• Learning Disability: mild, moderate, profound, severe

Down syndrome:

• susceptibility to periodontal disease rapid progression: bone loss, infrabony pockets, gingivitis, tooth mobility)
• can be fairly resiliant/not susceptible to caries (saliva composition? saliva immunoglubilines/enzymes protecting from caries?, non-sugary diet ?)
• some of the patients can be very compliant, better than ‘routine’ patients!
• malocclusion
• hypodontia and microdontia, usually lack of lateral incisors and/or second permanent premolars
• frequently persitent/retained deciduous teeth
• poor plaque control
• fluctuating nd changeable cooperation, from pretty good to not cooperative at all and agitated
• teeth malformation, hypodontia, microdontia
• persistent, retained deciduous teeth, often severey worn down
• often high level of anxiety and ‘sensitivity’ – do not like his/her mouth to be touched
• minor, non invasive procedures possible
• can be PEG fed – tendency to gross calculus accumulation/formation within posterior quadrants, sometimes may be resiliant to caries
• examination can be challenging, to consider ref for full asessment under IV or GA (if justified)
• often unable to indicate and express any dental problems – rely and liaise on relatives/carer statements
• tendency to grinding and clenching, severe tooth wear and attrition
• uncontrolled/unvoluntary movements
• expect malocclusions, teeth displacements, supernumerary/supplemental teeth, peg shape lateral incisors, missing teeth, delayed eruption, submerged deciduous molar teeth
• expect excessive dribbling and saliva excretion
• irregular brushing pattern, one day even severeal times a day, another nothing at all
• dislike strong taste toothpastes (eg. minty), prefers specific ones (eg. with ‘thomas the tank’ visual elements)
• can be very ‘sensitive’ towards needles (local anaesthetics) – AET to stabilise dental problems
• special caution re: post-op instructions, thorough explanations about sensations which patient ma find weird and uncomfortable, needs lots of reassurance, mirrors to be used to show patients he/she looks normal, they are just sensations which will wear off and dissappear compltely within 2-3 hours.
• build up gradually relationship with the patient! become his/her friend on professional level
• Patient with Down syndrom reluctant to accept new advise, needs a time to understand certain information
• repeat information with visual graphics, tools and clear examples.
• little rewards from time to time, eg. toothbrush holder, new TB, mouthwash, etc.

 

• can be very ’emotional’ during dental procedure, eg. may start crying or can be very inpatient
• some patient are able to communicate efficiently via specially designed tools, tablet, etc.
• aphtous ulcerations often in individuals with cerebral palsy
• risk of aspiration pneumonia
• often severe heart conditions: ASD/VSD, cyanotic appearance of patient’s lips, hands
• patients with Down Syndrome – frequent occurence of lips lacerations/lesions/non-healing cracks as habitual licking/biting/chewing, can be difficult to treat, long-standing and resistant to standard medications/oitments.
• antibacterial/Antifungal cream, preferably with steroids may be highly effective (eg. bacteriostatic fusidic acid, sodium fusidate if Staphylococcal infection)
• if any doubts regarding antibitic cover for patient with severe congenital heart conditio – to get a second opinion from consultant cardiologist
• some patients might be at increased risk of infective endocarditis and AB cover can be fully justified!

How to tackle:

• being very patience
• tone voice does matter
• gradual confidence build up, do not loose it !
• gentle, gradual approach, no place for rush, plenty of time for the patient
• small steps forward
• to try to establish a trust and even friendship, shake patient hand on initial appointment
• short appointment as patients quickly get uncooperative
• talk to the patient all the way with constant reassurance
• tell-show-do approach even for adult patients
• use distracting elements, eg. bright head light, movie on tablet
• break from dental treatment if patient getting upset/too distressed
• to consider eg. thorough check upper teeth per session and lower arch next visit
• technique worth to try: one quadrant assessment – chat with patient – next quadrant – chat with patient/parents/break – third quadrant and fourth can be usually checked easier than the first two.
• plastic mirror very useful – can be given to patient with an advice – ‘to practice at home’
• avoid any prolonged procedures as patient may not cope well and short attention span
• use fissures sealants, ‘fissurotomy’, sealant composite as often as possible asa prevention and prevent from ‘unnecessary restorative cycle’ in future
• use F/S to seal any areas with potential plaque accumulation, including, eg. talon cusp groove (usually upper incisors) or Carabelli cusp groove on upper molars
• variety of additional measures to deal with chronic and long-standing problems: intraoral irrigator, interdental brushes, etc.
• preparation for the exam, eg. lets count to 10, with the associated music, needs to be a routine for every appointment
• gentle clinical holding sometimes necesary
• be careful re: strong biting forces due to muscles spasms, semi -soft mouth prop can be damaged, even a wooden core inside! place mouth prop further inside as a tip of it not reinforced with wooden core, risk of detachment and swollowing/choking!
• “Down’s Syndrome and Oral Care” – DentalUpdate, 2001.
• “Diagnosis and Management of Chronic and Aggressive Periodontitis Part 1: Periodontal Assessment and Diagnosis”, Volume 44 Number 4 Page 306,  April 2017.

 

• routine prescription of sodium fluoride toothpate 0.619% (over 12 y.o. ) and sodium fluoride 1.1% (above 16 y.o.)
• pe
• try to distract patient talking about eg. nice shoes, school, favourite films, music, food
• use makaton language for communication
• some patient use ‘visual tablets’ or ‘alphabet keyboard’ to communicate with others
• capacity assessment even for simple full dental assessment and scaling ?
• regular use of preventative measures, eg. fluoride varnishes
• Recommendation of intraoral irrigator use in case of severe periodontal problems and poor OH regime.
• impregnated toothbrushes can be useful during dental appointment to encourage a patient for mouth opening – special needs patient are familiar with routine brushing and may easily accept it
• routine application of fluoride varnish 22600ppm
• preventative application of GIC resin modified on eg. worn down (attrition) persistent deciduous molars
• arrested, non progresing carious lesions can be left and monitored
• non flavoured and non foaming TP advised (eg. OraNurse+, pretty odd taste !)
• to leave small residue of toothpaste on affected surface (carious lesion) over the night time period
• special toothbrush can be beneficial: collin curve, dr Barmans TB
• clinical holding and protective immobilisation

 

• build up confidence very slowly but steadily and permanently, partucilary difficult if it is going to be the first dentla tx ever
• highly individual approach
• take the time ! do not rush yourself esp. in case of Down syndr patient
• create a long term relationship with pt, ask about hobby (fishing, dvd, music, etc) always ask question related to his/her hobby (eg. how was your fisihg recently? have you catch something nice? was it the sea bass, etc.
• be aware that any intervention may be perceived in totally unpredictable way (my case: pt suddently becomes upset cause was thinking that he looks different following LA, showed in the mirror that he looks fine, normal)
• lots of reassurence and encouragement
• explain the reason whye we are going to use topical gel, cotton roll, etc.
• keep tx time to minimum by quick and efficient cavity prep, using the bulk composites, etc. as short attention span
• avoid unnecessary procedures
• shaking hands on entrance and leaving, given hugs it is nothing wrong if pt wishes to do so

 

 

Cerebral palsy: spastic, dyskinetic, ataxic, mixed

• CP is non-progressive disorder, about 50% of persons have a learning disability however any people with CP are absolutely fine in terms of inteligence.
• usually wheelchair bound, neck stiffness, abnormal gait, spinal curvature, foot or leg dragging, uncontrolled mevements
• often (about 30%) associated epilepsy
• excessive drooling, difficulties in swallowing due to dysphagia
• speach impairements due to dyspraxia and dysphasia
• parafunctional habits (bruxism) masseter hypertrophy, TMJ disfunction/destruction/dislocation
• limited mouth opening
• mallocclusion, delayed eruption, poor oromuscular co-ordination, poor lips seal, oral habits
• poor head position
• bruxism and tooth wear, erosion
• periodontal disease due to predisposing factors
• food retention and packing
• fractured teeth due to seizures
• drooling or xerostomia due to mouth breathing, medications,
• increaed risk of secondary complications: respiratory problems, reflux, bladder infections arthritis, deformities
• difficult airway re: GA and intubation, fiber optic scope and nasal intubation can be helpful
• problems with swollowing/chocking

 

• vitally important  the same, routine way of doing brushing by carers eg. mouth prop on one site count to 10 and then give a break and another 10 on the another site
• seamless care: toothbrush holder adaptation, gentle brushing with soft TB or swab dipped in mucolytic solvent, use of lubricating gel (aqueous)
• appliance therapy for bruxisms
• hard acrylic bite rising guards, soft moulds, lip bumpers
• adaptable, cleansable cushins and neck and shoulders suport can be extremelly helpful to support the body
• gentle restrain of limbs in case of ‘jerky leg’ movements with the use of eg. Velcro strap
• the use of finger guard or prop to prevent sudden muscle spasms
• pre-medication with muscle relaxant can be helpful
• oral sedation of TM/IV conscious sedation in case of mild anxiety

 

Congenital syndromes affecting dentition and surrounding oral structures:

Down syndrome – often associated with congenital heart conditions: eg. ASD/VSD, cooperation varies – from fairly cooperative and compliant to severely anxious, long acclimatisation but usually fine with minor non-invasive procedures like restorations under LA, more complex treatment requires GA, prone to periodontal problems and tooth surface loss due to grinding/bruxism.

Rett’s syndrome

Williams syndrome

Di George syndrome – low lewel of calcium

Angelman’s syndrome

Prader-Willi syndrome

Sturge – Weber syndrome and Klippel – Trenaunay – Weber syndrome

Russel-Silver syndrome

Beckwith-Widemann syndrome

Lowe syndrome

Congenital Central Hypoventilation syndrome

Dandy-Walker Malformation

Dravet syndrome

Lennox-Gastaut syndrome

Klippel Feil syndrome – mallocclusion, patient may wear ‘speach aid bulb appliance’

Hereditary sensory and automatic neuropathy

SMMCI syndrome

Duchenne muscular dystrophy

Ectodermal dysplasia

Epidermolysis bullosa

Global delay development

Neuron Migration Syndrome – includes microgyria and severe learning disability

Noonan syndrome – short neck, may not have any problems with learning

Klippel-Feil syndrome

 

Profound learning disability case, global developmental delay

• allow person who knows patient (parent, carer) to communicate with the patient all the way through as he/she knows patient much better and is able to calm patient down easily
• allow person who knows patient (parent, carer) to escort and transfer the patient into dental chair, do not interfere with this if not necessary
• initial full examination vitally important, if not possible – to consider EUA under general anaesthesia along with other dental procedures required, including scaling, FMD, fillings and extractions
• not to recline chair too much at the beginning as patient can be scared
• mouth prop/mouth rest can extremelly useful
• demonstration of proper TB technique, adv to brush from behind s more efficient, gentle clinical holding can be necessary
• in case of special units residents, to encourage carers to carry on with brushing on regular basis, even if the patient is quite relucant, to show them appropriate technique with gentle cheek retraction, just brushing on buccal/labial surfaces in case of limited mouth opening is better than nothing
• if patient becomes agitated, positive behavioural management (PBM) can be very useful to cope with this situation, extra training needed, holding forearms above patient’s hand may prevent from sudden patient’s movement and risk of injury
• gentle use of heavy lead apron as a normal blanked may be halpful
• to show the parents/carers the areas which are missing while brusing, signs of local gingiva irritation/infection to prevent from further deterioration
• positive encouragement re: regular brushing
• slow, gradual introduction of new hygienic aids like electric toothbrush (vibrations !)
• regular prescription of 0.619% or 1.1% sodium fluoride toothpaste
• prescription of chlorhexidine gluconate gel 1% (Corsodyl) for 4 weeks tome for regular brushing after normal OH regime, adv to use gel 30 mints after normal brushing
• intraoral fibreoptic camera with endoscopic option can be very useful if limited mouth opening
• advice to use CPP-ACP as an additional, adjunct preventative measure in case of early lesions, demineralization areas and ‘white spots’
• to consider giving mouth rest and disposable mirror to parents/carers in order to improve brushing
• if anything suspicious, discoloured spots, localised perio conditions – recall every 3 months time
• OH review and plaque control if necessary with dental hygienist