Management of patients with Special Health

Care Needs

The American Academy of Pediatric Dentistry (AAPD) recognizes that providing both primary and
comprehensive preventive and therapeutic oral health care to individuals with SHCN is an integral part
of pediatric dentistry.
Background
• The AAPD defines special health care needs as 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.
• Conditions may be
• Congenital
• Developmental
• Acquired – through disease, trauma, or environmental cause and may impose
limitations in performing daily self-maintenance activities limitations in major life
activities.
• Health care for individuals with SHCN requires specialized knowledge, as well as increased
awareness and attention, adaptation and accommodative measures beyond what are
considered routine.
• Patients with compromised immunity or cardiac conditions associated with endocarditis may be
especially vulnerable to the effects of oral disease.
• Patients with mental, developmental, or physical disabilities who do not have the ability to
understand, assume responsibility for, or cooperate with preventive oral health
• Disorders or conditions which manifest only in the orofacial complex.
• amelogenesis imperfecta, dentinogenesis imperfecta, cleft lip/palate, oral cancer. >>
considered SHCN as their needs are unique, impact their overall health and require oral
heath care of specialized nature.
• The Americans with Disabilities Act (AwDA ) defines the dental office as a place of public
accommodation so dentists are obligated to be familiar with these regulations and ensure
compliance.
• Failure to do so can be considered disccrimination and violation of federal and/or state
law.
• Regulations require practitioners to provide physical access to an office ; i.e., wheel
chair ramps, disabled-parking spaces.
• Families with SHCN children experience much higher expenditures.
• Insurance plays an important role for families with SHCN children but it still provides
incomplete protection.

Bajracharya, Tendol.
 • They also rely on the government funding to pay for medical and dental care
• Other barriers they may face are psychosocial, structural, and cultural considerations.
• psychosocial- oral health beliefs, norms of caregiver responsibility and past dental
experience of the caregiver.
• Structural barrier - transportation, discriminatory treatment.

Recommendations
 Scheduling appointments
o When scheduling patients with SHCN, it is imperative that the dentist be familiar
and comply with Health Insurance Portability and Acountability Act (HIPPA) and
the AwDA regulations applicable to dental practices
o HIPPA- insures that the patients pricacy is protected
o AwDA- prevents discrimination on the basis of disability.

 Dental Home
o Patients with SHCN who have dental home are more likely to receive preventive
and routine care.
o When patients with SHCN reach adulthood, they will need to go to a doctor
knowledgeable in adult health care. It should be transitioned ccarefully in a way
that is comfortable for the patient.
 Patient Assessment
o Familiarity with patients medical history
o An accurate, comprehensive and up-to-date medical history is necessary for
correct diagnosis and effective treatment planning.
o Get all information regarding
 the chief complaint
 HPI
 medical conditions, medical care providers
 hospitilaizations/surgeries
 anesthetic experiences
 current medications
 allergies/sensitivities
 immunization status
 Family and social histories
 Thorough dental history
o On every visit, history should be consulted and updated. Recent medical attention
for illness or injury, newly diagnosed medical conditions, and changes in
medication should be documented.
 Medical consultations
o The dentist should consult with the patients other care providers.
o The physician should be consulted regarding medications, sedation, GA, and
special restrictions or preparations that may be required to ensure the safe delivery
of oral health care.
o Should always be prepared to manage a medical emergency.
 Patient communication

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 o When treating patients with SHCN, developmentally-appropriate communication
is critical
o A patient who does not communicate verbally communicate in a variety of non
traditional ways
o A parent, family member or caretaker may need to be present to facilitate
communication and/or provide information that the patient cannot.
o If attempts to communicate with the patient with SHCN/parent are unsuccessful
because of a disability the dentist must work with those individuals to establish an
effective means of communication.
 Planning Dental Treatment
o Before a treatment plan can be developed and presented to the patient/parent,
information regarding medical, physical, psychological, social, behavioral, and
dental histories must be gathered and clinical examination and any additional
diagnostic procedures completed.
 Informed Consent
o Informed consent is mandatory for all dental treatments.
o Informed consent should be well documented in the dental record through a
signed and witnessed form.
 Behavior Guidance
o Patients with SHCN are more anxious because of lack of understanding of dental
care.
o When behavior guidance techniques are not sufficient, protective stabilization can
be used.
o When protective stabilization is not effective, sedation or GA is the behavioral
guidance armamentarium of choice.
 Preventive strategies
o Education of parent/caregivers is critical for ensuring appropriate and regular
supervision of daily oral hygiene.
o Some strategies are:
 Brushing with fluoridated dentrifice twice daily
 Modified toothbrushes
 Non-cariogenic diet
 Sealants
 Topical fluorides
 Interim therapeutic restoration
 Chlorhexidine mouthrinse
 Recall every 2-3 months
o Dentists should also address traumatic injuries
 Anticipatory guidance about risk of trauma
 Mouthguard fabrication
 What to do if dentoalveolar trauma occurs
o Dentists shoud be aware of signs of abuse and mandated reporting procedures
 Patients with developmental or acquired orofacial conditions
o From the first contact with the child and family, every effort must be made to
assist the family in adjusting to and understanding the complexity of the anomaly
and the related oral needs.

Bajracharya, Tendol.
 o Be sensitive to the psychosocial well-being of the patient as well as the effects of
the condition on growth, function, and appearance.
 Referrals
o Once the patients needs are beyond the skill of the practitioner, the dentist should
make necessary referrals in order to ensure the overall health of the patient.


Bajracharya, Tendol.