General ConsiderationsChapter 1

The birth of a child is always eagerly awaited by its family members, as it is an event of great joy and happiness, but when it becomes apparent that something is amiss with their newborn, their world is shattered. The parents of such children suffer great agony including anger and denial.

As the child grows, he may be nurtured with great love and tenderness but, sometimes, the parents may vent their rage on the innocent child who suffers for no fault of his own. The maintenance of general and oral health of such children is difficult and their dentition may be ravaged by caries and periodontal disease. Hence, the management of these “God's forgotten children” is a task which needs special effort on the part of the dental surgeon and pediatric dentist.

Developmental disability is not a term denoting clinical diagnosis but a group established for the purpose of planning programs.

The term handicapped is somewhat more inclusive than developmental disabilities, but it is not the most acceptable term. Disabled is a more preferred term and includes all forms of handicapping conditions. Although these terms are thought to be interchangeable, it is necessary to distinguish between the two:

The plight of these children with developmental disabilities has been dependent on the customs, culture and beliefs of the era. In ancient Greece and Rome, infanticide was a common practice. In Sparta, for example, neonates were examined by the State Council of Inspectors. If they suspected that the child was defective, the infant was thrown from a cliff to its own death. By the second century AD, individuals with disabilities, including children who lived in the Roman Empire, were frequently sold to be used for entertainment or amusement. The dawning of Christianity led to a decline in these barbaric practices 4and a movement toward care for the less fortunate. In fact, all of the early religious leaders, i.e. Jesus, Buddha, Mohammed and Confucius, advocated human treatment for the mentally retarded, developmentally disabled or infirmed.

During the middle ages (476–1799 AD) the status and care of individuals with mental retardation varied greatly. Although more human practices evolved (i.e. decline in infanticide and the establishment of foundling homes) many children were sold into slavery, abandoned or left out in the cold.

Toward the end of this era (1690), John Locke published his famous work entitled “An Essay Concerning Human Understanding”. Locke believed that an individual was born without innate ideas. The mind is a blank slate. This would profoundly influence the care and training provided to individuals with mental retardation. He also was the first to distinguish between mental retardation and mental illness.

The Developmental Disabilities Services and Facilities Construction Act (1970), defines developmental disability to include people with mental retardation, cerebral palsy, epilepsy and other neurological conditions closely related to mental retardation which originate prior to age 18 and constitute a substantial handicap in the year 1975 amendments. The definition of developmental disability was expanded to include autism and dyslexia, in case dyslexia resulted from one of the other disabilities included in the definition.

A disability can be attributed to mental retardation, cerebral palsy, epilepsy or other neurological handicapping conditions of an individual that is found to be closely related to or requires treatment similar to mentally retarded individuals and:

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.

Blind or partially sighted

Deaf or partially deaf

Educationally subnormal

Epileptic

Maladjusted

Physically handicapped

Defective of speech

Senile.

Physically handicapped, e.g. poliomyelitis, scoliosis

Mentally handicapped, e.g. mental retardation

Congenital defects, e.g. cleft palate, congenital heart disease

Convulsive disorders, e.g. epilepsy

Communication disorders, e.g. deafness, blindness

Systemic disorders, e.g. hypothyroidism, hemophilia

Metabolic disorders, e.g. juvenile diabetes

Osseous disorders, e.g. rickets, osteopetrosis

Malignant disorders, e.g. leukemia.

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.

Handicapped for dentistry—children who fall into the above mentioned categories.

Dentally handicapped—with oral abnormality, e.g. cleft lip and palate disabilities may range from very mild to extremely severe.

Developmentally disabled child

Medically compromised patients.

There is little evidence to support the view that the severity of the child's conditions is associated with more negative outcomes. However, data shows that the number of disabilities increases with the advancement of age (Table 1.2). Particular disabilities (i.e. conditions such as epilepsy or mental retardation) however, appear to increase the negative impact on the child and family (Patterson, 1996).

Females with chronic physical disorders are reported to have no greater incidence of psychosocial problems than females without such disorders. By contrast, males with chronic physical conditions compared to males without chronic conditions, were found to have greater malaise, unemployment along with increased risk of developing psychological and behavioral problems.

Adolescents with chronic conditions are more likely to experience more behavioral problems than their counterpart. Adolescents with three or more chronic conditions spent more than twice days in bed and out of school, and were three times more likely to have limitation of activities than adolescents with one chronic illness (Newacheck, 1991).

Young people with chronic and disabling conditions have more age-related health concerns than teenagers (e.g. height, weight and acne).

While the data support the view that most young people with chronic conditions do just fine, the reality is that there is a higher than average prevalence of depression and suicide attempts as isolation and loneliness being the cause. Due to these factors young people with disabilities have less social and sexual information as well as contact with their peers, which eventually results in delayed social maturation with increased dependency on parents for daily care. These factors ultimately result into psychological dependence and overprotection leading to social incompetency.

According to Graffi et al. (1988), children as young as kindergartners demonstrate reluctance to interact with children with mental retardation, while other document acceptance.

An extended series presentations in the literature documents how children perceive and relate to children with mental retardation.

Lack of acceptance of children who “look” mentally retarded. According to Dion et al. (1972), children with mental retardation who are educated in self-contained special classes, are friendly but are also assertive. Children with mental retardation are perceived to have lower social status.

Children from low-income families, compared to children from high-income families, tend to be more favorable toward children with mental retardation.

Children's attitudes are more positive toward children identified as “mentally retarded”. Boys are more negative than girls toward children with mental retardation, particularly, when they are labeled as a “retarded”.

Parents of children with mental retardation describe stress associated with social attitudes of other children and adults, which includes staring, discomfort, inappropriately ignoring or draw-attention to the child. More favorable public attitudes have been observed toward mildly than severely-affected individuals. Parents of normal children who are not familiar with the behavior of these children tend to favor segregation of these children in the community.

Teachers who have dealt with more severe forms of disability had limited expectation from the child reaching a level of functioning equivalent to normal children. Thereby suggesting that regular class placement would be of little help.

Siperstein (1994) emphasizes on a more favorable prognosis for children with moderate or severe mental retardation. For example, psychologists, social workers and special education teachers as compared to physicians, have significantly greater expectations for individuals with mental retardation in basic selfhelp and interpersonal skills; thereby enabling them to live in supervised living arrangements and work in a supervised full-time employment setting.

Seligman and Darling (1997) reported that often the parents' initial reaction to the news that their child has a disability is likely to be negative, with rejection of the baby during the early postpartum period.

It is important to realize that not all disabilities are diagnosed in the immediate postpartum period. Some developmental disabilities, such as cerebral palsy and mental retardation, may not be apparent until quite a long time after birth. Most parents report that they were better able to adjust to the difficulties when they were aware of the child's diagnosis from the beginning,7 rather than redefining their relationships with a child who was once defined as “normal”.

Families of children with disabilities appear to be particularly vulnerable to the experience of stress. Several types of responses have been identified that seem to be manifested due to high levels of stress in parents of children with disabilities, including suicide, divorce and child abuse (Waldman, 1999). In addition to this, other contributing factors are:

As the child grows, the family may become increasingly isolated from relatives, family, friends and community events. The family ones it becomes a restricted system, tends to worsen its problems. Over the years, the parents often become fatigued, pessimistic blaming themselves, anxious even depressed that eventually may result in separation.

An extended literature points out that the absence of the father during working periods often can increase the stress placed upon the mother caring at home for a child with severe handicaps. Stress can range from the physical burden of care to the emotional disturbance created by the child and from the disruption of normal patterns of family life to the impact on family finances. These patterns persist for mothers of varying education, family income and racial composition.

In the 1960s, usually dental treatment for the mentally retarded has been restricted to the relief of a painful emergency (Miller et al. 1965).

In the 1970s, an average 20% of dentists surveyed (in 11 states) and responded that they would be willing to treat handicapped patients (Leviton et al. 1980).

In the 1980s, 40% of caretakers experienced difficulties in locating dentists willing to provide comprehensive dental services for residents (of group homes) (Burton et al. 1990).

In the 1990s, the number of lecture hours in the predoctoral curriculum (of 49 schools) devoted to teaching dental management of persons with disabilities ranged from 0 to 40, 23 schools reported 5 or fewer hours (Fenton et al. 1993).

There is a general agreement that the population with disabilities has higher rates for poor oral hygiene, gingivitis and periodontitis than general population.

Moderate or severe gingivitis has been found almost universally with increasing age and degree of mental retardation, especially for individuals with Down syndrome.

Patients who were unable to perform their usual activity because of their chronic health issues were reported to have less dental visits as compared to other categories.

An extended series of reports on the utilization of dental services by children and adults with disabilities focuses on limited physical access to buildings, limited practitioner willingness to provide care, associated insurance and financial difficulties resulting in longer periods between dental visits.

In the past, the emphasis has been on the need to provide care to youngsters with disabilities who reside at home or in institutions. While the need for dental care of these youngsters continues, the aging of people with developmental and disabling conditions is an increasing reality.

For years, pediatric dentists have treated patients with disabling conditions as they grew from childhood into their teens and twenties. As medical achievements continue to lengthen the life span of these patients beyond middle age, the skills of more and more pediatric dentists will be needed.

More than a half million children have mental retardation, 25,000 have visual impairments, 60,000 have orthopedic impairments and 22,000 are autistic. One would assume that the need for the services for any of these conditions would overshadow the concerns for dental care. Yet when questioned, the parents/guardians of children with disabilities and older persons with disabilities consistently: single out dental treatment as one of the most needed health services.

Government spending for dental care represents less than 4% of all expenditures compared to 32% for physician services and 61% of hospital costs. Since many states do not provide adequate funds for adult medicaid dental services, limited funds are available for adults with disabilities.

Practitioner training and experience is related closely to whether they will provide care to individuals with disabilities. If practitioners had predoctoral or postgraduate exposure that includes classroom education, clinical training in the treatment of children with disabilities, they are much more likely to treat such patients.

There are reasons of not treating children with disabilities, i.e. potential litigation within the jurisdiction of the Americans with Disabilities Act and the backlash of parental and support lobby groups with legislators.

There are numerous barriers encountered by people with disabilities in their effort to obtain adequate dental care, that include:

Many parents experience difficulties in feeding a child with sucking or chewing problems due to conditions such as congenital heart disease, facial cleft, esophageal defects, generalized hypotonia, muscular dysfunction or mental retardation. In such children:

Hypotonia and paresis influence salivation, thus causing drooling of saliva and chewing problems.

Hyperfunction results in extensive tooth wear due to bruxism. Traumatic ulcers are a common finding in spastic cerebral palsy and mentally retarded children.

More width of doorways, i.e. should be 32 inch wider than normal (Fig. 1.1).

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

Walk away

Entrance door steps/ground level

Slope 1:20

Railing 1:12

Floor of the entrance (nonslipping)

Entrance calling bell

Elevator 5 inch × 5 inch

Space for wheelchair and transportation

Telephone

Rest room

Space in the operatory

Mobile units

Mobile dental services.

This is done to gather basic information to assist the office in planning the patient's first dental appointment. It establishes credibility and confidence. Screening includes the following:

For the dentist to properly serve these unfortunate individuals in his practice, he should make a careful study of the family, regarding to their strengths and weaknesses of the family also the stresses and strains placed on each member should be considered. The dentist can play a significant role in reducing parental burden and many times can assist in making the child more manageable, thereby facilitating the achievement of a more healthy life for the child and the entire family.

When evaluating the situation prior to planning any care program, initial conversation with the parents or caretaker to evaluate their intelligence, dental IQ, understanding of the child's actual problem's prognosis, and the reasons for seeking dental care is essential. Certainly these parents' opinions of their child's previous dental experiences and reactions to such treatment are as important as the opinions of parents whose children are normal.

When talking with parents, the dentist and the auxiliaries must try to understand the anxiousness, the frustration these parents have gone through and will continue to go through in raising a child with a handicapping condition.

Generally, the parents are, so involved in a child's medical or social problems that they completely neglect the dental problems. In many cases, they sought dental care and were unable to obtain it by a dentist and subsequently told that nothing could be done or nothing needed to be done for the child.

Parents may turn hostile, uncertain, fearful, ashamed, and frequently frustrated. The worried parents are often afraid that the child may get hurt unnecessarily. The overly protective parents may be ashamed of their child or totally aware of the problems but not usually concerned. These parents are also certain that the dentist will have difficulty in treating their child and thus they display a lack of confidence directly in front of the child. The ashamed parent may feel humiliated when they appear in public.

Adequate radiographic records are often necessary in planning dental treatment for the disabled child. Occasionally, assistance from the parent or dental auxiliaries may be necessary to obtain the film. Better cooperation may be elicited from some children by delaying radiographic survey until second visit, i.e. when the child will get familiar with the dental office.

For patient with handicapping condition such as neuromuscular disease, mental retardation and spinal injuries, modified techniques may be necessary. Few of the indications for such techniques are:

When standard radiographic series is beyond the physical or emotional capacities of the patient, the alternatives which can be used are as follows:

However, each of these techniques compromises image quality to some extent as compared to standard projections. Regardless of the types of radiographs to be made, the patient should wear a lead apron with a thyroid shield and anyone who helps to hold the patient and the film steady should wear an apron and gloves lined with lead.

It provides an overall view of posterior maxillary and mandibular teeth and supporting structures on one side. It is very useful in patients who cannot open mouth, cannot tolerate intraoral technique and those who experience difficulty in maintaining a stable head position.

The projection is best obtained with aid of a parent, who is seated in a dental chair reclined at 45° and draped in lead apron. Patient is positioned on parent's lap with head resting on cassette, in a position where cassette is tangential to zygomatic area in posterior and tip of the nose in anterior. The cone is oriented perpendicular to the cassette, half an inch below and behind the angle of mandible on the contralateral side (Fig. 1.2A).

In case of uncooperative patient, helpful in orthodontic diagnosis and treatment planning.

Developmental status of posterior permanent and succedaneous teeth is evaluated.

Loss of fine radiographic details.

Provides information normally obtained from periapical radiographs.

No discomfort from impingement of film on soft tissues.

A single film is sufficient for both maxillary and mandibular teeth.

Child can stabilize the film.

It provides a detailed view of interproximal areas of posterior teeth. It is useful with children who cannot tolerate intraoral film placement. An 18 inch length of floss is attached through a hole made in the tab to facilitate retrieval of the film, if it falls toward the pharynx.

The projection adequately shows the details of the development of posterior permanent teeth, presence of proximal caries and periapical pathology.

Only the manner of film stabilization differentiates Snap-A-Ray from standard bitewing technique. A No. 0 film is placed in a Rinn Snap-A-Ray holder, so that film is bisected lengthwise by jaws of the holder. The film is placed intraorally, e.g. bitewing, and patient is instructed to close on bite tab of holder.

For a handicapped patient a suitable alternative— radiograph survey consists of two posterior buccal bitewings along with anterior occlusal screening film (Fig. 1.2C).

MS I: The patient is easy to manage, cooperative and friendly.

MS II: The patient has some reluctance but responds well to verbal management by the operator. There may12 be some hesitancy, some whining or slight amount of crying. The patient may be docile but may require a mouth prop. This may be categorized as a “potentially good patient”.

MS III: The patient is unable or unwilling to reason out. The patient may be generally docile but cry or vocalize. Cooperation may be considered poor but the patient is manageable with minimal restraint and a mouth prop.

MS IV: The patient requires restraint to allow any treatment, although with much difficulty. There is screaming, loud noise, some struggling and combativeness. Premedication may be needed in addition to the restraint.

MS V: The patient is extremely difficult to manage and requires complete restraint. There is much screaming, struggling and it is necessary for accomplishing any definitive treatment to deeply sedate the patient or place under general anesthesia.

MS VI: Small uncooperative child, who only needed a minimal amount of treatment, which did not warrant the use of general anesthesia. Child treated using physical restraint.

Howitt and Stricker (1970) measured physiologic responses to dental treatment in 8–14 years old patient during an examination appointment, restorative appointment and a recall visit. The authors found that children became more experienced with dental procedures and their arousal level was reduced.

Koenigsberg and Johnson (1972) and Pfeffer et al. (1982) found that parental predictions were accurate for behavior at an initial appointment.

Koenigsberg and Johnson (1975) pointed out that because subsequent restorative appointments might introduce more stressful experiences than at an initial examination visit, subsequent behavior might be negatively altered. These authors observed the behavior of 3–7 years old patient over three dental visits, where the initial visit included an examination, radiographs, prophylaxis and fluoride treatment. Subsequent visits consisted of restorative procedures. The behavior of over one-half of the subjects remained unchanged between visits while the remaining children's behavior either improved or deteriorated.

According to Venham et al. (1977), as a child gains experience with the dental environment, he may be able to distinguish between stressful and nonstressful procedures. These authors observed an increasing negative response in preschoolers over an initial examination appointment and three restorative visits while a fourth restorative appointment and a visit to polish alloys yielded improved responses. The authors concluded that following an initial sensitization, the preschooler's response improved, perhaps by developing the ability to distinguish between stressful and nonstressful procedures.

Venham and Quatrocelli determined children's responses to specific procedures within the six appointment regimen and found that these responses became increasingly negative over a series of four injections. Responses to oral examinations, however, improved over the last three visits. So, it appears that dental experience may desensitize the child to nonstressful procedures and sensitize him to stressful ones.

Udin (1989) found that the behavior of the disabled child to be consistent over the three visits regardless of the type of treatment rendered. Also, the prediction of the child's behavior made by the parent or care provider prior to treatment accurately reflected the behavior noted at each visit.

The Patient

The Family

Pediatric (dental) practitioner

Ideally, it would be impossible to manage the dental care of children in an ordinary office setting, but the reality is that the children with disabilities are as varied as the general population of youngsters for whom practitioners provide services. While some may require special setting most can be treated in the normal office setting. Regardless of the location for services, one of the paramount needs is for the practitioner is to recognize the emotional and psychological concerns of disabled children, adolescents and their families.

Experience can overcome many of the practitioner's concerns. The results from a 1997 to 1998 national study of United States and Canadian dental schools indicated that minimal hour should be dedicated to prepare predoctoral students to care for special patient populations. Twenty-two of the forty-five responding schools offer less than 5 hours of didactic courses and 34 schools reported 0–5% of clinic time devoted to care of special populations. Despite the fact that there are increasing numbers of disabled youngsters in our community and we are only professionals trained to provide the needed care, the number of treating illnesses is still very low.

From a psychological point of view, providing dental care for children is the same whether the patient is of normal intelligence or mentally retarded.

The response of the developmentally disabled person to dental treatment is as varied as are the patients themselves. A few patients have such overwhelming fear that they fight strenuously to keep themselves completely away from the dental operatory. On the other hand, there are those patients who are relaxed and happy on the dental chair, having no fear of local anesthesia or cavity preparation and obviously enjoy the entire session. Some will tolerate only a superficial examination and will not voluntarily set foot outside the waiting room area. While others will come to the dental operatory quiet happily, showing curiosity about the equipment, enjoy a ride on the chair, yet resist an examination.

Many developmentally disabled patients show specific fear or intolerance to certain aspects of dental treatment—the sight of the operating light, the movement of the chair especially when tipped backward, the spray of water in their mouth, the saliva ejector, the noise of rotary instruments. These individuals relate fear directly to some specific feature in the dental treatment process. Apart from this specific fear, they may be quite relaxed and confident. In such cases, it might be possible to eliminate the specific item of which individual is afraid of.

Shoben and Borland concluded that the most important factors in determining whether a person will react with anxiety is the attitude and experiences of the family in relation to dentistry. Johnson and Baldwin stated that maternal anxiety appears to be the major factor affecting the behavior of young children in the dental situation.

For someone who works closely with the developmentally disabled (e.g. in an institution or hospital where many handicapped and developmentally disabled individuals are seen), it is possible to get to know the patients well and to be known by them outside of the professional situation. A friendly relationship can be established wherein fearful reactive person is converted into a trusting responsive patient.

Dentists who have had experience with developmentally disabled patients know that the severely disabled, even those whose conversational abilities are limited, can sense whether a person feels genuine interest in and concerns for them or whether there is underlying hostility present. An important factor in patient relationships is that communication not be limited to words alone but include the dentist's attitude as a whole.

The tell–show–do technique is a familiar approach to orienting the child to new elements of dental management and is especially valuable in treating the developmentally disabled patient. We all fear things that we do not understand. Since an individual who is mentally retarded understands even less than the individual with normal reasoning power; it becomes somewhat more difficult for him to overcome these fears.14 If the dentist fears the child because of his inability to manage the child's fears, it results in loss of control. The child will inevitably dictate and take advantage of the situation. Friendliness is important but the maintenance of authority is also crucial for effective treatment.

Janks recommends that the dentist should attempt to emotionally support the child by permitting the child to express his emotions—tears, fears, wishes, complaints, anger—without any rejection, criticism, or denial of his right to express feelings.

The use of the “towel treatment” or the hand-overmouth exercise (HOME) has been advocated as a method of managing behavioral problems in children, particularly obstreperous children. These techniques have no place in the management of the mentallyretarded child who does not have the reasoning power to understand that the dentist is trying to help him to overcome his fear. Flattery and rewards as appropriate for each child will be more valuable.

It is difficult to generalize about authority in dentistry. The dentists may be both firm and gentle, limiting and permissive; permit the child to face and meet the situation head on and adapt the situation to the child to face. There should be no hard and fast rules of operation. Permit the child to become involved in the dental treatment. The hand signal given by the patient to stop treatment and permitting the patient to hold various instruments are techniques that can allow the patient some autonomy and control over his own treatment.

One of the recent recommendations for providing dental care to difficult and developmentally disabled or mentally retarded children is behavior modification.

In the application of reinforcement therapy to behavioral management, tokens, check marks and candy are used. It is postulated that the child will ultimately want to engage in appropriate behaviors because he will pair the social rewards of the teacher, peer or group with the extrinsic rewards used during the shaping program.

Within the behavior modification framework, reinforce is commonly defined as a stimulus that increases the probability of the response. In addition, certain practical ramifications should be considered by the practitioner prior to the application of reinforcers that are unrelated to the behavior they are reinforcing.

Behavior modification strategy has tremendous potential for working with atypical children. Its use with these children is promising. However, its misuse can be terrifying.

The intraoral examination is of paramount importance when providing care to developmentally disabled individuals. The dentist and his auxiliaries must remember that the child who is retarded will not think fast and may react more slowly to commands than would a normal child of the same chronological age.

It is generally recommended that three procedures should be attempted on the first appointment for the normal average child walking into the dental office; oral examination, oral radiographs and dental prophylaxis with topical fluoride application.

The same is true for the mentally retarded child, but the process is slower and a different approach may be necessary. An example of this would be utilizing a tongue blade to accomplish the initial examination of the child's mouth. This would give the dentist an idea as to how well the child can manage opening his mouth and whether there is a problem of biting. If dentist is not able to utilize this technique, there might be a problem of biting on and breaking mirrors during the initial examination.

If the child shows a tendency to bite and has difficulty in opening or refuses to open his mouth, a mouth block or prop may be used.

15The patient's head in a secure head lock should be able to control his head movement. The use of a rubber bite block is strongly recommended, particularly, in patients with whom you are unfamiliar, to help keep the mouth open and to prevent biting.

In planning dental treatment for disabled child, there is no room for shortcuts. Stronger restorations such as chrome steel crowns should be used rather than large amalgam restorations. Pulpotomies and endodontic therapy should be accomplished rather than less reliable pulp-capping procedures. When there are large facial decalcifications, particularly in the primary dentition, full coverage should be the treatment of choice. Chromic gut resorbable suture material should be used so the individual does not have to go through the second procedure of removing the sutures.

The placement of a stainless steel crown (SSC) on a tooth in a patient with uncontrolled movements can be very difficult.

The fear of loss and/or aspiration can be eliminated by spot welding—a small wire loop on the labial or buccal surface is used to thread a piece of dental floss. The floss is tied and held by the dental assistant or secured to the neck apron by means of an alligator clip.

After the crown has been cemented to place, the eyelet and dental floss are easily removed and the crown is polished.

There should be no doubt that premedication is of definite value in the treatment of severely disabled patients who cannot cooperate otherwise and who require dental treatment, particularly if we compare the number of disabled patients who are deemed “untreatable” prior to the use of any sedative premedication and who respond to treatment after premedication.

Premedication is of considerable value for short-term treatment effort but should not be considered in the long-term management of a patient, whether mentally retarded or of normal intelligence. Chambers states that pharmacological management only postpones the chance for the individual to learn to face the problem.

Goals as a practitioner should be able (1) to secure the friendship, confidence, and trust of the patient, (2) to educate individual to accept dental treatment in a pleasant frame of mind, and (3) to maintain them in good oral or dental health. These goals can best be accomplished if you (1) understand growth and development characteristic of the child, (2) understand that every patient, normal or developmentally disabled, presents a unique personality, emotional state and fears, (3) know in advance what you wish to accomplish, (4) do not lie to the patient, (5) do not keep the patient waiting, (6) use minimal instrumentation, (7) compliment and reward the individual appropriately to modify negative behavior and promote more positive behavior, (8) be firm and friendly but maintain authority, (9) beware of parental and sibling influences on the patient's fears, and (10) see the world as the patient sees it with his individual level of intelligence and comprehension.

One must understand that there is no general rule established to handle individual behavioral problem in a given situation. The way to approach management and behavioral problems is to anticipate specific problems and handle them on an individual basis. It is not so important that you treat all persons who come into your office the same way. There are times when no treatment is the best treatment and times when the patient should be referred to someone better equipped to handle a specific situation. The pedodontist trained in the treatment of the developmentally disabled is an excellent source of service.

The parents/caretaker have the initial responsibility for establishing good oral hygiene in the home. Reinforcement of good home dental care is provided through mass media—newspaper, radio, television, communication with other people and school activities.

Home dental care should begin in infancy; the dentist should instruct the parents to gently cleanse the incisors daily with a soft cloth or an infant's toothbrush. For older children who are unwilling or physically unable to cooperate, the dentist should teach the parent or guardian correct toothbrushing techniques that safely restrain the child when necessary.

If a child is institutionalized, the staff should be instructed in the proper dental care regimen for the child. Wrapped tongue blades may be of benefit in helping to keep a child's mouth open while plaque is being removed.

Some parents and health centers have encouraged disabled children to assume the responsibility for their own oral hygiene, but the results are usually poor. Although independent brushing is not contraindicated, parents and staff should be aware that without their 16follow-up, unsupervised oral hygiene procedures in disabled children can have serious dental consequences.

The brushing technique for disabled patients who have fine or gross motor deficiencies limiting their ability to brush should be effective and yet simple for the person performing the brushing. One technique often recommended is the horizontal scrub method because it is easy and can yield good results. This technique consists of gentle horizontal strokes on cheek, tongue and biting surfaces of all teeth and gums. A soft multitufted nylon brush should be used.

Diet and nutrition influence dental caries by affecting the type and virulence of the microorganisms in dental plaque, the resistance of teeth and supporting structure, and the properties of saliva in the oral cavity. A proper diet is essential to a good preventive program for a handicapped child.

One should assess the diet by reviewing a diet survey with the parent, realizing that allowance must be made for certain conditions that require dietary modifications. For example, conditions associated with difficulty in swallowing, such as severe cerebral palsy, may require the patient to be on pureed diet.

Patients with certain metabolic disturbances or syndromes, such as phenylketonuria (PKU), diabetes or Prader-Willi syndrome will have diets that restrict specific foods or total caloric consumption. Whatever the special circumstance, any dietary recommendations should be made on an individual basis after proper consultation with the patient's primary physician or dietitian.

Particular emphasis should be placed on discontinuation of the bottle by 12 months of age.

The judicious use of systemic fluoride is very important in the comprehensive management of any dental patient. The dentist should first determine the concentration of fluoride in the patient's daily water supply. If the level of fluoride is between 0.7 ppm and 1 ppm, no supplementation is normally required. If the dentist is not sure of the fluoride level of the patient's drinking water, an analysis to determine the level is indicated. Once the level has been documented, a determination of the need for fluoride supplementation can be made.

Whether the patient lives in a fluoridated area or nonfluoridated area, a topical fluoride should be applied after a regularly scheduled professional prophylaxis. An American Dental Association (ADA) accepted dentifrice containing a therapeutic fluoride compound should also be used daily. Some clinicians who treat disabled patients having chronically poor oral hygiene and high decay rates suggest as daily rinsing regimen with 0.05% sodium fluoride (NaF) solution. In certain cases, chewing a 2.2 mg NaF tablet (1 mg of fluoride) or a 1.1 mg NaF tablet is recommended daily to provide both topical and systemic effects. In most instances, the benefits of a reduction in decay are far more significant than the mild fluoride mottling that may result.

Physical restraint is only one means of behavior control to achieve an adequate level of dental treatment. Parents must be informed and give consent before the use of physical restraints. They should have a clear understanding of the type of restraints used and the reason for their use.

Physical restraint is a useful and effective way to facilitate the delivery of dental care for patients who need help controlling their extremities, such as infants or patients with certain neuromuscular disorders. Physical restraint is also useful for managing extremely resistant patients who need dental care but who are not candidates for general anesthesia.

Common mechanical aids for maintaining the mouth in an open position are:

Body control is gained through a variety of methods and techniques. The followings are some commonly used physical restraints:

The papoose board has several advantages. It is simple to store and use; it is also available in sizes to hold both large and small children. It has attached head stabilizers and is reusable. However, it does not always fit the contours of a dental chair and sometimes a supporting pillow is needed. Since it covers the patient's diaphragm, a pretracheal stethoscope is necessary to monitor respiration, if it is used in combination with sedation. An extremely resistant patient may develop hyperthermia if restrained too long (Fig. 1.3).

Mink describes the bed sheet technique (triangular sheet) and its use in controlling an extremely resistant child. It allows the patient to sit upright during radiographic examinations. Its disadvantages include the frequent need for straps to maintain the patient's position in the chair, difficulty of its use on small patients, and the possibility of airway impingent should the patient slip downward unnoticed. Hyperthermia may be another problem during long periods of restraint.

The Pedi-Wrap, which does not have supports or a backboard, also comes in various sizes, allows some movement while still confining the patient and because of its mesh-net fabric, permits better ventilation, lessening the chances of the patient developing hyperthermia. It too, requires straps to maintain body position in the dental chair and constant supervision to prevent the patient from rolling out of the chair.

The beanbag dental chair insert was developed to help comfortably accommodate the hypotonic and severely spastic persons who need more support and less restraining in a dental environment. It is reusable and washable, and one size fits most people. Many physically disabled patients tend to relax more in this setting, and they require less restraint during treatment.

The child's arms and legs can be immobilized with help from the parent or the dental assistant, with Poosey straps, or with a towel and adhesive tape. If movement of the extremities is the only problem, having a dental assistant restrain the child is very helpful. A towel wrapped around the patient's forearms and fastened with adhesive tape (without impeding circulation) is also often helpful.

It is a specially designed head rest which can be attached to the upper portion of the dental chair. It provides lateral support for children with compromised neck muscle strengths. It also helps to reduce head movements in patients who have spastic or athetoid muscle involvement.

Patient's head position can usually be successfully maintained through the use of forearm-body pressure by the dentist. Other options include an additional assistant to stabilize the child's head on the papoose board head positioner.

Physical restraints should never be used as punishment. An explanation of their benefits should be presented by the dentist before their use, if communication with the patient is possible. The mouth prop can be identified as a “tooth chair”, the Pedi-Wrap as a “safety robe”, or a restraining strap as a “safety belt”, allowing the patient to feel secure rather than threatened.

The values and interests of patients are varied and complex, particularly among the handicapped. For many, oral health holds a relatively low priority in contrast to other aspects of life. Therefore, it is not likely that many patients share the high priority of oral health. So, it is important to tailor the educational approach to the needs and desires of each patient with definite consideration for the parents and/or caretakers.

The goals should be attainable. When an objective is set at an unrealistic level, failure to achieve soon frustrates the patient and he may abandon the effort. For example, a mandate to totally eliminate refined carbohydrates from the diet is not likely to be accepted by a large number of patients or parents. Instructions to modify the diet in ways that do not impose drastic changes in existing habits are much more likely to be realistic.

Similarly, objectives should be meaningful and attractive to the patient and the parent.

For the purposes of teaching individual oral hygiene to handicapped persons, three groups are described by Benberg et al. the self-care group, (a) those able to brush their own teeth but needing some encouragement and minimal supervision; the partial-care group, (b) those able to carry out only part of their oral hygiene needs and requiring considerable training and direct supervision to complete the job properly; and the totalcare group, (c) those unable to assist in any way in their own care and must be assisted by a second party.

Modifications become necessary for patients with rheumatoid arthritis or chronic damage to the joints that result in an inability to close their hands. Other patients because of special problems may find it advantageous to have the size and weight of the toothbrush handle increased. Some patients with limited movement will also require a longer handle. They can then usually brush their teeth without much help and may even learn to floss.

School program: The individuals in this group will usually attend a special academic school or class, which can be valuable in motivation and educating them to care for their teeth. The teachers or aides can cooperate with hygienists, dentists, caretakers, parents, and other personnel in teaching good oral hygiene habits. Communication must be maintained between those teaching oral hygiene at school and the parents, since the parents are usually the ones who supervise the individual in their daily care of their daily routine. It might be advantageous to hold a planned meeting of teachers, hygienists, dentists, parents, and any others involved at the beginning of a program. 19Thus the individual would not be confused by inconsistent teaching methods between school and home.

Partial-care group: Individuals placed in this group will be moderately disabled and often retarded. They usually require close supervision and direct assistance to perform the routine tasks of everyday living. When individuals asked to brush their teeth, some will attempt it but will usually brush only the front teeth.

Total-care group: Patient will need much individual instruction and help as they may never be of much assistance in cleaning their own teeth.

Studies by Smith and Blankinship in 1964 and Neibel and Keough in 1972, found the electric toothbrush to be superior to conventional brushes and well worth the initial investment for individuals in this group who cannot master handbrushing or who are uncooperative. Electric toothbrushes also make it easier for the parent or caretaker to master brushing the individual's teeth.

This group will be more difficult to manage than the selfcare and partial-care groups, but fewer oral problems will develop, if proper care is administered.

In dealing with the self-care and partial-care groups, the most important aspect of developing an effective preventive program is communication. With the totalcare group, in which a second party must provide the care, the most important aspect is positioning. By providing the caretaker with a clear field of vision of the oral cavity, proper positioning will make it easier to give care and easier to do a proper job.

Bedridden patients: The approach for bedridden patients is somewhat a reversal of the positions previously described. The patient is approached from the front rather than from behind.

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Consider a situation “where the dentists did not provide care for people with disabilities”.