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Disabled child final

VIEWS: 375 PAGES: 56

									                       DISABLED CHILD

                          CONTENTS


1.   Introduction

2.   Classifications

3.   Cerebral palsy

4.   Seizure disorders

5.   Deafness

6.   Blindness

7.   Mental retardation

8.   Autism

9.   Down‟s syndrome

10. Learning disabilities

11. Fragile X syndrome

12. Fetal alcohol syndrome

13. Preventive methods for disabled child

14. Positioning

15. Physical restraints

16. References




                             1
INTRODUCTION:

      According to the report of committee on child health (Court,

1976).

A „defect‟ is some imperfection or disorder of the body.

A „disability‟ is a defect, which does result in some malfunctioning,

but which does not necessarily affect the individual‟s normal life.

A „handicap‟ is a disability, which, for a substantial period or

permanently,     retards,   distorts       or   otherwise   adversely   affects

growth, development or adjustment to life.

      According to Harris (1971), “impairment is lacking part or all

of a limb, or having a defective limb, organ or mechanism of the

body; disablement is the disadvantage or restriction of activity

caused by disability”.

      According to the developmental disabilities services and

facilities   construction    act   (Oct.        30,   1970),   developmental

disabilities are defined as:

      “A disability attributable to mental retardation, cerebral

palsy, epilepsy, or other neurological handicapping conditions of an

individual found to be closely related to mental retardation or to

require treatment similar to that required by mentally retarded

individuals, and

a.    Originates before the individual attains age 18.

b.    Has continued, or can be expected to continue indefinitely


                                       2
c.   Constitutes a substantial handicap to such individuals.

     In 1975, the definition was expanded to include “autism and

any other conditions found to be         closely related   to mental

retardation or to be attributable to dyslexia”.

     The WHO (1974) has defined a handicapped person as “one

who over an appreciable period is prevented by physical or mental

conditions from full participation in normal activities of their age

groups including those of a social, recreational, educational and

vocational nature”.

According to the APHA

     A child who cannot within limits play, learn, work or do other

things other children of his age can do; he is hindered in achieving

his full physical, mental and social potentialities (Troutman, 1970).

     Holloway and Swallow (1982) “a patient is only handicapped

as far as dentistry in concerned if he or she is unable to obtain

treatment in the ordinary way”.

     According to the American academy of pediatric dentistry

(1996), a person should be considered dentally handicapped if

pain, infection or lack of functional dentition which affects the

following:

a.   Restricts consumption of diet adequate to support growth and

     energy needs.

b.   Delays or otherwise alters growth and development.


                                   3
c.   Inhibits performance of any major life activity including work,

     learning, communication and recreation.

Classification:

A.   Frank and Winter, (1974), have classified handicap as:

     Blind or partially sighted
     Deaf or partially deaf
     Educationally subnormal
     Epileptic maladjusted
     Physically handicapped
     Defective of speech
     Senile

Agerholm (1975) classified handicapping conditions into:

     Intrinsic handicap
     Extrinsic handicap

     An intrinsic handicap is one from which the person cannot be

separated, while an extrinsic handicap is one from which the

person, the patient can be removed, for example, social deprivation.

Nowak (1976) has classified handicapping conditions into nine

categories as follows:

     Physically handicapped, e.g., poliomyelitis, scoliosis.
     Mentally handicapped, e.g., mental retardation.
     Congenital defects, e.g., cleft palate congenital heart disease.
     Convulsive disorder, e.g., epilepsy
     Communication disorder, e.g., deafness, blindness
     Systemic disorders, e.g., hypothyroidism hemophilia
     Metabolic disorders, e.g., juvenile diabetes
     Osseous disorders, e.g., rickets, osteopetrosis

                                  4
     Malignant disorders, e.g., leukemia.

Considering the variations in the types of treatment modalities for

handicapped children, for the convenience of management, they

can be categorized into two:

     Developmentally disabled child
     Medically compromised patients

CEREBRAL PALSY:

     Nelson et al. used the term cerebral palsy to describe a group

of non-progressive disorders resulting from malfunction of the

motor centers and pathways of the brain. These are characterized

by paralysis, weakness, in coordination, or other aberrations of

motor function that have their origin prenatally, during birth, or

before the CNS has reached relative maturity (before age 5).

Cerebral palsy encompasses the neuromotor manifestations of

organic brain damage and may occur in conjunction with other

manifestations (e.g., seizures, mental retardation, various sensory

defects, and behavioral and emotional disorders).

     Cerebral palsy is a heterogeneous disorder that may result

from congenital defects, mechanical and chemical injury, and

infection. The condition is frequently subclassified according to

clinical findings. The pathologic and clinical findings are varied. It

is generally a nonfatal, noncurable condition that, in part, is

amenable   to   education,   therapy,   and   training.   Patients   with



                                  5
cerebral palsy are frequently treated in neurology clinics in

hospitals,     and   pediatric   neurologists   often   request   dental

consultation for the many oral problems of these patients.

Incidence:

     Estimates of the incidence and prevalence of cerebral palsy

vary significantly among authorities. Capute(1974) reports that the

incidence at birth varies from 0.6 to 5.9 per 1000 and estimates the

prevalence in children of school age at 0.6 to 2.4 per 1000.

Classification:

Spastic type:

1.   Occurs in more than 40% of the cases (possibly 60% to 70%).

2.   Caused by a lesion in the cerebral cortex.

3.   Tendency for the antigravity muscles to maintain a state of

     contraction and for the antagonists to lengthen, producing

     the characteristic flexion deformities, particularly in the large

     joints.

4.   Spastic quadriplegia frequently associated with convulsions

     and mental retardation.

Oro-dental manifestations:

1.   Limited head movement
2.   Hypertonicity of facial muscles
3.   Slow jaw movements
4.   Hypertonic orbicular muscles
5.   Spastic tongue-thrust


                                    6
6.    Drooling
7.    Constricted mandibular and maxillary arches
8.    Class   II,   Division   II,    malocclusion   (75%),   usually   with
      unilateral crossbite.
9.    Mandibular shift.

Athetosis:

1.    Occurs in about 25% of the cases.
2.    Caused by a lesion in the basal ganglion.
3.    Distinguishing characteristic a slow, writhing, involuntary
      movement        that   occurs     with   volitional   movement    and
      interferes with normal muscle action.
4.    Muscle normal, with no spasticity or weakness.
5.    Involuntary movements either tremor or rotary.
6.    Most    often    nor   associated     with   convulsions   or   mental
      retardation.
Oro-dental manifestations:

1.    Excessive head movement or head drawn back with bull-type
      neck.
2.    Quick jaw movements.
3.    Hypotonic orbicular muscles.
4.    Grimacing and drooling (85%).
5.    Mouth breathing (continuous).
6.    Tongue protruding between teeth and lips.
7.    Bruxism.
8.    High, narrow palatal vault.
9.    Class II, Division I malocclusion may occur in 90% cases.
10.   Anterior openbite.
11.   Poor swallowing, sucking, etc., because of impaired function
      of muscles of deglutition.
Ataxia:

                                        7
1.   Occurs in 10% of cerebral palsy patients.
2.   Caused by a lesion of the cerebellum.
3.   Distinguishing characteristic a disturbance in equilibrium.
4.   No muscular involvement.

Oro-dental manifestations:

1.   Lack of positional sensation (balance).
2.   Poor proprioceptive sensations.
3.   Slow, tremorlike head movements.
4.   Hypotonic orbicular muscles.
5.   Ankyloglossia in some cases.
6.   Tongue protrusion and open bite in some cases.
7.   Grimacing and drooling.

Rigidity:

1.   Occurs in 5% of the cases.
2.   Caused by a lesion of the basal ganglion.
3.   Manifested by constant rigidity.
4.   Voluntary movement that is slow and stiff.
5.   Patients resistant to flexor and extensor movements with
     contraction of agonists and antogonists.
Tremors:

1.   Present in about 5% of the cases.
2.   Caused by a lesion of the basal ganglion.
3.   Distinguishing     characteristic   a     repetitive,   rhythmic,
     involuntary contraction of flexor and extensor muscles.



Any of these characteristic disorders can affect the following areas :

1.   Monoplegia, one extremity affected.
2.   Diplegia, affecting like parts on both sides of body.


                                  8
3.      Paraplegia, legs and lower part of body.
4.      Hemiplegia, half of body affected.
5.      Quadriplegia, all four limbs affected.

Prognosis and associated defects:
        The mortality rate is about 15% in the first 5 years of life. Of

these at least 45% are severely mentally defective. Abount 30% are

educable. Some 35% can be classified as normal. About 25% are

severely physically disabled, another 50% moderately disabled, and

the other 25% minimally involved.

        General disabilities associated with cerebral palsy occur at

the following rates :

        Speech defects                       50% to 75%
        Mental retardation (severe)          45%
        Visual defects                       20% to 50%
        Seizures (convulsions)               35% to 60%
        Deafness                             10% to 30%
Communication:
        An important aspect in the management of the patient with

cerebral palsy in the dental office is communication. It has been

noted that 45% may have severe retardation, 25% have hearing

loss, and 50% to 75% have associated speech defects. Even with

these     obvious     handicaps,      both       verbal        and   non-verbal

communication is possible and necessary. Because significant

personality    differences   exist   in   each    type    of    cerebral   palsy,




                                      9
understanding the characteristics of each can more easily attain

communication with the patient.

      The spastic patient has been described as shut in and

introverted. Fearfulness is prominent and spastic episodes may be

induced by any outside stimulus (e.g., loud noises, sudden jars,

new situations, or meeting strangers). Consequently the spastic

patients    prefers        an    environment     devoid    of     excitment     and

stimulation. He is even afraid of demonstrations of affection

because of their effect on him. The spastic patient is slow to show

anger and quick to recover. He needs preparation before he is

introduced      to     a   new    situation    and     requires    patience     and

understanding in every phase of handling.

      The      rigid   patient     resembles     the    spastic    individual    in

personality. Fear generally is not so pronounced, but it may be

prominent.

      The individual with athetosis is typically without excessive

fear. He is readily provoked to outbursts of anger, but his

annoyance is quickly forgotten. He craves attention and affection

and enjoys the company of people. Striking features are his lack of

insight into his shortcomings and his drive to succeed. Despite his

difficulties    in     expressing     himself,    he    likes     to   engage    in

conversation.




                                        10
         The personality of the ataxic individual resembles that of the

athetoid patient. He has little fear. Anger is readily provoked by his

inability to direct a movement. When asked to make repeated

efforts, he appreciates firm quiet handling. He craves affection and

is demonstrative and outgoing. He likes people and makes friends

easily     with   both    normal     persons      and       other   handicapped

individuals. Affection and approval are necessary when working

with him.

Dental considerations:

         No specific oral disease is related to cerebral palsy; however,

there     are   some    specific   characteristics      that    depend   on   the

musculature affected and the degree of mental or developmental

retardation present. The usual dental problems of caries and

periodontal disease are often exaggerated by neglect. Hence the

primary      problems    for   dentists     are   patient      management     and

preventive care. There is no significant difference in the eruption

time of primary and permanent teeth. The caries pattern is similar

to that of healthy individuals but may be exaggerated because of

poor diet, faulty nutrition, poor hygiene, and prolonged retention of

food on the teeth.

Dental management:

         Routine dental procedures can normally be accomplished

effectively with these patients. Generally the patient with cerebral


                                       11
palsy will understand and cooperate when the dentist takes the

time to show and explain before starting a procedure. These

patients typically want to cooperate, but their lack of muscular

control makes it difficult for them.

     One can also assist the patient by using a rubber mouth prop

to hold the mouth open. Care must be taken not to force the mouth

open but just to help keep it open. The dentist should at all times

support or cradle the patient‟s head as he works, to control

involuntary movements, and should be especially concerned with

the patient‟s positioning since most individuals with cerebral palsy

have a preferred comfortable postural state. Spastic patients, in

particular, have a definite postural preference since the affected

limbs tend to normally remain in a flexed position. This may

sometimes necessitate the dentist‟s working in an uncomfortable

position.

     Restraints or supports frequently help in immobilizing a

patient with excessive involuntary movements. The purpose and

function of the restraints should be explained to the patient and

the family before the procedure, with emphasis that they are not a

form of punishment but a protection for the patient. Restraints that

are too tight may increase involuntary movements.

     Premedication is a useful modality in the management of

patients    with   cerebral   palsy   who   have   difficulty   controlling


                                      12
movements or have excessive fear and apprehension. The dentist

should be thoroughly familiar with premedicant drugs and should

understand their interactions and effects before using them.

     Some older patients are too large for restraints, and pre -

medication is contraindicated in the large doses often required.

General anesthesia may be needed for these patients and others

extremely difficult to manage.

Seizure disorders:

     Nelson et al. described five main types of seizure disorders in

children   divided   into   two   etiologic   groups,   idiopathic   and

symptomatic. Seizures in the idiopathic group cannot be attributed

to a demonstrable structural lesion of the brain and are frequently

of genetic origin. Those in the symptomatic group are associated

with developmental anomalies, injury, or disease of the brain.

     Chronic or recurrent convulsions are the problem the dentist

will most often encounter in these patients. The dentist should be

able to recognize and manage the seizure if it occurs. Five different

types of seizures, which vary in severity, repetitiveness, length, and

cause, are examined here.

Classification of seizures:

Grand mal seizures:

-    These are preceded by a momentary aura in approximately a

     third of the patients.


                                   13
-    Characterized by generalized seizures, usually occurring with

     tonic and clonic phases of muscular spasm with rapid onset.

-    The patient looses consciousness and becomes pale.

-    Dilatation   of   pupils   upward   rolling   of   eyeballs,   facial

     distortion and rapid contraction of jaw muscles.

-    Micturition and defecation may occur.

-    Patient may experience cyanosis during the tonic phase,

     which generally lasts for 20-40 seconds. This is followed by

     the clonic phase, which may last for variable periods of time,

     usually for a few minutes.

-    Patients who awaken from the seizure generally have severe

     headache and are in a state of confusion.

Petit mal seizures:

-    They appear generally between 3 years of age and puberty .

-    They occur in more commonly in girls than in boys.

-    Characterized by transient loss of consciousness, frequency

     may vary from once or twice a month to several times a day.

-    The seizure generally lasts for about 30 seconds.

-    Other manifestations like rolling of eyes, moving of eyelids,

     rhythmic movement of the head and quivering of trunk and

     limb muscles may occur.

-    Many times these seizures go unnoticed.




                                  14
Psychomotor seizures:

-    Most difficult to diagnose and control.

-    Usually a slight aura manifests itself in a young child as a

     shrill cry or an attempt to run for health.

-    After an attack of seizure the child generally become drowsy.

-    Characterized   by   loss    of   postural   tone,   1-5   minute‟s

     unconsciousness.

-    Generally there are no tonic and clonic phases present.

Focal seizures (Jacksonian seizures):

-    These are produced by injury to some part of the brain, which

     may be due to trauma or toxic agents.

-    Manifestations are related to the part of the brain affected.

-    The seizures are sensory or motor and are of clonic in nature.

-    The muscles commonly involved are the voluntary ones

     required for movements of hand, face and tongue.

Self induced seizures:

-    Some children induce petit mal or grand mal seizures by over

     breathing, by watching a blinking light or by performing some

     form of learned behaviour.

-    These should be distinguish from other types because drug

     treatment alone may not be satisfactory in managing these

     children.




                                  15
-    It is generally an attempt to draw attention, indicating some

     kind of behavioural, psychiatric and/or family problems.

Dental management:

     Most convulsive disorders are controlled through mediation

and pose few problems in dental treatment.

     The dentist or hygienist should ask the following questions

during history taking of all seizure patients:

1.   What was the age of the patient at the time of onset of the

     seizure disorder?

2.   How many seizure types do the patients have?

3.   What is the frequency of the seizures?

4.   Is the attack preceded by an aura? If so, what is the nature of

     the aura?

5.   Does the patient tend to injure himself during the attack?

6.   Do the seizures occur at any particular time of day?

7.   How does the patient act immediately preceding the seizure

     and after the seizure is over?

8.   What types of medication is the patient taking and when is

     the medication taken?

     During    actual    dental   or    dental   hygiene   appointments,

adequate preparation must be made prior to the insertion of

instruments or tooth-anchored devices (rubber dam, clamps) into

the oral cavity. Since anxiety is a frequent precipitating factor of


                                   16
seizure activity, premedication with minor tranquilizers can be

considered. The particular anticonvulsant drug regimen of the

patient   must   be   carefully   evaluated,   however,   prior   to   the

administration of such sedative drugs. These patients often arrive

at the office in a slightly sedated state due to the CNS-depressed

activity of anticonvulsant medications. It must be stressed that the

patient should never alter the daily medication routine in either

time of administration or dosage on the day of dental treatment.

The prescribing of antianxiety premedications can also enhance the

postictal depression of major motor seizures if a seizure does occur

in the office.

      The use of a mouth prop is mandatory during actual

treatment. Once a seizure begins, it is usually impossible to insert

any device to prevent intraoral injury due to the strength of

masseter contractions. The mouth prop is the best preventive

measure against trauma during a seizure episode.

      Dental units that employ “over the patient” delivery systems

for handpieces and air-water syringes should be pushed away from

the working field in case the patient lurches forward during the

tonic phase of a seizure. This reduces the possibility of hitting

dental devices, which could cause facial lacerations.

      The major consideration for the dentist and auxiliaries during

a seizure is to ensure that the patient does not suffer any physical


                                   17
harm. Merely use stabilizing techniques to assure that the patient

does not fall out of the chair. Maintain the mouth prop in place.

Loosen the patient‟s clothing. Once the postictal phase begins, turn

the patient‟s head to the side, pulling the rubber dam material on

the Young‟s frame away from the face to evacuate any accumulated

oral secretions. Constantly and produce a calming effec t. If

treatment has not yet actually begun, be sure that all tissues are

without     damage.        Discontinue       dental   therapy.    If    restorative

procedures have already been started, either temporize or complete

the final restoration. Although the patient will be in a sedated form

of consciousness, this does not contraindicate completion of a

restoration       unless    some      injury    has   occurred     or     systemic

parameters are not within normal range.

     If appliances are indicated for tooth movement or tooth

replacement purposes, the fixed type is preferred because there is

less chance of dislodgement. If fixed appliances are used for

replacing     avulsed      anterior   teeth,    however,    the   possibility     of

fracturing prosthetic tooth material always remains a factor. It is

always     best    to   sacrifice     some     esthetic   qualities     for   safety

precautions be ensuring that no lateral or protrusive contacts are

present.

     Appointments should occur just after the patient has taken

daily medications. Confirmation that the medication has been


                                         18
taken should always be made before the dentist institutes any form

of treatment.

      Dilantin hyperplasia, an overgrowth of the gingival tissue

resulting from phenytoin (Dilantin) medication, can occur in,

patients with convulsive disorders. Baired and Bhaskar report that

10% to 30% of patients who receive phenytoin for control of

epilepsy have a generalized enlargement of the gingiva, with the

labial gingiva of the maxillary and mandibular teeth the most

frequently involved. A distinction should be made between the

excessive fibrous tissue that occurs because of the phenytoin and

the   unhealthy   inflamed   tissue    that   is   superimposed   on   the

hyperplasia. The hyperplastic tissue that becomes unhealthy and

inflamed because of poor oral hygiene may be a focus of infection

and cause pain, which can in turn precipitate a convulsion.

DEAFNESS:

      Deafness is a handicap that is often overlooked because it is

not obvious. Total deafness is not common, but a dentist is likely to

treat hearing impaired children who have varying degrees of

deafness. Almost inevitably, speech is affected. If an impairment is

severe enough that dentist and child cannot communicate verbally,

the dentist must use slight, taste, and touch to communicate and

to allow the child to learn about dental experiences.




                                  19
ISO     Handicap        Speech comprehension                  Psychologic problems in
(db)                                                                      children
 0     Insignificant Little or no difficult                  None
>25       Slight      Difficulty with faint speech; May show a slight verbal
                      language         and         speech deficit
                      development within normal
                      limits
>40       Mild-       Frequent        difficulty       with Psychological problems can
        moderate      normal     speech       at   1    m; be recognized
                      language skills are mildly
                      affected
>55      Marked       Frequent difficulty with loud Child            is     likely     to   be
                      speech at 1 m; difficulty educationally retarded, with
                      understanding with hearing more pronounced emotional
                      aid in school situation                and social problems than in
                                                             children with normal hearing
>70       Severe      Might      understand            only The prelingually deaf show
                      shouts or amplified speech pronounced                       educational
                      at 1 foot from ear                     retardation      and      evident
                                                             emotional        and       social
                                                             problems
>90      Extreme      Usually no understanding of The prelingually deaf usually
                      speech even when amplified; show               severe       educational
                      child    does     not    rely     on retardation      and      emotional
                      hearing for communication              underdevelopment
       Many times, mild hearing losses are not diagnosed, leading to

management          problems          because           of    misunderstanding              of

instructions, whereas children with more severe hearing losses

already possess psychological and social disturbances that make

dental behavior management more complex. No abnormal dental

findings are associated with deafness.

                                              20
The following are known causes of hearing loss;

Prenatal factors:
     Viral infections, such as rubella and influenza
     Ototoxic drugs
     Congenital syphilis
     Heredity (for example, Waardenburg syndrome)

Perinatal factors:
     Toxemia late in pregnancy
     Prematurity
     Birth injury
     Anoxia
     Erythroblastosis fetalis

Postnatal factors:

     Viral   infections,   such   as    mumps,   measles,   chickenpox,
        influenza, poliomyelitis, miningitis
     Injuries
     Ototoxic drugs, such as aspirin, streptomycin, neomycin,
        kanamycin.
The following should be considered when treating a hearing -

impaired patient;

1.   Prepare the patient and the parent before the first visit, with

     a “welcome” letter than states what is to be done.

2.   Through the parent, determine during the initial appointment

     how the patient desires to communicate, which will go far in

     decreasing the child‟s fears.

3.   Assess speech and language ability and degree of impairment

     by taking a complete medical history.

                                   21
4.    Face the patient and speak at a natural pace and directly to

      the patient without shouting. Exaggerated facial expressions

      and the use of slang make lip-reading difficult. Even the best

      lip-readers comprehend only 30% to 40% of what is said.

5.    Watch   the   patient‟s   expression.   Make   sure   the   patient

      understands what the dental equipment is, what is going to

      happen, and how it will feel.

6.    Reassure the patient with physical contact; hold the patient‟s

      hand initially, or place a hand reassuringly on the patient‟s

      shoulder.

7.    Employ the tell-show-do approach. Allow the patient to see

      the instruments, and demonstrate how they work – for

      example, vibrations of the handpiece, scratching of the

      explorer, scooping of the excavator, and texture of the rubber

      dam.

8.    Use smiles and reassuring gestures to build up confidence

      and reduce anxiety.

9.    Avoid blocking the patient‟s visual field.

10.   Adjust the hearing aid (if the patient has one) while the

      handpiece is in operation, since a hearing aid will amplify all

      sounds. Many times the patient will prefer to have it turned

      off.




                                   22
BLINDNESS:

     Blindness affects over 15 million people today and will affect

an estimated 30 million people by the year 2000. The list that

follows gives some of the known causes of blindness; however, in

over 35% of those affected the cause is either unknown or

unerupted. Blindness is not an all-or-none phenomenon; a person

is considered to be affected by blindness if the visual acuity does

not exceed 20/200 in the better eye, with correcting lenses, or if

the acuity is greater than 20/200 but accompanied by a visual field

of no greater than 20 degrees.

Prenatal causes:
     Optic atrophy
     Microphthalmus
     Cataracts
     Colobomas
     Dermoid and other tumors
     Toxoplasmosis
     Cytomegalic inclusion disease
     Syphilis
     Rubella
     Tuberculous meningitis
     Developmental abnormalities of the orbit
Postnatal causes:
     Trauma
     Retrolental fibroplasia
     Hypertension
     Premature birth


                                 23
     Polycythemia vera
     Hemorrhagic disorders
     Leukemia
     Diabetes mellitus
     Glaucoma

     Blindness may be only one aspect of a child‟s disability. For

example, a patient with congenital rubella may be afflicted with

deafness, mental retardation, congenital heart disease, and dental

defects, as well as blindness resulting from congenital cataracts.

Blindness    is     one   disorder    that     may      result    in     frequent

hospitalizations,     separation     from     family,     and     slow     social

development. Since a blind child‟s capabilities are difficult to

assess,     many     times   such     a      child   may     be        considered

developmentally delayed.

     Consideration must be given to every developmental aspect of

a blind child. Many times, early in development the parents

experience guilt and either overprotect or reject the child, resulting

in a lack of development of self-help skills and delayed development

in general, which is often misinterpreted as mental retardation.

Assessment of parental attitudes is of primary importance in

behavioral management. In addition, blind children may exhibit

self-stimulating activities such as eye pressing, finger flicking,

rocking, and head banging. Therefore assessment of the child‟s

socialization is useful in the management of dental behavior.


                                     24
      A distinction should be made between children who at one

time had sight and those who have never seen and thus do not

form visual concepts. More explanation is needed for children in

the latter category to help them perceive the dental environment.

Dentists should realize that congenitally blind children need a

greater display of affection and love early in life and that they differ

intellectually    from    children    who     are   not    congenitally     blind.

Although    explanation       is   accomplished       through     touching       and

hearing, reinforcement takes place through smelling and tasting.

The modalities of listening, touching, tasting and smelling are

extremely important for blind children, in that they help these

children to learn coping behavior. Once speech is developed,

reports    indicate    that    the    other   senses      assume     heightened

importance       and   that   other    development        can   occur     that    is

comparable to what takes place in children with sight.

      Reports      also   reveal      that    motor    activity    affects       the

development of language and perception. Blind children tend to

have more accidents than other children do during the early years

while they are acquiring motor skills.

      Hypoplastic teeth and trauma to the anterior teeth have been

reported with greater than average frequency in blind children.

Such children are also more likely to have gingival inflammation

because of their inability to see and remove plaque. Other dental


                                       25
abnormalities occur with the same frequency as in the normal

population.

     Before initiating dental treatment for a blind child, the

dentist should keep the following points in mind;

1.   Determine the degree of visual impairment. For example, can

     the patient tell light from dark?

2.   If a companion accompanies the patient, find out if the

     companion is an interpreter. If he or she is not, address the

     patient.

3.   Avoid expressions of pity or references to blindness as an

     affliction.

4.   In maneuvering the patient to the operatory, ask if the pat ient

     desires assistance. Do not grab, move, or stop the patient

     without verbal warning.

5.   Describe the office setting. Always give the patient adequate

     descriptions before performing treatment procedures.

6.   When making physical contact, do so reassuringly.

7.   Introduce other office personnel very informally.

8.   Allow the patient to ask questions about the course of

     treatment and answer them, keeping in mind that the patient

     is highly individual, sensitive and responsive.

9.   Allow a patient who wears eyeglasses to keep them on for

     protection and security.


                                 26
10.   Avoid sight references.

11.   Rather than using the tell-show-do approach, invite the

      patients to touch, taste, or smell, recognizing that these

      senses are acute.

12.   Describe in detail instruments and objects to be placed in the

      patient‟s mouth.

13.   Demonstrate a rubber cup on the patient‟s fingernail.

14.   Holding the patient‟s hand often promotes relaxation.

15.   Since strong tastes may be rejected, use smaller quantities of

      dental materials with such characteristics.

16.   Explain the procedures of oral hygiene and then place the

      patient‟s hand over yours as you slowly but deliberately guide

      the toothbrush.

17.   Use   audiocassette         tapes   and       “braille”   dental    pamphlets

      explaining       specific     dental      procedures        to     supplement

      information and decrease chair time.

18.   Announce exits from and entrances to the dental operatory

      cheerfully. Keep them minimal, and avoid unexpected loud

      noises.

19.   Limit the patient‟s dental care to one dentist.

20.   Maintain a relaxed atmosphere.

      An    in-depth     understanding         of    the   patient‟s     background

facilitates the provision of dental care to a blind child. A team


                                          27
approach by all health professionals involved in the care of the

child is ideal. Disease prevention and continuity of care are of

utmost importance.

MENTAL RETARDATION:

      Mental    retardation      is    a    general    term    used     when   an

individual‟s intellectual development is significantly lower than

average and whose ability to adapt to their environment is

consequently limited.

      According to the AAMD, as reported by Holmes et al. (1972)

      “Mental      retardation    is       subaverage     general     intellectual

functioning which originates during the developmental period and

is associated with impairment in adaptive behavior”.

      Capute (1974) described the following criteria for a patient

with mental retardation.

1.    IQ less than 70 and represents ≥ 2 standard deviations from a
      mean of 100.
2.    Impairment of adaptive behavior.

Etiology of mental retardation:
Pre-natal                 Natal                       Post-natal
Genetic diseases          Birth injuries              Cerebral infections
Infections                Infection                   Cerebral trauma
Kernicterus               Cerebral trauma             Poisoning
Cretinism                 Hemorrhage                  Cerebral vascular accidents
Fetal alcohol syndrome Hypoxia                        Encephalopathy
                          Hypoglycemia                Malnutrition


                                       28
Classification:

       The AAMD as classified mental retardation as follows;
                     IQ                Mental retardation
                    69-55              Mildly or educably retarded
                    54-40              Tranably retarded
                    39-25              Severely retarded
                     <25               Profoundly retarded


 Degree of                                                  Special requirements for
  mental    SB-IV WISC-III         Communication
                                                                   dental care
retardation
                                                           Treat the child as normal,
                              Able to communicate well
   Mild      67-52    69-55                                sedation or N2O analgesia
                              enough
                                                           may be beneficial
                              Language skills such that    Sedation may be beneficial,
 Moderate    51-36    54-40   the child can communicate    restrains and GA may be
                              at basic level               indicated in severe cases
                                                           Sedation may be beneficial,
 Severe or   35 &     39 &    Little or no communication
                                                           restrains and GA may be
 profound    below    below   skills
                                                           indicated in severe cases



       Mental retardation has been identified in approximately 3% of

the population. For many years the potential abilities of people with

intellectual     disabilities     were         poorly   understood.     They     were

described with the terms „idiot‟ (IQ below 25), „imbecile‟ (IQ 25-50)

and „moron‟ (IQ 50-70).

       Although a child who scores two standard deviations below

the mean of the Stanford-Binet test or the WISC may have some

degree of retardation, a diagnosis of mental retardation is not

based on IQ along. A person who demonstrates both inadequate


                                           29
adaptive functioning and intellectual deficiency is considered to

have mental retardation.

     A child with mental retardation because of low intelligence

requires special care in the school. Educational programs for mild

to moderate mentally handicapped children generally focus on

simplified versions of school programs and attainment of daily

living skills. The classrooms are designed in the way similar to

home and the curriculum includes dressing, grooming, cooking etc.

A child with severe mental retardation may present a significant

challenge. Such a child can achieve success with self-help, leisure,

and some vocational skills given sufficient training and support.

Dental management:

     Providing   dental    treatment   for    a    person   with   mental

retardation requires adjusting to social, intellectual, and emotional

delays. A short attention span, restlessness, hyperactivity, and

erratic emotional behavior may characterize patients with mental

retardation undergoing dental care. The dentist should assess the

degree of mental retardation by consulting the patient‟s physician

or other caregiver if the patient does not live with the parents.

     The    following     procedures   have       proved    beneficial   in

establishing dentist-patient rapport and reducing the patient‟s

anxiety about dental care.




                                  30
1.   Familiarization of the patient with the personnel and faculty

     in the dental office will help to reduce the patient‟s fear of the

     unknown.

2.   Repetitive slow speaking in simple terms is essential. Make

     sure that the patient understands explanations. Alternative

     communication methods such as a picture board or electronic

     devices may also be used.

3.   One      instruction   at    a   time       followed   by    rewards    with

     compliments after successful completion of each procedure is

     beneficial.

4.   Be attentive towards the patient, as these patients could be

     sensitive to gestures and verbal requests.

5.   The parent may be allowed in the operatory to aid in

     communication.

6.   Short appointments and gradual progression towards more

     complex operative procedures will help in good management.

7.   Appointment should be early in the day when the dentist and

     the staff also are fresh enough and the patient will be less

     fatigue.

     By thoroughly understanding the patients degree of mental

retardation     and   abilities    and      by     exercising     patience    and

understanding,     the   dentist      should      not   have     any   significant

problems in managing the mentally retarded child.


                                       31
Autism:

        Autism was first described by Leo Kanner in 1943. Klien and

Nowak (1998) have given an excellent article on autistic disorder in

1998.

        Autism is recognized as an organic disorder characterized by

abnormalities in the brain, especially the limbic system and

cerebellum. It is associated with abnormal emotional, social and

linguistic behavior. It is characterized by qualitative impairment of

social interaction, deviant behavior patterns and activities.

Etiology:

       Organically based neurodevelopmental disorder.

       Decreased number of purkinje fibers in the postero-inferior

        sections of the cerebellar hemispheres.

       Truncation in the dendritic redevelopment of the limbic

        system.

       Hypoplasia of cerebellar lobules VI and VII.

       Hashimoto et al. (1995) suggested that it could be due to

        disturbances in early pre or perinatal life.

             Pre-natal causes include chromosomal abnormalities,

        intrauterine viral infections and metabolic disorders.

       Autistic disorder is more common in males as compared to

        females, the ratio being 4:1. Because of this a x-linked mode

        of inheritance has been suggested.


                                    32
    Autistic disorder has also been associated with fragile x-

     syndrome, tuberous sclerosis and phenylketonuria.

     The incidence of autism is about 2-10 per 10000 births.

Clinical features:

    Kamen and Skier (1985) reported a higher pain threshold in

     patients with AD.

    AD patient dislike change in environment.

    Hyperactive     knee   jerk,    poor   muscle   tone   and   poor

     coordination.

    Drooling saliva, reduced masticatory abilities, tendency to

     pouch food instead of swallowing.

    Kopel (!977) reported high degree of lateral vision.

    Self injurious behaviors like self-pinching, scratching, head

     banging to attract attention may be seen.

    Johansson et al. (1996) reported gingival cleft on canine due

     to self-infected behaviour.

     The medications commonly used in patients with autism are

methyl phenindate, diphenhydramine, phenytoin, carbamazetine

and fluoxetine.

Prognosis:

     Development of speech by 5 years of age is considered as a

good prognostic indicator. Autstic disorder is a lifelong disorder

without regression, but symptom patterns do change. The IQ is less

                                    33
than 50 in 60% of AD patients, between 50-7- in 20% of the

patients and more than 70 in 20% of the patients (Klien and

Nowak, 1998).

Oral health status:

     The oral health status of AD patients has been described by

Shapira et al. (1999). Lowe and Lindemann (1985) found that the

dmf of children with AD was greater than normal children.

However, no differences were found in the DMF values.

     Kamen and Saier (1985) reported low incidence of caries in

patients with AD.

Management:

    Braff and Nealon (1979) reported that high concentration of
     nitrous oxide is required in these patients for sedation.
    High flexibility is required on behalf of dentist.
    Short clear commands should be given.
    Touch pressure may give the patient a sense of warmth and
     may be helpful in behavioral management.
    Generally restrains may have to be used.
    Parental presence should be avoided.

DOWN’S SYNDROME:

     It is one of the most common recognizable malformation

syndromes. It may occur due to trisomy of chromosome 21(95%

cases). It may also occur because of translocation (3% cases) or due

to mosaicism (2% cases).



                                  34
        It is also called as Mongolism. Schreiner (1992) found that

this term was inappropriate and may be insulting to the affected

families.

Etiology:

        Down‟s     syndrome     occurs    very   early   in   embryonic

development, possibly during first cell divisions.

Incidence:

It is found in one of every 600 new borns.

        Predisposing factors include advanced maternal age, uterine

and placental abnormalities and chromosomal aberrations. Benda

(1960)      reported   the   frequency   of   Down‟s   syndrome   to   be

approximately 1.5 per 1000 births of mothers in 18-29-year-old age

group. The frequency increases after the maternal age of 30 years,

reaching 29 per 1000 in the 40 year old and older age group and a

high risk of 91 per 1000 in the 44-year-old age group.

General manifestations:
Skull:
       Brachycephalic skull, flattened face and occiput.
       Presence of third frontanelle just anterior to the posterior
        frontanelle.
       Flat nasal bridges, small maxilla.

Eyes:
       Oblique palpable fissures, prominent epicanthic folds
       Brushfield‟s spots appear on the iris in a ring concentric with
        pupil.


                                    35
       Scanty eyelashes.
       Cataracts, squints and nystagmus are common.

Ears:

       Dysplastic ears with abnormal pinna.

Neck:

       Short and broad with excess skin posteriorly

Hands:

       Broad and short (clinodactyly) with a single transverse
        palmar crease (simian crease).
       Short incurved little finger.
       Multiple loops on finger tips.

Muscles and joints:

       Hypotonicity and hyper extensibility.

IQ:

       Often severely retarded with an IQ of 25-50.

Associated congenital abnormalities:

a.      Congenital heart lesions are found in upto 50% (atrial septal
        defect, atrioventricular canal and VSD).
b.      Duodenal atresia.
c.      Atlanto axial instability.
d.      Umbilical hernia.
e.      Multiple immunological defects affecting the skin, GIT and
        respiratory tracts.
f.      Acute lymphoblastic leukemia 20 times more common in
        these children.
g.      Hypothyroidism and Alzheimer‟s disease.


                                        36
Oral manifestations:

Mouth:

       Small drooping mouth
       Open mouth posture

Tongue:

       Protrusive, fissured (scortal) tongue.
       Circumvallate papillae may be enlarged but filiform papillae
        may be absent.
       Macroglossia.

Lips:
       Thick, dry, fissured.

Occlusion:
       Anterior open bite and crossbite, class III tendency.
       Small maxilla.

Palate:
       Often appears high with horizontal palatal shelves (omega
        palate).
       Bifid uvula, cleft lip and palate.

        Landau (1966) made a cephalometric comparison in childre n

with Down‟s syndrome with their normal siblings. They found that

there was a retardation in the growth of both maxilla and

mandible. Upper facial height was significantly smaller, midface

was smaller in both horizontal and vertical dimensions. They

concluded that because of this factor there was tendency towards

crowding and the tongue also tended to be larger than normal.



                                     37
Eruption of teeth:

      Retarded
      Early shedding of deciduous teeth.

       Ondarza et al. (1997) conducted a study of 127 males and

128 females with Down‟s syndrome and found, on average, that 6

primary teeth were delayed in eruption in boys and 11 in girls.

       Jara et al. (1993) in a similar study of 116 males and 124

females showed delayed eruption of 13 permanent teeth in boys

and 8 permanent teeth in girls.

Teeth:

      Hypodontia especially third molars and maxillary lateral
       incisors.
      Microdontia.
      Hypocalcification and hypoplastic defects.

      Low incidence of caries.

       Johnson et al. (1961) found that dental caries prevalence in

both   primary     and   permanent    dentition   in   Down‟s   syndrome

patients was low. Brown and Cunningham (1961) in a study found

that 44% Down‟s syndrome children were caries free.

Periodontium:

      Severe, early onset periodontal disease due to local factors

       like poor hygiene, tooth morphology and malocclusion and

       systemic factors like decreased humoral response, reduced

       chemotaxis, impaired phagocytosis, poor circulation etc.


                                     38
     Tannenbaum (1975) observed that prevalence and severity of

periodontal disease in children with Down syndrome is much

higher than the normal.

     Cichon et al. (1998) concluded that individual with Down‟s

syndrome as compared to the normal groups and exaggerated

immunoinflammatory responses, which could not be explained only

by poor oral hygiene and indicated that there may be some

abnormality in cell mediated or humoral immunities.

     Morinushi et al. (1997) obtained blood samples of 75 subjects

with Down‟s syndrome. They found that the extent of gingival

inflammation and anti-body titers was high and suggested that

colonization   of   certain   pathogenic   organisms   for   periodontal

disease occurred before 5 years of age.

      Carlstedt et al. (1992) demonstrated significantly higher

colonization of candida albicans in Down‟s syndrome children as

compared to control group. They believed that abnormalities in

immune response in Down‟s syndromes children are responsible for

making them more susceptible to oral diseases.

Dental treatment:

    These children (10%) are mentally retarded (moderate t

     severe) and require appropriate treatment.

    Incidence of cardiac disease associated with Down syndrome

     is 40% and will require adequate prophylaxis.


                                   39
    Increased incidence of leukemia and acute and chronic

     infections of the upper respiratory tract can also alter

     treatment.

    Children     are   generally   affectionate     and   cooperative   and

     present no special problems during management.

    Nitrous    oxide   analgesia    or   TSD   in    mildly    apprehensive

     patients can be used: general anesthesia in severe resistance

     to dental treatment.

    Preventive procedures along with chlorhexidine mouth wash

     may be beneficial.

    Pulp treatment in deciduous teeth are contraindicated in

     patients   with    cardiac     problems    because    of   the   risk   of

     bacteremia whereas in permanent teeth it can be considered

     if an adequate apical seal can be obtained.

Learning disabilities:

-    The term learning disabilities is applied to the children who

     exhibit a disorder in one or more of the basic psychological

     processes involved in understanding or using spoken or

     written language.

-    Affects 3 to 15% of the population

-    Four times more common in boys, as compared to girls.

-    May be manifested in disorders of listening, thinking, talking,

     and reading, writing, spelling or erythematic.


                                     40
-    Includes conditions that have been referred to as perceptual

     handicaps, brain injury, minimal brain dysfunction, dyslexia,

     and developmental aphasia.

-    Learning disabilities do not include problems caused by

     hearing, visual and motor handicaps, mental retardation and

     emotional or environmental disturbances.

-    Physiological factors such as brain injury or damaged to the

     CNS have been implicated.

-    Genetic factors have been also implicated.

-    Emotional disturbances can also develop as a result of

     learning disabilities.

-    Most children accept dental care and usually do not pose

     problems for the dentist although some cases may require

     pharmacologic management.

Fragile x-syndrome:

-    It is a common inherited form of mental retardation and

     autism.

-    It accounts for 30-50% cases of x-linked mental retardation.

-    It is due to abnormal gene in the terminal portion of the lon g

     arm of chromosome X.

-    Males are more vulnerable than females because of only one

     X chromosome.




                                 41
-    Patient   present   with   history    of    developmental     delay,

     hyperactivity.

-    Physical features include prominent ears, long face, and

     prominent jaw, high arched palate, flattened nasal bridge,

     hyperextensible joints, flat feet, and simian crease of palms

     and nacroorchidism.

-    Behavioral features include hand slapping, hand biting and

     poor eye contact.

-    May also concurrently have Down‟s syndrome or cerebral

     palsy.

-    Treatment is multidisciplinary – requiring speech, language,

     and occupational therapy. Mental intervention can be useful

     in decreasing hyperactivity and increase in attention span.

-    Prognosis is better in females than in males.

-    Severe    cases   may   have    to   be    treated   under   general

     anesthesia.

Fetal alcohol syndrome:

-    The consumption of 1-3 drinks daily during first 2 months of

     pregnancy may result in significant damage to developing

     baby.

-    Alcohol consumption can cause multiple problems, which

     include neurologic abnormalities, cardiac defects, growth

     retardation and cognitive defects.


                                    42
-    Physical findings include microcephaly, bilateral ptosis, a

     short and depressed midface, flat nasal bridge, a short

     philtrum, thin upper lip, cleft palate, micrognathic mandible

     and prognathic jaws.

-    As   children    grow   older,    these   children   become   less

     cooperative and are less difficult to treat.

Management of the disabled patient:

     A thorough knowledge of the patient‟s personal and social

background is valuable in enabling the practitioner to become

familiar with the disabled person‟s home environment. Cooperation

of the parents or the primary care taker is essential for complete

and planned treatment.

Family involvement:

     The clinician should make a careful study of the family, their

strengths and weaknesses and the stresses and strains of each

member of the family. The dentist can play a significant role in

reducing the burden and many times in assisting in making the

child more manageable, thereby facilitating for a more healthy life

of the child and entire family.

     Before evaluating the situation it is essential to sit down and

make the parents to evaluate the intelligence, IQ, understanding

the child‟s problem and their reasons for seeking dental care.




                                  43
     When talking to the parents the dentists and the auxilliaries

must try to understand the anxious times these parent have had

and are having and will continue to have in raising a child with

handicapping condition.

     Very commonly, the parents get involved with the child‟s

social and medical problems to such an extent that the childs

dental problems are neglected. For considerable number of these

children, diet consists of a large amount of soft foods with

considerable refined sugar. Lack of dental care further complicates

the problem of dental caries.

     Parents‟ attitude towards the handicap child dictates the

approach of the dentist towards the child. The behavior of the

parents may be hostile, uncertain, fearful, ashamed and frequently

frustrated. The fearful parents are often afraid the child may be

unnecessarily hurt. The over protective parents may be ashamed of

their child and neglect the problems of their child. The ashamed

parents feel humiliated when they appear with their child in the

public. If these parents are kept waiting in the reception room for a

long period of time, this certainly will have a negative effect on

their opinion about the dentist and his ways of handling the child.

Preventive methods for the disabled child:
Expectations and motivation:
     The dentist, owing to his professional background may

conceive of patient education as primarily transmission of facts

                                 44
about dental health. Patients have been educated about oral health

and oral hygiene only when they have been given information in

such a way so that they can apply it in everyday life. This requires

methods of presentation relevant to the needs of the child.

        The values and interest of the disabled child may be varied

and complex. For many children oral health is a relatively low

priority and these patients are unlikely to share the dentist high

priority for oral health.

        The goals for these children‟s should be attainable. When an

objective is set at an unrealistic level, failure to achieve the target

may frustrate the child and may abandon the task. For example,

total    elimination      of    carbohydrates       may    be        unacceptable.

Instructions    to   modify     the   diet   may    be    more       realistic.   The

objectives set should be meaningful and attractive to the patients.

        For   purposes     of   teaching     oral   hygiene     to    handicapped

persons, 3 groups have been described by Bensberg et al. (1969):

1.      Self care group
2.      Partial care group
3.      Total care group

1.      Self care group:

       The individuals are easiest to work with

       Most of them are ambulatory and are able to stand in the

        lavatory.



                                       45
    Modifications are necessary for patients with rheumatoid

     arthritis or chronic damage to joints.

    Some patients may find advantageous to have a heavier

     toothbrush handle.

    They can usually brush their teeth without much help and

     may even learned to floss.

    Although persons in this group are most capable, it is

     necessary to see that they have a daily set routine for oral

     care whether in school or at home.

    It is the duty of the dentist and more so of the parents to see

     that the daily routine is properly maintained.

2.   Partial care group:

    Individuals in this group are moderately disabled and often

     retarded.

    They require close supervision and direct assistance to

     perform the routine task of daily requirements.

    They may not be able to foresee long term benefits of proper

     tooth brushing. They may not understand that brushing now

     will be important to them 5 years from now.

    These children have to be taught tooth brushing on the

     premise that it makes them look more handsome or beautiful.




                                  46
    Rapid learning cannot expected in these patients the task of

     each step has to be repeated several times in order to achieve

     results.

     For Example it may be taught as following:

     -     Hold the toothbrush with help.

     -     Put the brush in the mouth with help

     -     Make the brush strokes in the mouth with help

     -     Make the brush strokes by self

     -     Brush the teeth from beginning to completion by self on

           being told to do so.

    The individual should have mastered the previous step in

     order to move to the next step.

    The teaching has to be in a pleasant manner.

    Compliment the individual on any effort he makes to brush.

    These children can be motivated a making fancy calendar and

     placing stars on the dates that they brushed or by providing

     tokens for accomplishments.

Total care group:

    This group consists of children who are severely disabled.

    Many children may be confined to wheelchairs or may be bed

     ridden.

    These children need individual instructions and help.




                                  47
     The proper training, these children may or may not able to

      achieve the responsibility.

     Many of these children may not able to use the routine

      toothbrush.

     Smith and Blankinship (1964) found electric toothbrushes to

      be    superior   to   the    conventional    toothbrushes.   Electric

      toothbrushes also make it easier for the parent to master

      brushing the individuals teeth.

     This group is more difficult to manage than the previous two

      groups.

Positioning:

      For self-care and partial care groups, most important aspect

is   development       of   an     effective   preventive    program   and

communication is very important. But for the total care group the

important aspect is positioning.

      Positioning should be in such a way that it should provide the

caretaker with a clear field of vision of the oral cavity. Thereby

making oral health care easier. The health care professionals,

teachers,    parents    and      caretakers    must   know   the   common

techniques used.

     Standing: With a larger child or an adult the person doing the

      brushing or flossing may stand behind the patient and cradle

      the patients head in one arm, holding the lower jaw open with


                                      48
    the same hand and brushing and flossing with a other han d.

    Mouth props or padded tongue blades may be useful in

    extremely uncooperative children.

   Sofa: Many mothers feel more comfortable sitting on a sofa

    and having the child to lie down with his head in the

    caretakers lap to accomplish oral hygiene procedures.

   Lap: The todler or small child may be handled with a

    caretaker sitting on a chair without arms or on the toilet

    seats in the bathroom. The child is draped across the parents

    lap with the head hanging down over one leg slightly to assist

    in the opening the mouth.

   Sitting one the floor: For difficult to control patients, the

    parents can easily restrain the child and get a clear view of

    the mouth, still maintaining a comfortable position, by having

    the child sit on the floor.

   Wheel chair patients: These patient present a special problem

    for persons who provide oral hygiene care. The same type of

    approach can be used as in standing. But with the design of

    some types of chairs, it may be more difficult.

   Bedridden patients: The approach for bedridden patient is

    somewhat a reversal of positions previously described. The

    patient is approached from the front rather than the back.




                                  49
     Transferring the patient from the wheel chair to the dental

chair is often a difficult problem several aids are used for this

purpose.

    A useful aid is the transfer or sliding board, which allows the

     wheel chair patients to be moved without lifting. One side of

     the wheel chair, which should be beveled at its narrower

     edges, is pushed beneath the patient‟s buttocks. The other

     end is resting on the dental chair. The patient with assistance

     slides across the board into the dental chair.

    A second aid that is useful is the turntable, having non -slip

     ribbed rubber surfaces on both top and bottom so that it will

     not move on a highly polished surface. The wheel chair is

     moved to the side of the dental chair and turntable is placed

     beneath the patient‟s feet. The patient is then assisted to

     stand. After rotating him/her through the required angle, the

     patient is allowed to sit on the dental chair.

    Another transportable device is the Hatrick recliner, which

     allows the wheel chair to be reversed into its framework so

     that the occupant‟s head rests against a support.

    Another simple way is having a two-person lift.

Physical restraints:

     The physical restrains are mainly used for immobilization

during treatment.


                                 50
Indications for immobilization:

      Patient who requires diagnosis or treatment and cannot

       cooperate because of lack of maturity.

      Patient who requires diagnosis or treatment and cannot

       cooperate because of mental or physical disabilities.

      Patients who require diagnosis or treatment and do not

       cooperate after other behavior management techniques have

       failed.

      When safety of the patient would be at risk without the

       protective use of immobilization.

Contraindications:

      Cooperative patients
      Patients who cannot be safely immobilized
      Underlying medical or systemic conditions
      As a punishment
      As a convenience to staff
      Without informed consent

       The commonly used immobilization aids are those for the

body, extremities and the head:

Body                          Extremities        Head
Papoose board                 Posey straps       Forearm-body support
Triangular sheet              Velcro straps      Head positioner
Pedi-wrap                     Towel and tape     Plastic bowl
Beanbag dental chair insert   Extra assistant    Extra assistant
Safety belt
Extra assistant


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Papoose board:
    Simple to store and use

    Available in both large and small sizes

    It has attached head stabilizers

    Reusable

    Does not always fit contour of dental chair. Sometimes a

     pillow may be required.

    Because it covers the patient‟s diaphragm, a pretrachial

     stethoscope is necessary to monitor respiration.

    Extremely resistant patient may develop hyperthermia

Triangular sheet:
    Mink (1966) described it as bed-sheet technique.

    Allows patient to sit upright during radiographic examination.

    Disadvantages include frequent need for straps and difficulty

     to use small patients, and possibility of airway obstruction if

     patient slips downwards unnoticed.

    Hyperthermia may be another problem.

    Constant need for supervision.

Pedi-wrap:
    Comes in various sizes and allows for some movement but

     does not have a head stabilizer.

    Its mesh fabric permits better ventilation. Thereby lessening
     hyperthermia.
    Straps are required and constant supervision is necessary.


                                52
Bean bag dental chair insert:

    Comfortably accommodates severely spastic children.

    Reusable and rewashable, available in several sizes.

     If movement of extremities is the only problem having the

dental assistant to restrain the child is helpful. Posey straps fasten

the arms to the dental chair and allow limited movement. A towel

wrapped around the patient‟s arms is often useful in athetoid –

type of cerebral palsy.

     Patient‟s head can be usually maintained successfully by use

of forearm of dentists although other equipments may also be used.

     For keeping the patients mouth open, a mouthprop can be

used by identifying it as a tooth chair. Rubber bite blocks may also

be used which are available in various sizes to stabilize the mouth

in open an position. A padded tongue blade may also be used.

Oral appliances used in disabled children:

    Mouth stick appliances are devices, which are of benefit to

     patients whose head and neck remains the only neurologically

     intact part of the body. Patients who may benefit include

     those with cerebral palsy, poliomyelitis or quadriplegia.

    Palatal training aids are appliances used by patients with

     acquired or congenital defects of neuromuscular control of

     the velopharynx as described by Selley (1977). Patients with

     velopharyngeal insufficiency suffer from nasal escape of air


                                 53
    with an associated lack of intraoral pressure leading to

    hypernasal speech patterns, abnormal articulation and fewer

    words articulated with each breath.

   Anti-chewing devices may also be used in comatose patients

    who may develop powerful chewing movements, which can

    lead to self-inflicted trauma.

   ISMAR (Innsbruck Sensorimotor Acticator and Regulator),

    this appliance is a combination of the activator and the

    Frankle    appliance.    Hoppenbrauer   (1989)   described     it.

    Recently Gisel (2001) gave a review article describing the use

    of this appliance. This appliance is especially useful for

    training    proper      chewing   methods   in-patients      with

    neuromuscular abnormalities like cerebral palsy.




                                 54
REFERENCES:

Agarholm,    M.   (1975):   “Handicaps   and   the   handicapped   –   A

     nomenclature and classification of intrinsic handicap”. J.R.

     Soc. Health.; 1: 113.

Braff, M.H. and L. Nealon (1979): “Sedation of the autistic patient

     for dental procedures”. J. Dent. Child.; 46: 404-407.

Capute, A. (1974): “Developmental disabilities - An overview”. Dent.

     Clin. North Am.; 18(3): 559.

Court, S.D.M. (1976): “Fit for future. Report of the committee on

     child health in London”.

Franks, A.S. and G.B. Winter (1974): “The management of the

     handicapped and chronic sick patient in dental practice”. Br.

     Dent. J.; 136: 20.

Gisel E.G. et al. (1999): “The innsbruck sensorimotor activator and

     regulator (ISMAR) : Construction of an intraoral appliance to

     facilitate ingestive functions”. J. Dent. Child: 180-187.

Harris, A.I. (1971): “Handicapped or impaired in great Britain. Part-

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Hashimoto, T. et al. (1995): “Development of the brainstem and

     cerebelium in autistic patients”. J. Autism Dev. Disord.; 25:

     1-18.

Holloway, P.J. and J.N. Swallow: “Child dental health”. 3 rd Ed.,

     Bristol john Wright, 1982: 155.


                                  55
Johnson, C.D. et al. (1996): “Preventing factitious gingival injury in

      an autistic patient”. J. Am. Dent. Assoc.; 127: 244-247.

Johnson, R. and D.C. Baldwin (1961): “Maternal anxiety and child

      behaviour”. J. Dent. Child.; 36: 87.

Kamen, S. and I. Skier (1985): “Dental management of the autistic

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Kopel, H.M. (1977): “The autistic child in dental practice”. J. Dent.

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Mink, J.R.: “Dental care for the handicapped child”. In Goldman,

      H.M. et al. (Ed) Current therapy in dentistry. Vol. 2, St.

      Louis, Mosby, 1966.

Nowak, A.J.: “Dentistry for handicapped patient”. 1 st Ed., St. Louis,

      Mosby, 1976.

Selley, W.G. (1977): “Dental health for the stroke patients”. Br.

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Shapira, J. et al. (1989): “Oral health status and dental needs of an

      autistic population of children and young adult”. Spec. Care

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Tannenbaum, K.A. and J.W. Miller (1960): “Oral conditions of

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WHO     (1952):   “Joint    expert    committee   on   the   physically

      handicapped child”. Report series No. 58, Geneva.




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