A Practical Approach to Special Care in Dentistry

Mother is a nurse and is highly motivated to support and protect her daughter

Attends a mainstream school; assisted by a support teacher

Excellent co‐operation during the oral examination

Mixed Angle class III malocclusion (hypoplasia of the superior maxilla and mandibular prognathism)

Thickened upper labial frenulum ( Figure 3.1.1)

Upper midline, interincisal diastema

Excellent oral hygiene

Incipient/early caries in #36 and #46 (require restoration)

Deep caries in #85

Cone beam computed tomography confirms a fusion defect in the superior maxilla, associated with the presence of a cleft palate that had previously been undetected ( Figure 3.1.2)

1 Although the patient's blindness is likely to be a sequela of the surgery, what other causes should be excluded in liaison with the patient's physician?Following detection of the cleft palate, it is important to consider the presence of an underlying hereditary syndromeUnderlying syndromes are identified in ~20% of cases of cleft lip and ~40% of cases of isolated cleft palateFurthermore, an associated syndrome, such as polymalformative syndrome, may be responsible for some of the patient's other conditions, including visual impairment Figure 3.1.1 Thickened upper labial frenulum. Figure 3.1.2 Cone beam computed tomography showing a considerable isolated cleft palate.

2 The patient's mother insists that her daughter's midline diastema should be corrected. What should you determine when deciding whether to proceed?Is the patient aware of the diastema (in view of her visual impairment) or is it more of a concern to her mother who is very involved in her care?What are the patient's wishes – although she is 9 years old, any elective/cosmetic treatment should be discussed with her to determine her viewThe patient's age: she is still in the mixed dentition stageThe size of the diastema and if it is increasing in sizeTreatment options in relation to the patient's compliance (frenectomy, orthodontics, restorative treatment)

3 What dental considerations are there for this patient in relation to her underlying diabetes insipidus?Diabetes insipidus and diabetes mellitus are different entities; although both can present with constant thirst and polyuria, central diabetes insipidus is an antidiuretic hormone deficiency caused by damage to the hypothalamus or, as in this case, the pituitary glandSome patients can present with dental fluorosis (due to excessive intake of fluoride in drinking water) and/or dry mouth (due to excessive fluid loss)These patients are susceptible to episodes of orthostatic hypotension

4 What factors are considered important in assessing the risk of managing this patient?SocialImpaired communication due to loss of vision; may be further impaired due to the cleft palate (can lead to unclear speech, hearing problems due to middle ear infections)Potential for overprotection due to the mother's professional backgroundMedicalAcute complications resulting from panhypopituitarism and diabetes insipidus (e.g. hypoglycaemia, hypotension, agitation)The congenital heart disease has resolved and hence does not require further consideration in relation to planned dental treatmentDentalCleft palate may be associated with malalignment of the teeth and/or nasal regurgitationComplexity of orthodontic treatment and surgery necessary to address the cleft palate

5 You decide to undertake the dental fillings before attempting a frenectomy. After an injection of local anaesthetic, the patient begins to cry and becomes anxious. What would be your approach?The pain threshold for children with blindness can be significantly lower than that of children without blindnessStop and undertake acclimatisation appointments, allowing the patient to feel and touch equipment (with sharp components/needle removed)Ensure you explain what you are going to do at each stage of treatment and acknowledge that this is necessary for all steps as the patient is blindConsider adjuncts to reduce the discomfort associated with local anaesthesia infiltrations (e.g. computer‐controlled local anaesthetic delivery)Consider the use of sedation

6 When attempting restoration of the #85, the dental caries is more extensive than previously thought. The tooth is not restorable and requires extraction. The patient is taking 20 mg of hydrocortisone a day. What corticosteroid supplementation regimen should be administered to prevent an adrenal crisis (see Chapter 12.1)?Hydrocortisone is a short‐acting glucocorticoidThe equivalent dose for 20 mg of hydrocortisone is 5 mg of prednisone or prednisolone (intermediate‐acting)Therefore, no supplementation regimen is needed

It has been suggested that children with severe visual deficits have more caries, more dental trauma and, in general, poorer oral health compared with children without visual deficits

However, in most controlled studies with a favourable socio‐economic setting and close supervision from parents/carers/dental teams, the oral health of patients with blindness or severe visual deficits is similar to that of the general population, except for a greater accumulation of dental plaque and a higher prevalence of gingivitis

In general, levels of dental plaque are determined by the degree of visual deficit and are lower in patients with acquired blindness than those with congenital blindness

Adults and elderly individuals with blindness sometimes have better oral hygiene practices than the general population and achieve similar oral hygiene indices but are incapable of detecting oral diseases early

Many patients with visual deficit have complained of shortcomings in the availability of accessible oral health services

The visual deficit can jeopardise oral hygiene and the success of certain procedures (e.g. the insertion/withdrawal of removable dental prostheses and the cleaning of interdental spaces in fixed prostheses)

A targeted approach is required to ensure appropriate adaptations are in place for dental management ( Table 3.1.1)

Orthodontic treatment can be performed for selected patients ( Figure 3.1.3)

A patient is considered to have a visual deficit if they have considerable difficulty differentiating objects at a distance of 40 cm even when using the best correction possible. Blindness is defined as the complete absence of vision or slight light perception but not in the form of objects (visual acuity less than 3/60). It is estimated that 124 million individuals worldwide have a severe visual deficit (2% of the population) and that 37 million have blindness (0.6% of the population).

Table 3.1.1 Considerations for dental management.

Figure 3.1.3 Orthodontic treatment for a patient with visual impairment.