.

• Applied behavioral therapy using familiarization and repetitive tasking has been
successful in patients with autism.

• Children with balance disorders such as Down syndrome may accept the chair more
easily if it is already reclined.
• Physical restraints/protective stabilization/treatment immobilization

• Main purpose of restraints is to limit or stop the movements of the

patient’s head, extremities and torso, in controlling resistant patients.

• Informed consent to be taken before use of any type of physical

restraints.
 INDICATIONS
• Un-coperative because of lack of
emotional maturity, but requires
dental treatment.
• Un-coperative because of physically
or mentally challenging conditions.
• When all the other behavior
management techniques failed.
• When there is a risk for the patient or
the practitioner, if physical restraints
are not used.
CONTRA-INDICATIONS
• A cooperative patient
• Patients with underlying medical
conditions which contraindicate the
use of physical restraints
• Treatment immobilization should
never be used as a punishment for
children
 Classification Of Physical Restraints
PART IMMOBILIZED NAME
Triangular sheet
Papoose board
Body Pedi-wrap
Beanbag dental chair insert
Safety belt
Extra assistant
Posey straps
Extremities Velcro straps
Towel and tape
Extra assistant
Forearm body support
Head Head positioner
Plastic bowl
Extra assistant
Molt’s mouth prop
Intra-oral McKesson bite blocks
Wrapped tongue blades
Open wide disposable mouth prop
 Patient in a Pedi-Wrap

Patient confined in a triangular sheet with leg Patient lying in a beanbag dental chair insert.
straps

A, The Olympic Papoose Board (Olympic Medical Corp., Seattle, Wash) secured to a dental chair. B, Patient being
placed in Papoose Board. C, Papoose Board in use.
 Towel and tape on forearm

Proper positioning of the dentist’s hands, forearm, Use of the Olympic Papoose Board head
and body positioner

Posey strap (Posey Co.,

Arcadia, Calif) on wrist
 Protective stabilization aids to keep the patient’s mouth open.
A-Wrapped tongue blades.
B-Open Wide (Specialized Care Co., Hampton, NH) disposable mouth prop in proper position.
C-Molt Mouth Prop (Hu-Friedy, Chicago, Ill) in proper position.
D-McKesson bite blocks.
 Preventive strategies
• Daily preventive care (diet, toothbrushing, fluoridated toothpaste,
fluoride rinses)
• Professionally applied fluoride gel or foam
• Professionally applied fluoride varnish
• Antimicrobials
• Dental sealants
• Oral prophylaxis
 Daily Preventive Care (Diet, Tooth-brushing, Fluoridated
Toothpaste, Fluoride Rinses)

• Non-cariogenic diet & sugar-free liquid medicine

• Modified toothbrush/electric toothbrush & floss holders.
• Fluoridated toothpaste:
Smear  infants & children under <3yrs
Pea‑size  children aged >3yrs
• Fluoride rinses – alcohol-free, with cotton-swab.
‘Superbrush’ Collis Curve brush
 Professionally Applied Fluoride Gel Or Foam &
fluoride varnish

Topical fluoride application in disposable trays. Application of fluoride varnish

 Antimicrobials

• Chlorhexidine (CHX) : gels, gum, varnishes, and rinses, and in

various concentrations
 alcohol‐free solutions with 0.12% or 0.06% CHX can be used.
 2% chlorhexidine can be diluted 1:1 with water.
 very uncooperative, CHX in a spray form / applied as a gel on a
finger directly or with a finger brush.

• Xylitol : additive dental caries preventive effect with fluoride.

Used for 3–5 min per session, three to five times per day.
Dental sealants
 Oral motor function
• If the child is not fed by mouth, this will interfere with the
development of oral sensory and motor skills.

• The oral cavity often becomes hypersensitive, making it difficult

to touch the mouth or to brush the teeth.

• Children and adolescents with hypersensory problems will not

tolerate toothbrushing or the dentist checking the teeth.

• The acceptance of objects in the mouth has to be built up step by

step; again an area of multiprofessional collaboration.
• Massage techniques : sensorimotor stimulation can affect muscle tone and
improve motility.

• Argentinian neurologist Rodolfo Castillo Morales  includes working on

body posture, use of massage, and use of palatal plates or other oral
devices.

• Patient can also train with an oral screen device, individually fabricated
palatal plates to be used for specific training stimulation of, foremost, the
tongue.
 Child with Worster Drought syndrome and custom-
made exercise appliance to encourage mouth-
opening

Child using an oral screen to improve lip competence

• Some results from studies in patients with Down syndrome indicate that
training with palatal plates has a positive effect on oral muscle function
and speech development.

• Palatal plates can also be used to train children in overcoming

articulatory problems.
 Barriers
• McIver has described following barriers to access dental care
1. Primary medical care system
2. Child’s parents
3. Child himself
4. The dentist
5. Payment for dental care
• Accessibility
• Psychosocial
• Communication
• Disruption of normal office routine & other patients
• Ignorance by parents & intituitions
• Al-Shehri  46% of the children with disability had difficulty in seeking
dental care and 55% of those with disabilities had unmet dental needs.
• AL-Shehri observed that fear of dentist was one of the difficulties to
obtain dental care.

• Rapalo et al. and Schultz et al.  high cost is a potential barrier in

seeking dental care among children with disabilities.
Bhaskar BV, Janakiram C, Joseph J. Access to dental care among differently-abled children in Kochi. J
Indian Assoc Public Health Dent;14:29-34.
Behavior management techniques
employed in managing CSHCN
Barriers encountered in treating CSHCN

Rajan S, Kuriakose S, Varghese BJ, Asharaf F, Suprakasam S, Sreedevi A. Knowledge, Attitude, and Practices of
Dental Practitioners in Thiruvananthapuram on Oral Health Care for Children with Special Needs. Int J Clin Pediatr
Dent. 2019;12(4):251-254.
Adyanthaya A, Sreelakshmi N, Ismail S, Raheema M. Barriers to dental care for children with special needs: General
dentists' perception in Kerala, India. J Indian Soc Pedod Prev Dent 2017;35:216-22
Adyanthaya A, Sreelakshmi N, Ismail S, Raheema M. Barriers to dental care for children with special needs: General
dentists' perception in Kerala, India. J Indian Soc Pedod Prev Dent 2017;35:216-22
 CONCERNS
PATIENT
• Dependent behavior
• Immaturity
• Severity of c/c illness
• Lack of support system
• Poor adherence to treatment regimen

FAMILY
• Excessive need for control
• Emotional dependency
• Psychopathology
• Parenting styles  overprotection
• Heightened perception of severity/condition
• Lack of trust in caregivers
• Mistaken perception of potential
 PEDIATRIC/DENTAL PRACTITIONER

• Economic concerns
• Emotional bond with pt.& parents
• Comfort with status quo
• Perception of own skills
• Perception of potential survival of parents
• Distrust of adult caregivers
• Increased time
• Architectural accessibility
• Disruption in the office setting & scheduling
END OF PART-1
 REFERENCES
1. Textbook of pediatric dentistry – Nikhil Marwah : 4 th ed
2. Pediatric entistry for Special Child - Priya Verma Gupta
3. Pediatric dentistry- A clinical approach –Goran Koch : 3 rd ed
4. Pediatric dentistry principles & practice – Muthu & Sivakumar : 2 nd ed
5. Textbook of pedodontics – Shobha Tandon : 2 nd ed
6. Dental Care for Children with Special Needs A Clinical Guide - Travis M. Nelson :
Springer
7. AAPD Management of Dental Patients with Special Health Care Needs – Latest
revision 2016
8. Khokhar et al.; Dental Management of Children with Special Health Care Needs
(SHCN) – A Review, BJMMR, 17(7): 1-16, 2016
9. Kowash M (2017) Dental Management of Children with Special Health Care
Needs: A Review. JSM Dent 5(2): 1090.
10. Dharmani CK. Management of children with special health care needs (SHCN)
in the dental office. J Med Soc 2018;32:1-6.
11. Nunn, J., Gorman, T. Special care dentistry and the dental team. Vital 7, 22–25
(2010).
 PART 2
MENTAL RETARDATION
 INTRODUCTION
• Developmental disabilities.

• One of the major disorders in the category of development

disabilities.

• Intellectual disability (ID) / Intellectual development disorder

(IDD) / General learning disability.

• ID - Diagnostic and Statistical Manual 5th Revision (DSM-V)

• AAMD/AAMR  AAIDD (2007)

• MR : "Significantly sub-average general intellectual functioning existing
concurrently with deficit in adaptive behavior, and is manifested during the
developmental period"
AAMD-2010

• Intellectual disability (ID) or is defined as ‘‘a condition of arrested or

incomplete development of the mind, which is specially characterized by
impairment of skills manifested during the developmental period, which
contribute to the overall level of intelligence, i.e. Cognitive, language,
motor, and social abilities’’ AAPD

American Association on Intellectual and Developmental Disabilities (2010). http:// www.aamr.org/content_100.cfm?navID=21.

Accessed June 28, 2018.
• ID – significant limitation both in intellectual functioning & adaptive
behavior.

• MR Developmental delay

• A child <2yrs should not be diagnosed as MR unless the deficits are severe
& highly correlated with MR
• 3 levels of impairment identified

1. Idiot : development arrested at the level of 2yr old.

2. Imbecile : development equivalent to that of a 2-7yr old maturity.

3. Moron : development equivalent to that of a 7-12 yr old maturity.

 EPIDEMIOLOGY
• McLaren & Bryson (1987)  prevalence of 1.25%
• Baroff (1991)  0.9% of population assumed to have MR.
• WHO  apprx. 170 million worldwide (3% of world’s population).

• According to DSM 5, the prevalence of intellectual disability is 1% of the

general population; with 6 per 1,000 persons reported to have severe
intellectual disability

• The male to female ratio for ID is 2:1

Patel DR, Apple R, Kanungo S, Akkal A. Intellectual disability: definitions, evaluation and principles of treatment. Pediatr Med
2018;1:11.
• The recent NSSO report  the no:of disabled persons in the country
is estimated to be 18.49 million (1.8% of the total population) while
the MR population amounted to 0.44 million individuals

• MR
 50 times more prevalent than deafness
 28 times – neural tube defects like spina bifida
 25 times - blindness
 CLASSIFICATION
• DSM-IV-TR : classifies 4 different degrees of MR. (based on
person’s level of functioning)
* Mild
* Moderate
* Severe
* Profound

• Syndromic

Non-syndromic
 MILD MR

• ‘Educable’ category.
• IQ : 55-70
• Mental age of 8-12 yrs.
• Highest functioning level
• Largest category - 85%
• Level of functioning may change with age.
• During preschool yrs: Minimal impairments- esp.in sensorimotor areas.
• During school yrs : can be educated up to sixth grade
 MODERATE MR

• ‘Trainable’ category (can be trained in manual skills)

• IQ : 40-55
• Mental age of 5-8 yrs.
• 2nd highest functioning level.
• 10%
• With extensive efforts, they can function up to grade II level.
• Cannot read for information.
• Unskilled & semi-skilled work possible in sheltered environments.
 SEVERE MR

• IQ : 25-40
• Mental age of 3-5 yrs.
• Lower functioning level
• 3 - 4%
• During school age years : speaking ability + minimum self-care skills.
• Poor fine motor skills.
• Requires supervision for ADL (Activities of daily living).
 PROFOUND MR

• IQ : < 25
• Mental age of <3 yrs.
• Lowest functioning level
• 1-2%
• Neurological condition
• Training limited because of sensorimotor deficits
• Totally dependent for hygiene.
Shree, A., & Shukla, P.C. (2016). Intellectual Disability: Definition, classification, causes and characteristics. Learning
Community-An International Journal of Educational and Social Development, 7, 9-20.
 ETIOLOGY
I
PRENATAL NATAL POST-NATAL

• Genetic disorders • Birth injuries • Cerebral infections

• Maternal & fetal • Infection • Cerebral trauma
infections • Cerebral trauma • Poisoning
• Kernicterus • Hemorrhage • Cerebrovascular
• Cretinism • Hypoxia accidents
• Prenatal unknown • Anoxia
• FAS • Hypoglycemia
 II
HEREDITARY ENVIRONMENTAL

• Phenylketonuria • Infections in the prenatal,

• Cretinism perinatal and post-natal periods
• Defmutism • Fetal irradiation
• Microcephaly • Rhesus incompatibility
• Neurofibromatosis • Bacterial meningitis
• Huntington’s chorea • Viral encephalitis in the perinatal
• Mongolism period and childhood
• Anoxia at the time of delivery
• Traumatic injury to the brain
during delivery or subsequently.

Nirmala SVSG (2018) Dental concerns of children with intellectual disability - A narrative review Dent Oral Craniofac Res, 2018
INTELLIGENCE QUOTIENT
SCALES
• Cattell infant intelligence scale
• Stanford-Binet intelligence scale
• Wechsler intelligence scale for children
• Wechsler adult intelligence scale

• Standard formula for computing IQ:

IQ = (MA/CA) X 100
(Stern in 1913)
CLINICAL MANIFESTATIONS
• Tensely reclined head, abnormal behavior & poor mobility.
• Retained primitive reflexes & delayed milestones.
• Hyperactivity and impulsiveness.
• Impulsiveness
• Distractibility
• Fearful behavior
• Self mutilation and Craving for non-food items
 ORAL MANIFESTATIONS
1. Poor oral hygiene
2. Periodontal d/s
3. Dental caries
4. Structural abnormalities
5. Malocclusion
6. Destructive oral habits (Tongue thrusting, clenching and bruxism)
7. Halitosis
8. Enamel deficits
9. Fractured & non-vital teeth
10. Altered salivary flow
11. Gingival hyperplasia
12. Drooling
13. PICA (ingestion of inedible objects)
14. Self-injurious behavior (SIB)
• Modric, VE et al.  Children with intellectual disabilities have more
developmental defects of enamel than children in the control group.
Enamel defects increase caries risk.

• Yuki O et al.  Patients with ID harbouring both S. mutans and S.

sobrinus have a significantly higher incidence of dental caries than
those with S. mutans alone.
 RADIOGRAPHIC EXAMINATION
• For patients with limited ability to control film position, intraoral
films with bite­-wing tabs are used for all bitewing and periapical
radiographs.

• An 18-inch (46-cm) length of floss is attached through a hole made

in the tab - to facilitate retrieval of the film if it falls toward the
pharynx.
 Dental Caries and Periodontal Status of
Mentally Handicapped Institutilized Children

Journal of Clinical and Diagnostic Research. 2014 Jul, Vol-8(7):

ZC25-ZC27
DENTAL MANAGEMENT
I. Medical h/s
II. Behavioral h/s
III. Dental h/s
IV. Behavioral management.
V. Preventive strategies
VI. Recall examinations
• Tooth brushing
• Flossing
• Chemical plaque control (CHX)
• Plaque disclosing solution
• Fluorides
• Dietary counseling
• Give family a brief tour of office before treatment
• Introduce the patient and family to the office staff.
• Allow the pt.to bring a favourite item(stuffed animal, toy etc.)
to hold for visit.
• Be repetitive, speak slowly & in simple terms
• Give only one instruction at a time & reward the patient after
successful completion
• Actively listen to patient
• Invite parent into operatory for assistance
• Keep appointments short
• Schedule the patient early in the day when the dentist ,staff and
patient will be less fatigued.
• Gradually progress to more difficult procedures after pt.used to
dental environment
• Summary of dental findings & specific treatment
recommendations provided to caregiver & physician when
appropriate
2 core objectives attained by
 Familiarisation (desensitization)
 Effective communication
 Active listening
 Short appointment time
 Structuring & scheduling
 Positive reinforcement.
TREATMENT MODIFICATIONS
• Restorative
• Endodontic
• Periodontal
• Prosthetic
 CONCLUSION
• Provision of dental treatment & prevention services to special
children is an important part of dentists’ professional responsibilities.

• Making a difference in oral health of a person with MR may go

slowly at first, but determination can bring positive results.

• Pediatric dentist can create significant impact not only on the oral
health of these children, but also their quality of life.
 REFERNECES
1. Textbook of pediatric dentistry – Nikhil Marwah : 4 th ed
2. Pediatric entistry for Special Child - Priya Verma Gupta
3. Amjad H Wyne -Dental management of mentally retarded patients ; Pakistan
Oral & Dent. Jr. 22 (1) June 2002
4. Nirmala SVSG (2018) Dental concerns of children with intellectual
disability - A narrative review; Dent Oral Craniofac Res, 2018, Volume 4(5):
1-4
5. Khokhar et al. Dental Management of Children with Special Health Care
Needs (SHCN) – A Review ; BJMMR, 17(7): 1-16, 2016
6. Practical Oral Care for People With Mental Retardationitender
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