This document discusses the dental management of children with disabilities. It covers examining handicapped children, such as allowing extra time and using immobilization devices if needed. It also discusses preventive dentistry like home dental care, diet, fluoride exposure, and sealants. Treatment of children with specific disabilities is covered, such as Down syndrome, cerebral palsy, epilepsy, asthma, cystic fibrosis, hearing and visual impairments. Behavior management techniques are suggested for treating children with mental disabilities. The document provides guidance on treating children with disabilities to ensure their dental needs are met safely and properly.

1. Virgen Milagrosa University Foundation
Dr. Martin Posadas Ave., San Carlos City, Pangasinan
COLLEGE OF DENTISTRY
Sy. 2015-2016
ORTHOPEDO SEMINAR 1 REPORT
PRESENTED BY: Ma. Hermie Culeen F. Barapon
PRESENTED TO: Dr. Ma. Mildred L. De Vera
MANAGEMENT OF THE HANDICAPPED CHILDREN
I. FIRST DENTAL VISIT
a. Schedule patient at designated time (early in the day)
b. Allow sufficient time to talk with the parents and patient before initiating
treatment
II. RADIOGRAPHIC EXAMINATION
a. Occasionally, assistance from the parent and dental auxiliaries and the
use of immobilization devices may be necessary to obtain the films
b. Better cooperation may be elicited on second visit
c. For patient with limited ability to control film position, intraoral films with
bite-wing tabs are used
d. Patient should be wear lead apron with thyroid shield
III. PREVENTIVE DENTISTRY
A. HOME DENTAL CARE
a. The dentist is responsible for the consulting with the caregiver of the
child with disabilities
b. Home dental care should begin in infancy
c. Some of the positions most commonly used for children requiring
oral assistance
d. Electronic toothbrushes
B. DIET AND NUTRITION
a. Influence caries by affecting the type and virulence of
microorganism in dental plaque, the resistance of teeth and
supporting structures, and properties of saliva in the oral cavity
b. Conditions with difficulty in swallowing (cerebral palsy) – pureed
diet
Dental Management
Of Handicapped children

2. c. Metabolic disturbance – diets restricting total caloric consumption
d. Discontinuation of nursing bottle – 12months
e. Cessation of breastfeeding – after teeth begin to erupt
C. FLUORIDE EXPOSURE
a. Patient with disabilities who has poor oral hygiene – daily rinsing of
0.05% NaF 0.4% Stannous fluoride brush on gel at night
D. PREVENTIVE RESTORATION
a. Sealants are appropriate for patient with disabilities
b. Deep occlusal pits and fissures should be restored with long
wearing composites to prevent further breakdown and decay
c. Patient with bruxism and interproximal decay – restore with stainless
steel crowns
E. REGULAR PROFESSIONAL SUPERVISION
a. Although most patient are seen semiannually for professional
prophylaxis, examination and topical fluoride application, certain
patient can benefit from recall examinations every 2, 3 or 4 months.
IV. MANAGEMENT OF A CHILD WITH DISABILITIES DURING DENTAL TREATMENT
A. TREATMENT IMMOBILIZATION
o INDICATIONS:
 Patient requires diagnosis or treatment and cannot cooperate
because of lack of maturity
 Patient requires diagnosis or treatment and cannot cooperate
because of mental and physical disabilities
 Patient requires diagnosis or treatment and does not cooperate
after other behavior management techniques have failed
 The safety of the patient/practitioner would be at risk without the
use of protective immobilization
o CONTRAINDICATIONS:
 Cooperative patient
 Patient who cannot be safely immobilized because of underlying
medical or systemic conditions
o PHYSICAL AIDS TO KEEP MOUTH OPEN:
 Wrapped tongue blades
 Open wide disposable mouth props
 Molt mouth props
 Rubber bite blocks
BODY EXTEMETIES HEAD
Papoose board Posey straps Forearm-body support
Triangular sheet Velcro straps Head positioner

3. Pedi-wrap Towel and tape Plastic bowl
Beambag dental chair
inself
Extra assistant Extra assistant
Safety belt
Rainbow stabilizing system
B. NITROUS OXIDE ANALGESIA
With the handicapped child, inhalation analgesia with nitrous oxide can
be a safeand effective method of decreasing apprehension or resistance to
dental treatment. Except for children who have severe mental retardation or
emotional disturbance, there are few contraindications to its use.
C. GENERAL ANESTHESIA
Indications for general anesthesia:
1. The uncooperative child who resists treatment after all conventional
management procedures have been tried.
2. The child with a hemostasis disorder who needs extensive dental service.
3. The mentally retarded child so severely handicapped that dentist-patient
communication is impossible.
4. The child suffering from central nervous disorders manifested by extreme
involuntary movements.
5. The child with severe CHD who is considered incapable of tolerating the
excitement and fatigue of extensive dental service.
I. MENTAL DISABILITY
 General term used when an individual’s intellectual development is
significantly lower than average and ability to adopt to the environment is
consequently limited
o SEVERE SUBNORMALITY (IDIOT) – IQ OF 0 - 19
o MODERATE SUBNORMALITY (IMBECILE) – IQ OF 20 – 49
o MILD SUBNORMALITY (MORON) – IQ OF 50 – 69
 CLASSIFICATION OF MENTAL RETARDATION

4. o DENTAL TREATMENT OF PERSON WITH MENTAL DISABILITY
1) Give family brief tour of the office before attempting treatment
2) Be repetitive; speak slowly and in simple terms
3) Give only 1 instruction at a time. Reward the patient with
compliments
4) Actively listen to the patient
5) Invite the parent into operatory for assistance and to aid in
communication with patient
6) Keep appointments short
7) Schedule the patients’ visit early in the day.
A. DOWN SYNDROME
 Best known chromosomal disorder and is caused by presence of three copies
of chromosome 21.
 Have underdeveloped midface creating a prognathic occlusal relationship
 Medical conditions occurring include cardiac defects, leukemia and upper
respiratory infections.
 Oral findings include mouth breathing, open bite, macroglossia, fissured lips
and tongue, angular cheilitis, delayed eruption times, missing and malformed
teeth, oligodontia, small roots, microdontia, crowding and low level of caries
 Children with down syndrome experience a high incidence of rapid
destructive periodontal disease
B. LEARNING DISABILITIES
 Applied to children who exhibit a disorder in one or more of the basic
psychologic processes involved in understanding or using spoken or written
language.
 May be manifested in disorders of listening, thinking, talking, reading, writing,
spelling or arithmetic

5.  Includes condition that have been referred to as perceptual handicaps,
brain injury, minimal brain dysfunction, dyslexia, and developmental aphasia
C. FRAGILE X SYNDROME
 Common inherited form of mental disability and autism
 The defect is an abnormal gene on the terminal portion of the long arm of an
X chromosome
 A history of developmental delay and hyperactivity, and physical features
such as prominent ears, long face, prominent jaw, high arched palate,
flattened nasal bridge, hyperex tensible joints, flat feet, cardiac murmur,
simian creases of the palms, post adolescent macroorchidism in males.
 Behavior features such as hand slapping, hand biting and poor eye contact
 Dental treatment depends on level of developmental delay , cognitive ability
and, degree of hyperactivity
 Mild cases may be treated by scheduling short appointments and using
immobilization/ conscious sedation
 Severely affected (generalized anesthesia)
D. FETAL ALCOHOLIC SYNDROME
 Consumption of 1-3 drinks a day during the first 2 months of pregnancy.
 Physical findings include microcephaly, bilateral ptosis, short depressed
midface, flat nasal bridge, short philtrum and thin upper lip
 Most of the dental problems associated with fetal alcohol syndrome in
children are related to high incidence of dental and skeletal malocclusions
E. AUTISM
 An incapacitating disturbance of mental and emotional development that
causes problems in learning, communicating and relating to others
 Manifest during the first 3 years of life
 Have poor muscle tone, poor coordination, drooling, hyperactive knee jerk,
strabismus and epilepsy
 Children prefer soft and sweetened foods
 Because of their tendency to adhere to routines, children with autism may
require several dental visits to acclimate to the dental environment
 Use papoose board or pedi- wrap and preappointment conscious sedation
F. CEREBRAL PALSY
 One of the primary handicapping conditions of childhood; most severely
handicapping problem affecting newborn
1) SPASTIC
a. Hyperirritability of involved muscles

6. b. Tense, contracted muscles
c. Limited control of neck muscles
d. Lack of control of muscles supporting the trunk
e. Lack of coordination of intraoral, perioral and masticatory muscles
2) DYSKENETIC
a. Constant and uncontrolled motion of involved muscles
b. Athetosis and choreoathetosis
c. Frequent involvement of neck muscles (excessive movement of
head)
d. Possibility of frequent uncontrolled jaw movement
e. Frequent hypotonicity of perioral musculature
f. Facial grimacing
g. Speech problems
3) ATAXIC
a. Combination
4) MIXED
a. Muscle are flaccid
5) RIGIDITY
a. Muscle are in a constant state of contraction
 Neonatal reflexes may persist long after the age at which they normally
disappear. Three of the most common reactions which a dentist should
recognize are the ff:
1) Asymmetric tonic neck reflex
2) Tonic labyrinthine reflex
3) Startle reflex
 Manifestations of Cerebral Palsy
1) Mental retardation
2) Seizures disorders
3) Sensory deficits/dysfunction (strabismus : most common visual defects)
4) Speech disorders
5) Joint contracture
 Intraoral anomalies more common in patients with cerebral palsy
1) Periodontal diseases
2) Dental caries
3) Malocclusion
4) Bruxism ( common in athetoid CP)
5) Trauma

7. G. SPINA BIFIDA AND LATEX ALLERGY
TWO TYPES:
1) SPINA BIFIDA OCCULTA
 Presents with skin covering an area where tissue protrudes through a bony
cleft in the vertebral column
 These children may develop foot weakness or bowel and bladder sphincter
disturbances
2) MYELOMENIGOCELE (SPINA BIFIDA APERTA)
 Most sever because spinal cord, spinal fluid, and membranes protrude in a
sac through the defect
 Can suffer from hydrocephalus, paralysis, orthopedic deformities and
genitourinary abnormalities
 Taking folic acid during 6 weeks of pregnancy can prevent 50% of neural tube
defects
 Children with neural tube defects are at high risk for caries secondary to poor
oral hygiene , poor nutritional intake and long term therapy
 Ideal time – beginning of a working session such as in the morning or after a
vacation when the office has been closed or after the office has been
professionally vacuumed and cleaned to remove latex – tainted cornstarch
H. EPILEPSY
 Various disorders may cause abnormal neuronal discharge in the brain that
may induce a seizure.
 If these seizures are recurrent, the condition is termed epilepsy, and may
affect a person by a change in the state of consciousness, an abnormal
sensory experience, tonic or clonic muscular contractions, or a disturbance in
behavioral contractions.
 A dental problem peculiar to this condition is fibrous hyperplasia of the
gingiva produced by the anticonvulsant drug Dilantin.
1. PETIT MAL SEIZURE
Characterized by episodes of abrupt, momentary loss of consciousness.
The child has a blank expression and discontinues any voluntary activities
he is engaged in at that time. Duration is approx. 10 secs.
2. GRAND MAL SEIZURE
Has a much more violent nature. Typically the eyes roll up, the pupils
dilate, and the face becomes flushed or pale. Consciousness is lost and
the body is seized by atonic spasm followed by violent muscle
contractions. The dentist is primarily concerned with preventing the child
from injuring himself.

8. II. RESPIRATORY DISEASES
A. ASTHMA (Reactive Airway Disease)
 Very common childhood diseases
 Chronic airway disease characterized by inflammation and bronchial
constriction
 Diffuse obstructive disease of the airway caused by edema of the mucous
membranes, increase mucous secretions and spasm of smooth muscle
 Symptoms: coughing, wheezing, chest tightness, and dyspnea
 Patient with taking systemic corticosteroids and those who were hospitalized
or in emergency dept. in the last year should be treated with caution
because they are at higher risk of mobility and mortality
 Patient who use bronchodilators should take a dose before their
appointment, and they should bring their inhalers/nebulizers
 Hydroxyzine HCl and diazepam may be used to alleviate anxiety
 Contraindications: barbiturates, narcotics, aspirin and NSAID’s
 Position the child with mild asthmatic symptoms in an upright/ semi – upright
position
 Emergency treatment: discontinuing dental procedure, reassuring patient
and opening airway
 Administer 100% oxygen while placing patient in upright/ comfortable
position
 Keep the airway open, administer patient B2 agonist with inhaler/nebulizer
 If no improvement, administer subcutaneous epinephrine
B. BRONCHOPULMONARY DYSPLASIA
 Chronic lung disease usually resulting from occurrence during infancy of
respiratory distress syndrome that requires prolonged ventilation with a high
concentration of inspired oxygen
 More likely in the premature infant
 Some children develop right ventricular hypertrophy (cor pulmonale)
 Major causes of death include cor pulmonale, respiratory infections, and
sudden death
 If the patient is taking O2 continuously via a nasal cannula, short
appointment with frequent breaks are necessary to prevent pulmonary
vasoconstriction
C. CYSTIC FIBROSIS
 Autosomal recessive disorder
 Most common lethal genetic disorder affecting whites

9.  The defective gene products cause abnormal H2O and electrolyte transport
across epithelial cells, which results in a chronic disease of the respiratory and
GI system, elevated levels of electrolytes in sweat, and impaired reproduction
function
 In the lungs, retention of mucous occurs which causes obstructive lung
disease and increased frequency of infections
 Symptoms: increase chest diameter, clubbing fingers and toes, decrease
exercise tolerance and chronic productive cough
 Children with cystic fibrosis have a high incidence of tooth discoloration,
mouth breathing, and open bite malocclusion
 Incidence of dental caries is low
 They prefer to be treated in a upright position and avoid sedative agents
III. HEARING LOSS
The following should be considered when treating a hearing impaired patient
1. Prepare the parent and the patient before the visit a welcome letter
2. Let the patient and parent determine how the patient desires to communicate
3. Assess speech, long ability and degree of impairment
4. Enhance visibility for communication
5. Reassure the patient with physical contact
6. Employ the tell-show-do approach
7. Display confidence
8. Avoid blocking the patient visual field
9. Adjust the hearing aid
10. Make sure the parent/patient understands explanations of diagnosis treatment
IV. VISUAL IMPAIRMENT
 Dentists should realize that congenitally visually impaired children need a
greater display of affection and love early in life and that they differ
intellectually from children who are not congenitally visually impaired
 Explanation is accomplished through touching and hearing, smelling and
tasting
 Hypoplastic teeth and trauma to ant. Teeth are common also gingival
inflammation
DENTAL TREATMENT
1. Determine the degree of visual impairment
2. Find out if companion is an interpreter
3. Establish rapport
4. In guiding the patient to the operatory, ask if the patient desires assistance

10. 5. Paint a picture in the mind of visually impaired child
6. Introduced other office personnel very informally
7. When making physical contact, do so reassuringly
8. Allow patient to ask questions about the course of treatment and answer them
9. Allow a patient who wear glasses to keep them on
10. Invite the patient to touch, taste, or smell rather than tell-show-feel-do
11. Describe in detail instruments and objects to be placed in the patient mouth
12. Because strong taste may be rejected, use smaller quantities
13. Some patient may be photophobic
14. Explain the procedures of oral hygiene and then place the patient’s hand over
yours
15. Use audio cassette tapes and Braille dental pamphlets
16. Announce exits and entrance to the dental operatory cheerfully
17. Limit providers of the patients’ dental care to one dentist whenever possible
18. Maintain a relaxed atmosphere
V. HEART DISEASE
A. CONGENITAL HEART DISEASE
Divided into two groups:
1. ACYANOTIC CHD
 Characterized by minimal or no cyanosis, and has 2 major groups:
a. (Ventricular and atrial septal defect) Left to right shunting of blood
within the heart – CM: CHF, pulmonary congestion, heart murmur,
labored breathing and cardiomegaly
b. (Aortic stenosis and coarction of aorta) obstruction – CM: labored
breathing and CHF
2. CYANOTIC
 Characterized by right to left shunting of blood within the heart
 Cyanosis is often observed even during minor exertion ( tetralogy of
fallot, transposition of the great vessels, pulmonary stensis and
tricuspid atresia)
B. ACQUIRED HEART DISEASE
1. RHEUMATIC FEVER
 A serious inflammatory disease that occurs as a delayed sequel to
pharyngeal infection with group A streptococci
 Commonly diagnosed cause of acquired heart disease in patient
under 40 years old
 Appears most commonly in 6-15 years old
 Cardiac involvement is the most significant pathologic sequela of
rheumatic fever and can be fatal or can lead to chronic RHD as a
result of scarring and deformity of heart valves

11. 2. INFECTIVE BACTERIAL ENDOCARDITIS
 One of the most serious infections of humans
 Characterized by microbial infection of the heart valves or
endocardium in proximity to congenital or acquired heart defects
a) ACUTE
 Fulminating disease that usually occurs when microorganisms of high
pathogenicity attack a normal heart, causing erosive destruction of
valves
 Caused by staphylococcus, grp. A streptococcus and Pneumococcus
b) SUBACUTE (SBE)
 Usually develops in persons with pre existing congenital cardiac
disease or rheumatic valvular lesions
 Also caused by surgical placement of prosthetic heart valves
 Commonly caused by viridians streptococci, microorganism common
to the oral flora
 Embolization is a characteristic feature of infective endocarditis
 Symptoms: low irregular fever( afternoon or evening peaks) with
sweating, malaise, anorexia, weight loss and arthralgia, painful fingers
and toes and skin lesions
DENTAL MANAGEMENT
 Behavior management techniques are useful and conscious sedation and
nitrous oxide – oxygen analgesia have been proven beneficial in reducing
anxiety in such patient
 Cardiopulmonary resuscitation equipment should be readily available
during the appointment
 If gen. anesthesia is indicated, the dental procedures should be
completed in a hospital setting
ENDOCARDITIS PROPHYLAXIS

12. VI. HEMOPHILIA
 Collection of several inborn abnormalities of metabolism which manifest
themselves as hemostasis disorders
 The most common hemophilic condition is the disorder caused by deficiency
of factor VIII (antihemophilic globulin)
 Bleeding may occur from any site, but is most common in the muscles, kidneys,
mouth and joints.
Dental Treatment:
 During most routine dental treatment, the dentist must exercise extreme
caution to prevent tissue lacerations.
 The use of local anesthesia is contraindicated for these children except when
pain is extreme and then it should be used with caution.
 Mandibular block should be avoided.
 Tooth extraction should be considered only as a last resort.
VII.CLEFT LIP AND PALATE
CLASSIFICATION:
GROUP I – clefts lying anterior to the incisive foramen
GROUP II – clefts lying posterior to the incisive foramen
GROUP III – combination of clefts of primary and secondary palate
 Surgical Treatment: Surgical closure is performed between 2-12 weeks of age
 Dental Treatment: Initial visit should be between 2-3 years old. Many of the
patients are mouth breathers, has dental enamel hypoplasia and orthodontic
problems.
 Special prosthetic appliances, speech appliances and overlay denture are
useful for these patients.
REFERENCES:
o Avery, David R., et al. Dentistry for the Child and Adolescent 8th ed. Elsevier, 2006.
pg. 526-555.
o Finn, Sidney B. Clinical Pedodontics 4th ed. W.B. Saunders Company, 1973.
Pg.562-589.