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Forum Category: General Dentistry

Moderated by:
Molly Stice

Considerations when treating patients with special needs

Dental treatment and oral hygiene care for patients with special needs can be challenging due to their decreased manual dexterity and intellectual impairment. My dental school has a special needs clinic, so I have learned a few techniques to aid in better compliance with oral hygiene and better cooperation while in the dental chair. With the decreased manual dexterity, electric toothbrushes, dual-sided toothbrushes, and dental floss holders make it easier for them to brush and floss. The skinny handle on a toothbrush makes it difficult for them to grab and hold, so adding a tennis ball or a Velcro strap to the end of the handle makes it easier for them to hold and use. Also, it's important to instruct the caregiver on proper oral hygiene practices and show them how to help brush the patient's teeth. It's easier for the caregiver to stand behind the patient and cradle the patient's head in one arm while brushing with the other arm. As far as increasing cooperation while in the dental office, it is important to schedule short appointments typically in the morning or at the best time of day for the patient. Gradually exposing the patient to the dental office and dental equipment helps ease their nerves. Patients with special needs typically like routine and do not do well with change. Therefore, having the same staff, dentist and operatory will make them feel more comfortable and increase their cooperation. It is also helpful for the caregivers to have a routine when it comes to oral hygiene practices, such as brushing/flossing at the same time every day in the same room. Lastly, the tell-show-do technique is very helpful when performing a dental procedure on a patient with special needs. Trust is gained, anxiety is reduced, and cooperation is enhanced. These are some simple techniques I have found helpful when treating patients with special needs. What are your experiences with patients with special needs, and what are some other recommendations to improve cooperation and compliance?
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Considerations when treating patients with special needs

06:16 AM | May 30,2017
This was an informative read ! At the University at Buffalo we take multiple classes where patients with special needs are mentioned. We discuss proper treatment strategies, caries risk, etc. But our actual experience is limited. The only time we are able to see special needs patients is on our pediatric dentistry rotation which we only have 2 weeks per semester. Even within those 2 weeks, in all of dental school, I have now graduated, I treated 1 patient with special needs. Even though we learn about it extensively, nothing beats hands on experience. We have plenty of opportunities to work with them in the special olympics and the special needs clinic (patients are treated primarily by pediatric residents) in the hospital but none of these are required and I feel that sometimes with all the load students must deal with in dental school, we may avoid doing additional things because we feel that we don't have the time to. There are certain days when these patients come into the clinic and if you are not at that site at all, you would not see them, so as a student you have to seek out the opportunity. I personally have taking part in events where I interacted and had to provide oral hygiene instructions and educate patients with special needs but I don't think it was enough. But, this past semester during senior year, it is now required that each student treats a patient with special needs and I think that is important and necessary. If it wasn't for that, I do not think I would have had the opportunity. It's a good step in the right direction ! As providers we need to be comfortable and prepared to see these patients because they are a part of our population. If we don't start getting ready early, we may never feel comfortable providing them with dental treatment.

Considerations when treating patients with special needs

08:11 PM | Mar 23,2017
Nova Southeastern University also has a special needs clinic, where students gain exposure to methods which can help make treating patients a little easier for both the patient and the care provider. Early appointments seem to help ease anxiety facilitate treatment, as well as patient cooperativity. Using the tell-show-do method is a wonderful adjunct to oral hygiene instructions, and it sometimes helps to place the base of the patient's toothbrush into a tennis ball to ameliorate existing grip issues. It is important to establish routines with patients, especially those with special needs, and the earlier they are established, the easier it is to get the patient to cooperate. Desensitization of the dental office can also help in the future, so routine check-up visits are advised. In addition, the divorce rate in the United States has skyrocketed, especially in families with a family member who has special needs, so it is important to dispense two toothbrushes and two tubes of toothpaste during visits to aid in preservation of oral health and hygiene practices. In office, making sure that the patient is comfortable will help the treatment process in the future visits when necessary. When I rotated through the special needs clinic, I saw that the dentists at the North Miami Beach clinic were not only care providers for their patients, but also their friends, rewarding patients for cooperative behavior and inquiring certain details that make the patient happy or more relaxed. The clinic was bright and decorated with friendly pictures and drawings from patients to decrease anxiety and dispel misconceptions about dental treatment.

Considerations when treating patients with special needs

01:50 PM | Jan 26,2017
I agree with the sentiments of others; this piece is wonderfully written and it addresses a topic that warrants more attention in the dental field. One of my professors mentioned in a recent lecture that treating patients with special needs will become a much larger in the coming years because an overwhelming number of current dentists have much apprehension about treating these patients. I believe this apprehension is well-intentioned and is deeply rooted in desire to provide the best, safest care for this population, but that does not excuse ignorance on the topic. It’s great that you’re school has a special needs clinic! My school has a Special Patients clinic, but I think it encompasses more than patients with special needs (I’m just starting to see my own patients and have not been in the Special Patients Clinic yet). All of your recommendations are superb; I have the tendency to overthink when it comes to patient accommodations, but all the suggestions you made are relatively easy to do, and can make a huge difference in the oral hygiene status of the patient. I try to volunteer regularly, seek a diverse patient family, and dialogue freely about treating patients with special needs. I still don’t feel as comfortable as I would like, however. Does anyone have any suggestions or ideas for anyone (myself, other student, dentist, etc.) who is interested in getting more exposure to patients with special needs? I know there are events like Buddy Walk and etc., but I’d really like to do more. Thanks in advance for your feedback!

Considerations when treating patients with special needs

01:13 AM | Dec 15,2016
I loved this piece and agree with everything that was said! I used to work at a pediatric dental practice and we had quite a few special needs patients come through our office. Probably the biggest takeaway I gained was that no two patients - even those with the same special needs diagnosis - are the same. We saw one patient who, every five minutes, would need to get up out of the dental chair to run his hands through cold water because that was what calmed him down. We saw another patient who had been coming to us for over 40 years and would act out if the furniture was not exactly where it was placed before. The general guidelines for treating patients with special needs are helpful, but I would just like to add that in practice, knowing what makes your patient unique and how to specifically make him or her comfortable is key!

Considerations when treating patients with special needs

02:40 PM | Dec 13,2016
These are all great considerations and thoughts all practitioners should be having when treating and managing special needs patients. The recommendations are similar to those used in our special needs clinic at UPitt. I have found the tell-she do technique very helpful and giving proper oral hygiene instructions to the parents. Often the parents, themselves, might not know much about oral hygiene maintenance. Developing a routine with the parents and special needs child is very important!

Considerations when treating patients with special needs

05:43 PM | Dec 11,2016
This is a great topic and I am totally in line with these recommendations. In my school we do see patients with special needs in our pediatric rotation which is only once a semester. So it is not that much exposure but we do learn about about it in our classes. Desensitizing the patient is always a good start in ensuring a successful appointment. Getting the patient's familiar with the dental environment , materials and instruments is important to prevent adverse emotional reactions. We also speak to the caregivers and check the notes in the patient's chart to pinpoint any triggers that the patient may have, what makes them comfortable/uncomfortable. Another important aspect of management is also knowing when the patient has to be sent to the OR. Some of these experiences may be severely traumatic and it may be beneficial to the patient to see them in a different setting if they are unable to cooperate in the general practice setting.

Considerations when treating patients with special needs

06:05 PM | Dec 04,2016
Great read with some great recommendations! Unfortunately, my school does not have a special needs clinic. We do not have many special needs patients in our patient pool, but I was lucky to be assigned a patient with special needs. When asking a friend who happens to be a Special Ed teacher, she advised me that no to special needs patients are exactly the same and you must realize that working with one is going to be completely different than working with another...going along with that, it's important to figure out what works. For me it's been spending extra time in the beginning of appointments to explain and show exactly what we are going to do and answer all questions my patient may have to get her more comfortable before we start.

Considerations when treating patients with special needs

12:36 AM | Nov 27,2016
When I was in undergrad, I worked with intellectually disabled individuals as a caregiver. One of my duties in my shift was making sure they brush their teeth before they go to bed. I used techniques like show tell do and that seemed to be the most effective technique. We also switched out regular tooth brush with electric tooth brushes with timer on them. Dental visits are almost always challenging and requires me to work harder to get the procedures done. The presence of a caregiver or parent is key for the dentist to perform the procedure.

Considerations when treating patients with special needs

03:11 PM | Aug 10,2016
As a few others mentioned, my school also does not have a special needs clinic or external rotation. For the 4th year students, there are a couple sites that see a high influx of special needs patients, but it's luck of the draw if you get chosen for that site, so there's a good chance one might not ever interact with a special needs patient (I should probably disclose also that I am a member of my school's inaugural class so we're the resident guinea pigs and it's just as likely that the experiences of the underclassmen might be different). We do, however, participate in post-clinical session group huddles where students will share any tips or relevant experiences they had that day and while I have not employed your suggested techniques, I will definitely share them at our next huddle. I agree with Daniel in regards to the importance of exuding confidence. It's important for all patients, but especially patients with high anxiety. Additionally, and I believe this to be true for all patients, but building a strong patient-doctor relationship is key- you want them to know you have their best interest in mind and make their experiences with you as enjoyable as possible. I really enjoyed this post, great work Molly!

Considerations when treating patients with special needs

08:26 PM | Jul 23,2016
Those are fantastic ideas, Molly! I had the pleasure of volunteering with the Special Olympics Special Smiles Program, and I found that patients with special needs took particularly well to the "Tell-Show-Do" method when it comes to explaining proper methods of oral hygiene. Laying down a foundation by explaining the role of each instrument, as well as the importance of oral health maintenance is an important first step in establishing a good rapport with the patient. Once the patient has an understanding of the basic steps and why they are important for prevention, the provider can reinforce the technique by showing the patient the proper approach to each step. After showing, ask the patient to show you or their guardian how to brush or floss, and instruct them to try another way if they need assistance to maintain their oral health. During regular visits, dentists should explain what each instrument does in order to reduce patient anxiety and build their trust. Reinforce the patient's cooperative behavior with words of encouragement. A little bit goes a long way!

Considerations when treating patients with special needs

04:33 PM | Jul 05,2016
These are great suggestions, Molly! I really like the idea about the tennis ball to the end of a toothbrush! We have a special care clinic at the University of Maryland and I think the education gained from a simple rotation through that clinic will help tremendously in the future. In the special care clinic, dentistry is important but equally as important is behavior management. In our special care clinic rooms, we have pictures of puppies and animals up on the walls for the patient to look at and feel more comfortable. It also starts good conversations and allows the patient to remember the room from their last visit. I also recently volunteered at the special olympics and we made mouthguards for the athletes. This was challenging as it was hard to get the athletes to bite on the mouthguard while it set. Every person is different and some things may bother some more than others so it is always important not to assume. I think treating patients with special needs is something that every dental student should experience in dental school, whether it be in a special care clinic or volunteering.

Considerations when treating patients with special needs

12:58 AM | Jun 29,2016
I'm with Nancy, I wish that my school had a special needs clinic or even an external rotation to a special needs environment just to at least help students feel comfortable treating them. I feel like it is a real patient expectation to be able to take care of those in our communities that have impaired physical/cognitive ability but we don't spend much time learning about it or being exposed to it in school. It is really important to exude confidence in working with special needs so that they feel as normal as possible. Having members of my family that are mentally challenged, I can say with a surety that when they are treated with confidence by others, they mirror that confidence and "feel ok" themselves. With situations involving anxiety (like a dental procedure) it can really be a challenge, but I know that by acting like we know them, are familiar with them, and sincerely care for them they will pick up on our intentions and the process is smoother for everyone. (Also really like the tennis ball idea for those with dexterity/hand issues, thanks for that!)

Considerations when treating patients with special needs

10:31 PM | Jun 27,2016
This is a great post! I wish my school had a special needs clinic like yours! Instead, we do community rotations and I chose my first rotation to be at a clinic which provides care for adults with developmental disabilities. Looking forward to using some of your tips in the upcoming weeks!

Considerations when treating patients with special needs

09:08 AM | Jun 23,2016
These are really great suggestions Molly! My school also has a special needs clinic and I feel that treating those patients was one of the most valuable experiences in my dental education. I found communication and education with the caregiver was one of the most important keys to improving oral hygiene and reliability of showing up to appointments. Which such limited dexterity in this patient population, caregivers are the primary individuals that will be assisting and performing daily oral hygiene for such special needs persons. Patience is very key when treating special needs patients, especially children and adolescences. Some patients have never been to the dentist or haven't been in years. When treating such patients you must take into consideration additional factors such as: - Can he or she sit properly and comfortably in a reclined dental chair? - Does the patient have such limited opening that a smaller pedo handpiece needs to be used? - What medications is the patient on and will this interfere with any of your planned treatment? As you mentioned, desensitization is important for patients who are timid and may present with behavioral issues. Have the patient come in and tour the office, meet the staff, and just hangout in a dental chair before day of planned dental care. If possible, have the patient observe dental care being performed on the caregiver as well. Overall compassion and understanding is essential when delivering dental care to this patient population.