By: Sheila Stille, DDS; Karen Foster, DDS; and Joann LeClaire, RDH, MS

“Disability” is defined as any physical, developmental, sensory, behavioral, cognitive, or emotional impairment or limiting condition that requires medical management, health care intervention, and/or use of specialized services or programs.3 Developmental disabilities originate before the age of 18 and are expected to continue indefinitely. Typically, patients in this population have multiple interacting medical, cognitive and/or behavioral problems, are on multiple medications, are under the care of multiple healthcare providers and receive community services.

This group of individuals has difficulty accessing dental treatment in a routine manner. Reasons include the inability to identify dentists comfortable treating this population, the need for appointment time flexibility and a lack of awareness among caregivers about which dentists to contact. This can cause serious problems in maintaining dental health. Dental urgencies and emergencies often result in a trip to the local emergency room or urgent care. Unfortunately, dentists do not play a prominent role in these facilities.

Every dentist in Colorado should be able to treat this patient population. With the following suggestions, it can be a fun and rewarding experience for the dentist and their team.

INITIAL CONTACT

Prior to any appointment, dentists should review the patient’s medical history and clarify their disability, medications, behavioral issues and past dental experiences. This will provide the opportunity to prepare for the initial visit. It can be helpful for practices to forward new patient materials to the patient or caregiver in advance of the appointment. Then upon the return of the new patient information, a practice team member should call the caregiver to review the information. With this exchange of information, you are also able to identify the patient’s legal guardian and/or medical proxy. Consider sending the family a “Social Story” of the office. This consists of photographs of the outside of the office, front desk and waiting room, operatories, dentists and team. Patients can come in for a tour as their first visit to the office. Team members show them around, have them meet the hygienist and “see” the mirror, explorer, prophy cup, and end by giving them a toothbrush or sticker. This visit can be about 15 minutes. It is important all team members are involved in helping the patient adjust to the office. When the actual exam and prophy appointment comes around, the patient is more prepared and comfortable.

YOUR FACILITY

One concern for many dental providers is, “do I have the correct space to treat this patient population?” There are several issues to consider. Mobility: does the patient have a walker or wheelchair? If your office is ADA-compliant, mobility should not be an issue. Sensory Integration: It is true many special needs patients have sensitivities to noises, lighting, tastes, textures, smells and touch. It is preferable to have a closed room or a room that is out of the way, so it is easier to control some of these factors. You can control the number of people in the room, (e.g., one provider and one caregiver) to limit distractions. Some patients enjoy music. Putting on their favorite artist can be a great distraction, while other patients may find it annoying. Watching a movie on an iPad may help as well.

Consider scheduling the patient at a time when the office has fewer patients. This allows for fewer distractions and less anxiety for the special need patient, as well as the treating provider and team. Another effective technique is a weighted blanket or laying the lead apron on top of the patient. This “pressure” has been known to provide comfort to the patient and calm anxiety while in the dental chair.

Lighting can be another negative stimulation in this patient population. You can dim the lights in the room and use loupes only. You can also use sunglasses to block the light. Who wouldn’t want to wear cool sunglasses?

Other sensory issues are taste, texture and smell. Extremes in taste, texture and smell can cause the patient to exhibit behavioral issues. For instance, mint and cinnamon can cause an adverse reaction, where the patient may try to leave or otherwise act out. Try milder flavors or no flavor, like melon fluoride varnish, bubblegum or vanilla toothpaste and prophy paste that is fruit flavor. The grit of the prophy paste may also be too much for some patients. Consider asking the caregiver to bring the patient’s own toothpaste with them to the appointment. If you prescribe fluoride toothpaste for the patient to use at home, remember to make sure the flavor is mild so the patient will use it. Try to avoid strong smells in the room, such as perfumes or air fresheners. This too can
cause the patient to react poorly. Remember that many patients have special diets or allergies. It is best to make sure the products that you use for this patient population are both gluten-free and dye free.

APPOINTMENT TIMING

 Ask the caregiver for advice as to the best time of day for the patient to be treated. Often the patient needs significant help with their Activities of Daily Living, (ADLs), such as getting up, bathing and dressing, having breakfast, and taking multiple medications, so an 8:00am appointment could be challenging. On the other end of the spectrum, a late afternoon appointment could be difficult because the patient has had a full day, is very tired and does not have the resources to cope with a new environment. Be sure to ask the caregiver what the best time is for each patient.

Another issue is time in the operatory. Many special needs patients cannot sit for a usual 60-minute appointment. You may be lucky to perform your treatment in 30 minutes! You need to be efficient and prioritize areas to concentrate on, such as the lower anterior teeth this time and concentrate on the posterior teeth next time. For your safety and the safety of the patient, utilize tools to help you be efficient. One such tool is mouth props. They come in many types: disposable, rubber with handles on the outside and metal molt props. The use of a restraint board (papoose board), pillows and suction toothbrushes can also be helpful. It is never a bad idea to begin with a toothbrush to debride the patient’s mouth to get a better view. The patient is used to seeing a toothbrush and this familiarity may allow you access to their mouth.

Behavioral techniques, such as show-tell-do; counting, rewards, videos, singing, and fidget toys can distract the patient enough to be able to perform your dentistry. It helps the patient know what’s next and how long it will take. Please don’t set your expectations high for initial visits. Sometimes, just performing a toothbrush prophy is a win! You may need additional appointments, but this also allows you to desensitize the patient to you and your office. You will surprise yourself with how rewarding it can be to treat the special needs adult population. Just a little compassion and empathy will go a long way in helping these patients and their families. Sometimes you will find it challenging to treat certain patients and in those cases referral to another practice or center is
appropriate. This is not a failure.

Just keep trying and most of all—Have Fun!

REFERENCES
1. https://www.cdc.gov/ncbddd/disabilityandhealth/impacts/colorado.html
2. Ervin DA, Hennen B, Merrick J, Morad M. Healthcare for persons with intellectual and developmental disability in the community. Front Public Health. 2014 Jul 15;2:83. doi: 10.3389/fpubh.2014.00083. PMID: 25077139; PMCID: PMC4098023.
3. Merriam-Webster.com, online dictionary

ADDITIONAL RESOURCES
https://decisionsindentistry.com/article/dental-care-patients-special-needs/
https://www.ada.org/resources/practice/practice-management/specialconsiderations
https://www.dentalhealth.org/dental-care-for-people-with-special-needs
https://www.aapd.org/media/Policies_Guidelines/BP_SHCN.pdf
https://dimensionsofdentalhygiene.com/article/caring-%E2%80%A8forpatients-with-special-needs/
https://dimensionsofdentalhygiene.com/5-strategies-when-caring-forpatients-with-special-needs/

Dr. Sheila Stille graduated from the University of Connecticut School of Dental Medicine. She then completed her residency at UCONN. She works at the University of Colorado School of Dental Medicine as the General Practice Residency Program Director. She is excited to share her love for her special needs patients with anyone who will listen.

Dr. Karen Foster received her DDS from Baylor College of Dentistry and completed a pediatric residency at the University of Texas-Houston Dental Branch. Dr. Foster is an associate professor at the University of Colorado School of Dental Medicine in the Special Care Clinic. She is also Vice President of the Metro Denver Dental Society and ADA 14th District Vice Caucus Chair for 2023. In addition, she serves on several MDDS committees and served on the Colorado Dental Association executive committee from 2014-2019.

Ms. Joann LeClaire, RDH, MS received her Bachelor of Science degree in Dental Hygiene from the University of Colorado School of Dentistry and her Master of Science in Dental Public Health from Boston University. She received a certificate from the University of Washington School of Dentistry in Dental Education in the Care of Persons with Disabilities. After working as a professor in the Department of Community Dentistry and Population Health at CUSDM for 30 years she recently retired and is working as a dental hygiene instructor for Concorde Career Colleges.