patients with special needs
DESCRIPTION
Patients with Special Needs. Wichita Dental Hygienists’ Association January 10, 2008 Barbara M. Gonzalez, RDH, MHS. Disabilities. Disability = one or more life skills is altered by physical or mental impairment ADA = Americans with Disabilities Act Passed in 1990 Employment Environment. - PowerPoint PPT PresentationTRANSCRIPT
Patients with Special Needs
Wichita Dental Hygienists’ AssociationJanuary 10, 2008
Barbara M. Gonzalez, RDH, MHS
Disabilities
Disability = one or more life skills is altered by physical or mental impairment
ADA = Americans with Disabilities ActPassed in 1990EmploymentEnvironment
Not your dentist’s ADA
The Americans with Disabilities Actenacted in 1990Covers employment, public services, public accommodations, etc.
http://www.usdoj.gov/crt/ada/statute.html
What is a “Disability”?
Social PerceptionsThe Obvious
Wheelchair…Spinal cord injuryCerebral PalsyMuscular Dystrophy
– ALS (Lou Gehrig’s)
“You don’t look disabled…”
Social Perceptions?The Not-so-Obvious
Sensory Deficits– e.g. hearing impaired
Seizure disordersChronic managed
– e.g. multiple sclerosis, lupusInfectious diseases
– e.g. HIV
The Dental Hygienists’ Role
Make good use of anecdotal notesMeet basic patient needs, i.e.
Modified oral hygiene techniques & aidsGeneral Practice
Learn special techniques or skills, i.e.Sign languageWheelchair transfers
Specialized Practice
PHYSICAL IMPAIRMENTS
Visual Impairment
Half of legally blind Americans are 60+
Legal Blindness Visual acuity of 20/200 or less with optimal correction
10% of legally blind Americans are school age children or younger
Etiology
TraumaIncidence is markedly decreased due to better workplace safety controls
Diseasei.e. macular degeneration, etc.
Structural / development defectsCataracts, etc.
Major Problems Encountered
Unsolicited and inappropriate assistance by strangersMistaking blindness for DEAFNESSAddressing companions and not personVerbalizing pity
Visually impaired usually independent and productive sans other disabilities
Barriers to Care
Accessing “yellow pages” to find dentistTransportationRelease time from workNegative attitudes about service dogs in office settingFinancialPhysical environment
Physical Environment
Loose rugsPoor lighting
Legal blindness vs. total blindness
StepsSmall print / written formsUnwieldy doorsSudden changes in surface texture
Assisting Your Patient
Verbal questioning to gain information
Schedule additional time
ASK for patient’s preferences
Oral Manifestations
Same as general peer populationOral hygiene may be compromised
Poor OH may contribute to oral disease
Patient Management
Greet patient upon arrivalDescribe office layoutEscort patient while describing changes, obstaclesOffer physical assistance
Do NOT take by hand!
Allow service dogs in operatory
Patient Management
Introduce patient to other staff members
Designate one as primary communicator
Minimize noise!Identify sounds, smells, equipment
Allow them to touch
Inform patient upon approach to mouth
Patient Management
Inform the patient upon leaving and returning to operatoryOHI – use hand-over-hand techniqueOHI – good verbal descriptionsOHI – use typodonts
Hearing Impairments
Can exist with no other disabilityOften accompanies other disabilities
Cleft palate – 90%Cerebral palsy – 20%Down’s Syndrome – 70%
Oral Manifestations
BruxismOthers as general population
Barriers to Care
Difficulty contacting officeTDD
Telecommunications device for the deaf
Patient Management
Allow interpreter into operatoryBUT, speak to the Patient!
Do not shout, unless directed to by patientMaintain voice volumeLearn simple ASL / SEE signs
Patient Management
Write out information in advance of appointment
For children, use drawings or pictures
Use touch to communicateHearing aids often turned offOHI – use disclosing, visual cues
Neuromuscular Disorders
Cerebral Palsy…Muscular dystrophyALS
Neurological Disorders
Multiple Sclerosis
Cerebral Palsy
A static, non-progressive neuromuscular condition resulting from damage to brain, often peri-partumMotor dysfunction, weakness, un-coordination, paralysisMay be accompanied by other diagnoses
Classifications of CP
Spastic – 50-75%S. diplegia, s. hemiplegia, s. quadriplegia
Athetoid dyskinetic – 15 – 25%Ataxic – 10%Hypotonic (Flaccid)- <10%Mixed – 5-10%
Limb Involvement Classifications
MonoplegicHemiplegicParaplegicDiplegicQuadriplegicTriplegic
Oral Manifestations
BruxismMalocclusionClenchingFood retention / pouching
CariesPlaque control
PeriodontitisGingivitis
Patient Management
Schedule initial interview to acquaint with patientAssess
muscle / reflex patternsCommunication and comprehensionMedical conditions
Caregiver should participate
Patient Management
Speak to adult patient as an adultSpeak to a child patient as a childGear information to patient’s level of intelligence, not communication
Managing Reflex Patterns
Tonic labyrinthine reflexOccurs when head tilts backward
Asymmetric tonic neck reflexOccurs when head turns to side or away from midline
Gag reflexCough reflexBite reflexSwallow reflex
Gag and Cough Reflex
If HypoactiveAt risk for aspirationUse small bursts of waterUse frequent suction
If HyperactiveFlex patient’s head with chin to chestIntroducing items intraorally will probably induce reflex
Bite Reflex
Mouth prop may be helpful
Tie off!
Treat lingual as quickly as possible
Mouth Gag (molt)
Adjustable
Swallow Reflex
Swallow ReflexAvoid mouth propsBe patient!
Retraction Issues
Tongue retraction may be difficult
Patient Management
Allow adequate timeBe aware that un-coordination (ataxic) becomes aggravated with time Support patient with pillows, bean bags, restraints, as neededControl tonic neck reflex by cradling
May require second person
Sedation / Gen. Anesthesia
Oral Hygiene Needs
Food retention a big problem!Frequent toothbrushingLubrication of gingival tissuesNutritional analysis
Cariogenicity Fluoride Frequent prophylaxesModified oral hygiene aids
Spinal Cord Injury
Location of injury determines extent70% < 40 years of ageOverwhelmingly male50% auto or motorcycle accidents18% sporting accidents20+ % occupationalRemaining GSW, falls, etc.
Other Considerations
Grieving ProcessShockDenialReactionMobilizationCoping
Other Considerations
AngerDepressionWithdrawal
Oral Manifestations
Depends on degree of injuryLower limb involvement onlyUpper limb involvement
Depends on nature of injuryFractured teethBroken jaw / facial bones
Attritionmouthstick
Patient Management
Inspect office and operatories for barriers
Parking availabilityAccessible entranceDoorway widths (32 “+)Flooring materials Hallway width (36”+)Turnaround space (60”+)Restroom access
Patient Management
Operatory AccessibilityWheelchair transfer access
Follow the patient’s leadUse the brakesHave adequate physical supportCheck urinary catheters during and after
Oral Hygiene Needs
Extremely importantMouth and teeth often substitute for arms and handsModified aidsEngage caregiver
Mental Disabilities
Mental IllnessMental Retardation
Mental Illness
“an illness with psychological or behavioral manifestations and/or impairment in functioning due to social, psycholgic, genetic, physical/chemical, or biologic disturbance. The disorder is no limited to relations between the person and society. The illness is characterized by symptoms and/or impariment in functioning.”
Mental Retardation
“A significant subaverage general intellectual functioning which originates during the developmental period and is associated with impairment in adaptive behavior”
Adaptations
Mental illness requires adaptations in both physical and emotional realmsMental retardation requires adaptations in both physical and educational realms
Mental Illness
Affects one-sixth of Americans at some point in their lifetimeChronic major depression affects 3-5% of total population
Mental Illness
For womenPhobiasDepression
For MenChemical dependencePhobias
2-5% of populationAnxiety disorders
Patient Management
ConsistencyRegularityReliability
Important for patients still working on stabilization
Patient Management
Dietary analysisSugar addiction
Pain controlAnxiety issues
Informed consentCompliance
Patient Management
Drug interactionsOral complications
What are side effects of meds?
Xerostomia often with psych meds
Mental Retardation
Mild – 89% IQ 50-55 to 70 – “Educable”
Moderate – 6%IQ 35-40 to 50-55 – “Trainable”
Severe – 3.5%IQ 20-25 to 35-40
Profound – 1.5%IQ below 20 or 25
Etiology
Acquired – 9%Physical disorders of childhoodEnvironmental / chemical influences
Inherited – 13%i.e. Down’s Perinatal problems i.e. FAS
Unknown – 75%
Oral Manifestations
Thick lipsTooth anomaliesPeriodontal conditionsOral habitsDental caries
Personalization of Care
Nutritional counselingSimplified OH techniquesRepetitive follow-up“An aggressive approach to preventive care, not an aggressive approach to the patient….”
Patient Management
Tailor to patient skills and comprehensionSedation and/or general anesthesia may be requiredNEVER “HOM”
(hand over mouth)
Oral Hygiene Needs
Prevention and SimplificationBetter to prevent than treat
Have patient demonstrate and repeat!KISSEngage caregiversTreat the Patient!
Talk to the patient, not about the patient
HOME CARE HELPS
Daily Oral Hygiene
Manual toothbrushes can be easily modified
For selfFor care-giver
Specialized Toothbrushes
Collis Curve Brush 1-800-298-4818
Specialized Brusheswww.colliscurve.com
Specialized Brushes
The Surround1-800-722-7375www.specializedcare.com
Specialized Brushes
DexTBrush1-800-352-9669www.prevdentspec.com
Conclusion
PreparationRespectRecognize Limitations
PatientsYour own!
Resourceshttps://ice.iqsolutions.com/nohic/poc/publication/general.aspx
(This resource has great tips!)
LinguaFix1-800-328-3899www.zirc.com
Resources
Collis Curve Brush1-800-298-4818www.colliscurve.com
The Surround1-800-722-7375www.specializedcare.com
DexTBrush 1-800-352-9669www.prevdentspec.com