Module 3: Influence of Special Health Care Needs on Oral Health



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Module 3: Influence of Special Health Care Needs on Oral Health




INTRODUCTION

Although oral health problems affect all children, the importance of oral health promotion for children with special health care needs is particularly relevant. Special health care needs can increase a child’s risk for oral health problems and can also make the overall effects of poor oral health more severe.


This module reviews some of the oral health implications that special health care needs can have and presents some considerations that should be made when developing an individualized care plan.
After completing this module, you should be able to:

  • Describe the potential impact of various special health care needs on oral health

  • Identify the potential effects that medications can have on oral health risk

  • Identify nutrition and oral health systems of care for children with special health care needs



INFLUENCE OF SPECIAL HEALTH CARE NEEDS

Special health care needs can increase a child’s risk of developing oral health problems for a number of reasons:



  • Physiologic risk factors associated with the condition (e.g., structural anomalies, oral-motor problems that prevent adequate hygiene)

  • Risk factors associated with secondary conditions and/or therapies (e.g., feeding problems that necessitate frequent, prolonged meals and snacks; medications)

  • Barriers to appropriate dental care

Potential effects of some specific conditions are discussed in the next several pages and are summarized in Table 3-1.


A list of questions to consider when addressing the oral health needs of a child with a special health care need is included in the Practical Applications section of this module.

Conditions with Potential Abnormalities of Oral Structures

Down syndrome (Trisomy 21)

Cerebral palsy

Craniofacial malformations

Other syndromes and conditions

Other Conditions

Prematurity

Gastroesophageal reflux (GER)

Failure to thrive

Developmental delay

Cardiac conditions

Diabetes

Compromised immune function

Cancer

Conditions Associated with Abnormal Food-Related Behaviors

Autism


Prader-Willi syndrome

Metabolic Disorders

Disorders requiring a restricted semi-synthetic diet

Glycogen storage disease

Galactosemia

Lactose intolerance
Conditions with Potential Abnormalities of Oral Structures
Down syndrome (Trisomy 21)

Down syndrome (trisomy 21) is caused by an “extra” 21st chromosome. Children with Down syndrome often have mental retardation, cardiac defects, and hypotonia (decreased muscle tone). Duodenal atresia (blockage of the intestine) may be present.


Children with Down syndrome have delayed dental development, with primary teeth erupting later than among children without Down syndrome. Some permanent teeth may be missing as well, and teeth may have thin enamel or be hypoplastic. Children may also have a small oral cavity resulting in tongue protrusion and flared incisor teeth. These problems, along with the potential for feeding problems and gastroesophageal reflux, make preventive oral care for children with Down syndrome especially important. One study also found that bruxism is more common among children with Down syndrome than children without. (Bell) Children with Down syndrome are also more prone to periodontal disease (Meyle). Down syndrome is often associated with secondary cardiac defects; this can affect fluid intake and thus, saliva production.

Figure: bruxism



Cerebral palsy


Cerebral palsy (CP) involves chronic, nonprogressive central nervous system (CNS) dysfunction leading to problems with tone and movement. Children with CP make up a very heterogeneous group. Depending on the original insult, this diagnosis has many clinical manifestations, from very mild to very severe neurological involvement. Children with cerebral palsy may or may not be ambulatory and may or may not have mental retardation.
A child with cerebral palsy may have a forward-positioned tongue thrust and hypotonia of peri-oral muscles, resulting in (malocclusion). Children with cerebral palsy may have problems consuming an adequate intake because of oral-motor problems and/or increased energy needs (for children with athetoid CP); they may be more likely to consume cariogenic foods at frequent intervals, increasing risk of caries. In addition, oral-motor sensitivities (e.g., heightened gag reflex) may prevent adequate oral hygiene. Some children with CP use feeding tubes. (See below) Gastroesophageal reflux (GER) is also common among children with cerebral palsy and presents oral health risks. Medications commonly used by individuals with CP also have oral health implications. Anti-seizure medications and anti-GER agents are often prescribed.
Craniofacial malformations

Children with craniofacial malformations are at higher risk of developing oral problems. For example, children with cleft lip/palate disorders have more decayed, missing, and filled teeth than children without (Faine, Redford-Badwal). In a study of children with cleft lip and/or palate, the prevalence of rampant caries seemed to be related to infant feeding practices. (Bian)



Other syndromes and conditions


Other syndromes are associated with oral-motor problems that might limit a child’s intake of specific foods and make oral hygiene difficult. These syndromes include Fragile X, deLange, trisomy 18, achondroplasia, Klinefelter, Marfan, Lowe, Williams, Rett, Smith-Lemli-Opitz, Angelman, and fetal alcohol.
Children with other conditions such as muscular dystrophy and some metabolic disorders and children who are drug-affected at birth may also be at increased risk for oral health problems because of oral-motor difficulties.
Other Conditions

Prematurity


Prematurity and intrauterine malnutrition can have adverse effects on an individual’s oral health. The last trimester provides the neonate with fat, fat soluble vitamin, and mineral (including calcium and phosphorus) stores. When an infant is born before these stores are accrued, oral health problems can develop. Even with extra calcium, vitamin D, and phosphorus, an infant can have generalized enamel hypoplasia in the primary teeth. (Boyd)
One study of infants who weighed less than 2000 grams at birth indicated more porous dental enamel and subsurface lesions. (Noren) Another study followed 25 infants born with very low birthweights (less than 1500 grams). Around age 4 ½ years, an average of 7.6 primary teeth had enamel defects, compared with 1 defect in children with normal birthweights. (Lai) Likewise, malnutrition in the first few months of life (when oral structures develop) can increase the risk for oral problems. (Alvarez, Ismail)
Gastroesophageal reflux (GER)

Gastroesophageal reflux (GER) is the regurgitation of gastric contents into the lower or upper esophagus or mouth. GER is common among children with cerebral palsy and other conditions, including asthma, and can contribute to oral problems. As the acidic gastric contents are regurgitated, primary and permanent teeth can be eroded. (Faine, Boyd)



Failure to thrive


Failure to thrive and other problems with weight gain and growth can contribute to oral health problems as well. If frequent meals and snacks are needed to maintain an adequate energy intake, or if mealtime is longer than usual, the demineralization period may exceed remineralization. Weaning may be delayed, and children allowed to sip on a bottle throughout the day. (Faine, Boyd) In addition, severe malnutrition may be associated with oral manifestations such as caries, gingivitis, angular cheilitis, candidiasis, and delayed tooth eruption. (Meyle)

Developmental delay


Children with developmental delay constitute a diverse group. Oral health problems associated with developmental delay can include enamel hypoplasia due to other conditions and/or the use of medications, oral sensitivity, and delayed feeding skills that require prolonged use of the bottle and/or extended mealtimes. (Boyd)

Cardiac conditions


A cardiac condition can increase a child’s risk of oral health problems because of medications (see below). Some children with cardiac conditions have increased energy requirements that may require frequent meals and snacks. Children with cardiac conditions are also at increased risk for systemic infection during oral procedures.

Diabetes


Both type 1 and type 2 diabetes can present oral health implications.
Increased prevalence and severity of periodontal disease and gingivitis has been associated with poorly controlled diabetes (types 1 and 2). Poor control increases the risk for alveolar bone loss. (Meyle) Periodontal disease may also have a negative effect on blood sugar control. In addition, persons with uncontrolled hyperglycemia often have a poor response to periodontal therapy. (Palmer)
Oral health and prevention of disease should also be considered when recommending nutritional therapy for diabetes. For example, the frequency of snacks can increase the risk of caries. While it may not be beneficial to decrease the number of snacks a child consumes, recommendations for oral hygiene and non-cariogenic foods are appropriate. (See Module 4) (Palmer)

Compromised immune function


Children with compromised immune function (for example, children with AIDS or who take immunosuppressive medications) are more susceptible to oral infections such as candidiasis, viral infections, dental caries, and periodontal disease. (Meyle) One study indicated higher caries rates in children with HIV infection than local and national rates. Use of sucrose-containing medication, xerostomia, and use of sweetened beverages at night were identified as factors that increased a child’s risk of caries. In addition, cachexia, if present, makes maximizing nutrient intake especially important. (Eldridge)


Cancer


Cancer and many treatments for cancer have major implications for both oral health and nutrition. Implications include increased energy needs with cachexia and thus altered eating patterns (e.g., timing, types of foods consumed), medications that decrease saliva production, treatments that decrease immunity, enamel erosion due to vomiting caused by treatments, and treatments that increase oral lesions. In addition, oral lesions can make adequate hygiene difficult. Communication between the dental professional, physician, and registered dietitian to minimize oral health problems and maximize nutrient intake is important for optimal management. (Palmer)

Eating disorders


Eating disorders are characterized by abnormal eating patterns and cognitive distortions related to food and body weight and affect individuals of all ages and from all socioeconomic strata. Eating disorders can include anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified. Oral manifestations of eating disorders can include enamel erosion (due to self-induced vomiting), dental caries (for example, due to binging on sweet foods), dentin hypersensitivity, xerostomia, and periodontal disease. (Faine)
Conditions Associated with Abnormal Food-related Behaviors
Autism

Diagnostic criteria for autism include problems with verbal and nonverbal communication, ritualistic behaviors, and inappropriate social development. About 75% of children with autism have some type of cognitive deficit. (DSM IV)


The potential for oral health problems related to autism is associated with food- and oral-motor-related behaviors. Children with autism often prefer only a few foods, and these foods may be high in fermentable carbohydrate. Some children retain food in their mouths, rather than swallowing, further increasing the exposure of acid to the teeth. In addition, oral hypersensitivities may make adequate oral hygiene difficult. Some medications used by children with autism have dental implications. (Friedlander 2003)

Prader-Willi syndrome


Prader-Willi syndrome is a genetic disorder caused by partial deletion of chromosome 15 (paternal) or disomy (maternal). Children with Prader-Willi syndrome have mental retardation and abnormal food-related behaviors. Prader-Willi syndrome is characterized by feeding problems during infancy, and hyperphagia, often resulting in obesity, in childhood and adolescence. (Nativio)
Dental considerations for the child with Prader-Willi syndrome can include rampant decay because of diet-related issues; if not well-controlled, frequent food intake can increase a child’s risk of developing oral health problems. Poor oral hygiene, decreased salivary flow, and some medications contribute to increased risk as well. Delayed tooth eruption and periodontal disease have been reported in individuals with Prader-Willi syndrome. (Friedlander)
Metabolic Disorders
Disorders requiring a restricted semi-synthetic diet

Phenylketonuria, urea cycle disorders, organic acid disorders or other metabolic disorders requiring a restricted semi-synthetic diet are not associated with abnormal oral structures. However, caries risk may be increased with inadequate provision of critical nutrients or too frequent exposure to sweet, sticky, low protein foods (e.g., candy, low protein cookies, fruit snacks).


Glycogen storage disease

Glycogen storage disease may increase a child’s risk of oral health problems if adequate oral hygiene is not provided after cornstarch therapy. (Cornstarch is part of therapy for several forms of glycogen storage disease. It is often given every 4 hours.)


Galactosemia

Galactosemia requires the restriction of galactose and thus, milk products. If adequate amounts of calcium and vitamin D are not provided, a child’s risk of oral health problems is increased.


Lactose intolerance

As with galactosemia, restriction of milk and other sources of lactose without adequate vitamin D and calcium supplementation can lead to oral health problems.



Table 3-1. Conditions with the Potential to Affect Oral Health


Condition

Potential Effects on Oral Health

Conditions with Potential Abnormalities of Oral Structures

Down syndrome (trisomy 21)

Delayed dental development; some children have congenital absence of some permanent teeth

Hypoplastic enamel

Small oral cavity with normal sized tongue that appears to be large, thus may develop malocclusion, maintain open mouth, breathe through the mouth

Bruxism occurs frequently, may cause tooth abrasion, loss of enamel from chewing surfaces

Potential for feeding problems, gastroesophageal reflux, and cardiac defects (See below)

Increased risk of periodontal disease

Behavior issues and lack of cooperation with oral hygiene procedures at home

Cerebral palsy

Forward tongue thrust may cause open bite

Malocclusion may develop if tongue in abnormal position

Abnormal or depressed movement of the tongue, lip and cheek; thus food particles remain lodged in the teeth and contribute to cavities

Problems with feeding and/or increased energy needs (with athetoid cerebral palsy) may cause frequent intake of cariogenic foods

Oral-motor problems may make adequate hygiene difficult

Gastroesophageal reflux (See below)

Medication use, including anti-seizure, anti-gastroesophageal reflux common

Cleft lip and/or palate and other craniofacial malformations

Malformed teeth and/or poorly aligned teeth occur frequently, even with early surgical repair

Infant feeding practices may increase rate of decayed, missing, or filled teeth

Low self image may contribute to lack of oral hygiene

Other syndromes (e.g., Fragile X, deLange, trisomy 18, achondroplasia, Klinefelter, Marfan, Lowe, Williams, Rett, Smith-Lemli-Opitz, Angelman, fetal alcohol)

Oral-motor difficulties may limit intake of specific foods and may make oral hygiene difficult

Other conditions (e.g., muscular dystrophy, some metabolic disorders, drug-affected)

Oral-motor difficulties may limit intake of specific foods and may make oral hygiene difficult

Other Conditions

Prematurity

Early malnutrition affects tooth development and eruption and results in increased caries in the primary teeth

Gastroesophageal reflux (GER)

Erosion of primary and permanent teeth may result from regurgitation of the acidic gastric contents into the mouth

Failure to thrive and other problems with weight gain and growth

Frequent meals or snacks or prolonged mealtimes may lead to development of caries

Delayed weaning and/or child allowed to sip on bottle or sippy cup throughout the day increases risk of caries

Feeding problems

Oral hypersensitivities make oral hygiene difficult and may limit types and/or textures of foods eaten

Nutrient intake may be affected, making nutrients needed for tooth mineralization unavailable

Tube-feeding

Increased calculus

Associated oral-motor problems and/or gastroesophageal reflux add to oral health risk

Developmental delay

Oral health problems can include enamel hypoplasia, oral sensitivity, delayed feeding skills that prolong the use of the bottle and/or length of mealtimes

Cardiac conditions

Increased risk for systemic infection during oral procedures

Increased potential for medication interactions

Higher energy requirement may result in increased carbohydrate exposure and acid production

Diabetes

Poorly controlled type 2 diabetes associated with increased prevalence and severity of periodontal disease, alveolar bone loss; poor response to periodontal therapy with hyperglycemia; periodontal disease may also negatively affect blood sugar control

Frequency of snacks can increase risk of caries

Compromised immune function (e.g., AIDS, chemotherapy for cancer, post-organ transplant)

May develop painful oral lesions which interfere with oral hygiene and food

May be more susceptible to infections (e.g., candidiasis, viral infections, caries, periodontal disease)

If cachexia is present, frequent meals may increase risk

Xerostomia

Conditions with Associated Abnormal Food-Related Behaviors

Autism

Often prefer only a few foods which may be high in fermentable carbohydrate

May retain food in the mouth rather than swallowing

Oral hypersensitivities may make adequate oral hygiene difficult

Prader-Willi syndrome

Increased frequency of food intake because of insatiable appetite

Poor oral hygiene

Delayed tooth eruption

Decreased salivary flow

Metabolic Disorders

Disorders requiring a semi-synthetic diet (e.g., phenylkentonuria, urea cycle disorders, organic acid disorders)

Caries risk may be increased with inadequate provision of critical nutrients or too frequent exposure to sweet, sticky low protein foods

Glycogen storage disease

Frequent exposure to cornstarch without adequate hygiene may increase risk of caries

Galactosemia

Restriction of galactose may interfere with calcium and vitamin D intake and thus bone development

Lactose intolerance

Restriction of lactose may interfere with calcium and vitamin D intake and thus bone development



Influence of Medications
Medications can have dental implications as well. For example:


  • liquid syrups with sugar can contribute to dental caries (Sahgal)

  • medications that cause dry mouth (e.g., albuterol, antihistamines, anticholinergics, antidepressants, antibiotics, anti-GER medications, stimulants) decrease saliva flow, thereby decreasing saliva’s protective factors (Boyd, Friedlander 2003)

  • medications that interfere with vitamin D metabolism (e.g., phenytoin) interfere with tooth mineralization (Boyd)

  • medications that affect folate status (e.g., phenytoin) can cause symptoms of folate deficiency, including lesions on lips; in addition many liquid vitamin supplements do not contain folic acid (Boyd)

  • phenytoin can also lead to hyperplasia of the gum tissue, making good oral hygiene even more important

Use of medications with oral health implications is common among children with myelomeningocele, asthma, and seizure disorders.


Figure: hyperplasia


Influence of Feeding and Eating Problems

Feeding problems


Feeding problems, common among many children with special health care needs, contribute to oral health problems in a number of ways. Oral hypersensitivities may make good oral hygiene difficult and may also limit the types and textures of foods eaten. When mechanical or behavioral problems limit the amount or types of foods that can be eaten, nutrient intake may be affected and nutrients needed for development and remineralization may be unavailable. (Faine, Boyd)

Tube-feeding


Use of feeding tubes can also present oral health problems. Even with an intensive oral hygiene program, individuals receiving tube feedings have more plaque and calculus than individuals without tube feedings. In addition, the need for tube feedings is often associated with dysphagia and other oral-motor problems, neurological impairment, and gastroesophageal reflux, all of which have nutrition and oral health implications. (Dyment, Jawadi)
Dental Visits
An AAP policy statement recommends the establishment of a dental home for children who are at risk (including children with special health care needs). AAP recommendations for at-risk children also include referral to a dentist by 12 months of age (or 6 months after the eruption of the first tooth) and anticipatory guidance about growth and development and nutrition-related oral health issues (AAP). The American Academy of Pediatric Dentistry (AAPD) recommends that all children visit a dentist before 12 months of age or 6 months after first tooth erupts (AAPD).
The dentist or dental hygienist may help families identify modifications for toothbrushes (e.g., for easier gripping, if a child’s grip prevents him from brushing his own teeth) as well as to identify positions to support the head and body when teeth are being cleaned.
Access to Oral Health Care
Access to appropriate dental care can be difficult for children who are developing typically. For a child with special health care needs, especially one who does not live in an urban setting, appropriate dental care can be even more difficult to obtain. Many dental practitioners do not have adequate training to provide services to children with special health care needs. In addition, many offices are not set up to accommodate children with physical disabilities and many dentists do not participate in the Medicaid program, which is the primary funding source for dental services for many individuals with special needs. (Waldman, NMCHORC, Casamassimo)
Some dental clinics have developed partnerships with public health departments, school districts and early intervention programs to provide preventive care. In other communities, families may need to travel to obtain services.
A number of oral health resources available for children with special needs are described below. Contact information is summarized in the Resource section of this module.
Medicaid

Dental care is mandated under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) service. EPSDT is the Medicaid program for individuals under 21 years of age and includes periodic screening, vision, dental, and hearing services. Dental services include, at a minimum, relief of pain and infections, restoration of teeth and maintenance of dental health. A direct dental referral is required for every child in accordance with the state’s periodicity schedule and at other intervals as medically necessary.


The Americans with Disabilities Act requires dentists to serve children with special health care needs and also requires that dentists make reasonable modifications to facilitate access to care.
Title V of the Social Security Act: Maternal and Child Health Services Block Grant

US states and jurisdictions use funds allocated by Title V of the Social Security Act of 1935 for a wide range of maternal and child health programs. Programs and services vary, however the overall goal is the same, to improve the health of all mothers and children. Thirty percent of Title V funding is reserved for children with special health care needs. In some areas, this funding provides direct service (or reimbursement for service), including dental and nutrition care.


Early Intervention

Part C of the Individuals with Disabilities Education Act (IDEA) provides funding for early intervention services. This program provides assessment and intervention services for infants and children 0-3 years old with developmental delay or other special health care needs. Services provided vary from state-to-state, but could potentially include oral health screening and care.


Head Start and Early Head Start

Head start and Early Head Start services include screening and referral for oral health problems and education for children (ages 0-5 years) from low income families. At least 10 percent of enrollment slots must be available to children with special health care needs. (Bertness)


Head Start Program Performance Standards require that programs determine a child’s oral health status within 90 days of entry into the Head Start Program. This includes helping families to arrange for further assessment and intervention, if needed. (Bertness)
Special Smiles Program

Special Olympics includes a Special Smiles program. The mission of Special Smiles is to increase access to dental care for Special Olympics athletes and others with intellectual disabilities. The program provides dental screening, education about oral hygiene, and information about local dental care providers. More information can be found on the Special Olympics website: www.specialolympics.org/Special+Olympics+Public+Website/English/Initiatives/Healthy_Athletes/Special+Smiles/default.htm.


Access to Baby and Child Dentistry (ABCD) Program

The Access to Baby and Child Dentistry (ABCD) Program focuses on provision of preventive and restorative dental care for children ages 0-6 years who are eligible for Medicaid. It is a collaborative effort between public and private sectors. Education (of the dental health community and the target population) is central to the program, supporting dentists in private practice to increase access to care in the community. The Washington State program serves as a model for programs in other states. More information is available on the project website: www.abcd-dental.org/.


Other programs

Regional and local programs that provide oral health care for persons with disabilities and training for dental professionals are also available. Examples of these programs include DECOD at the University of Washington. A list of these programs can be found in the resource section of this module.


What non-dental providers can do

Access to a pediatric dentist is often difficult. (There are about 4000 pediatric dentists practicing in the US, compared to more than 60,000 pediatricians). Because access to care is such an issue, it makes sense for non-dental health care providers to incorporate preventive messages into their interactions with children and their families. In fact, the Surgeon General’s report on Oral Health identified assessment (and action) by non-dental professionals as critical to improving oral health (US DHHS).


Health care providers can perform screening for oral health problems and make referrals to dentists and dental hygienists, as appropriate. In some states, non-dental health providers (e.g., physicians, nurses, physician assistants, and nurse practitioners) can apply fluoride varnish. (See Module 4 for more information about prevention of oral health problems and Module 5 for screening information and resources.)

PRACTICAL APPLICATIONS



Questions to consider related to special health care needs

When addressing the oral health needs of a child with a special health care need, it can be helpful to ask the following: How does the disorder (or treatment for the disorder) affect



  • development of oral structures?

  • saliva production?

  • frequency of eating?

  • types of food consumed?

  • the ability of the child/parent to perform good oral hygiene at home?


Case examples: Identify the oral health risk factors.
Case example #1: Marc

Marc is a 6-year old with spastic quadriplegic cerebral palsy. The school district’s occupational therapist (OT) works with Marc to improve his feeding skills and also provides strategies that Marc’s teachers and family can use. Marc needs to eat 6-8 times per day in order to have an adequate intake and to maintain appropriate weight gain. His medications include phenytoin (to control seizures) and glycopyrrolate (to control excessive drooling).


The correct answers are b, c, and d.
Frequent meals and snacks increase caries risk by increasing the amount of time teeth are exposed to an acidic environment.
Phenytoin has several drug-nutrient interactions, including interfering with folate (lesions on lips) and vitamin D metabolism (tooth mineralization), and can lead to gum hyperplasia.
Decreased saliva, associated with use of glycopyrrolate is also a risk factor.
The Registered Dietitian (RD) working with Marc’s family used the Bright Futures in Practice: Oral Health guidelines to identify some strategies to address potential problems:


  • The RD confirmed that Marc was connected with a dentist and had regular visits; Marc’s dentist sees children with developmental delays as part of his practice and develops a plan to minimize anxiety and discomfort during cleanings and procedures with each family.




  • The RD asked questions about the types of foods offered and access to oral care after meal and snack times. Because the frequency of eating was not negotiable, she helped the family to identify foods to offer when oral care was not immediately accessible. For example, Marc’s family decided to offer the cheese that he usually ate for lunch as an afternoon snack in place of a sweetened cereal bar. The cereal bar was offered at lunchtime, since his teeth were brushed after lunch.




  • The RD ensured that Marc’s vitamin D, calcium, and folate needs were met, since his seizure medication could interfere with those nutrients.


Case example #2: Lucinda

Lucinda is a 26-month old with trisomy 21 (Down syndrome). She had cardiac surgery as an infant and does not like procedures around her face or mouth. She has gastroesophageal reflux that is treated with medication. Lucinda receives speech and physical therapies through the early intervention program in her community.


The correct answers are a, b, and c.
Potential problems associated with trisomy 21 include delayed dental development, hypoplastic enamel, malocclusion, bruxism, feeding problems, and problems with oral hygiene.
Lucinda's dislike of procedures around her face and mouth may interfere with good oral hygiene at home.
Gastroesophageal reflux can increase the time that Lucinda's teeth are exposed to acid.


  • The Family Resource Coordinator helped make a referral to a pediatric dentist.

  • Lucinda’s family asked her therapists to help them find ways to minimize Lucinda’s oral hypersensitivity, to make oral hygiene easier.



QUIZ





  1. Gastroesphageal reflux is common among children with which of the following conditions:

    1. Autism

    2. Cerebral palsy

    3. Prader Willi syndrome

    4. Craniofacial malformations




  1. Gastroesophageal reflux (GER) is a risk factor for oral health problems because:

    1. GER is associated with increased calculus development

    2. Teeth are eroded as acidic gastric contents are regurgitated

    3. The medication used to treat GER interferes with remineralization

    4. Oral-motor problems associated with GER alter the types of foods a child can consume




  1. Children with cerebral palsy can have oral-motor sensitivities. This can increase risk of oral health problems because:

    1. Duration of mealtime is longer

    2. Adequate oral hygiene may be prevented

    3. Food must be consumed more frequently

    4. None of the above; oral-motor sensitivities do not increase oral health risk




  1. Prematurity and/or malnutrition in the first few months of life can increase risk for which of the following:

    1. Bruxism

    2. Cleft palate

    3. Gum hyperplasia

    4. Enamel hypoplasia




  1. Which of the following is NOT a common oral health risk factor associated with failure to thrive and other problems with weight gain and growth:

    1. Delayed weaning

    2. Longer mealtimes

    3. Medication interactions

    4. Frequent meals and snacks




  1. Which of the following medications can lead to hyperplasia of the gum tissue?

    1. Albuterol

    2. Phenytoin

    3. Acetaminophen

    4. Anticholinergics




  1. What is the oral health implication of a medication that interferes with vitamin D metabolism:

    1. Can interfere with tooth mineralization

    2. Can cause development of lesions on lips

    3. Can lead to hyperplasia of the gum tissue

    4. Can decrease saliva flow, thereby decreasing saliva’s protective factors




  1. True or False: An American Academy of Pediatrics (AAP) Policy Statement recommends the establishment of a dental home for children at risk (including children with special health care needs):

    1. True

    2. False




  1. Which of the following resources includes restoration of teeth and maintenance of dental health:

    1. WIC

    2. Head Start

    3. Medicaid/EPSDT

    4. Food Stamps program




  1. Which of the following resources includes screening and referral services for oral health and may include parent education and classroom activities:

    1. WIC

    2. Head Start

    3. Medicaid/EPSDT

    4. Food Stamps Program



REFERENCES

Alvarez JO. Nutrition, tooth development, and dental caries. Am J Clin Nutr. 1995; 61(suppl):410S-416S.


American Academy of Pediatrics (AAP), Section on Pediatric Dentistry. Oral health risk assessment timing and establishment of the dental home. Pediatrics. 2003; 111(5): 1113-1116. Online: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;111/5/1113
Bell EJ, Kaidonis J, Townsend GC. Tooth wear in children with Down syndrome. Australian Dental Journal. 2002;47(1): 30-35.
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Bian Z, Du M, Bedi R, Holt R, Jim H, Fan M. Caries experience and oral health behavior in Chinese children with cleft lip and/or palate. Pediatr Dent. 2001;23(5):431-434.
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Casamassimo PS. Seale S, Ruehs K. General dentists’ perceptions of educational and treatment issues affecting access to health care for children with special health care needs. Journal of Dental Education. 2004;68(1): 23-28.
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Faine MP. Recognition and management of eating disorders in the dental office. Dent Clin N Am. 2003;47:395-410.
Faine MP. The role of dietetics professionals in preventing early childhood caries. Building Block for Life. 2001; 25(1).
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Friedlander AH, Yagiela JA, Paterno VI, Mahler M. The pathophysiology, medical management and dental implications of Fragile X, Rett, and Prader-Willi syndromes. J Calif Dent Assoc. 2003; 31(9): 693-702.
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Meyle J, Gonzalez JR. Influences of systemic diseases on periodontitis in children and adolescents. Periodontology 2000. 26:92-112.
National Maternal and Child Oral Health Resource Center (NMCHORC). Inequalities in Access: Oral health services for children and adolescents with special health care needs. 2001. Online: www.mchoralhealth.org/PDFs/OHSCSHCNfactsheet.pdf. Accessed March 10, 2004.
Nativio DG. The genetics, diagnosis, and management of Prader-Willi syndrome. J Pediatr Health Care. 2002;16:298-303.
Noren JG. Enamel structure from deciduous teeth from low-birth-weight infants. Acta Odontol Scand. 1983;41:355-362.
Palmer CA. Diet and Nutrition in Oral Health. Upper Saddle River NJ: Prentice Hall. 2003.
Redford-Badwal DA, Mabry K, Frassinelli JD. Impact of cleft lip and/or palate on nutritional health and oral-motor development. Dent Clin N Am. 2003;47:305-317.
Sahgal J, Sood PB, Raju OS. A comparison of oral hygiene status and dental caries in children on long term liquid oral medications to those not administered with such medications. J Indian Soc Pedod Prev Dent. 2002; 20(4): 144-151.
US Department of Health and Human Services (US DHHS). Oral Health in America: A report of the Surgeon General – Executive Summary. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. Available at www.nidcr.nih.gov/sgr/sgr.htm and more information at www.nidr.nih.gov/sgr/children/children.htm
Waldman HB. Perlman SP. Providing dental services for people with disabilities: why is it so difficult? Mental Retardation. 2002;40(4): 330-333.

RESOURCES

Prevention



The Oral Health Tip Sheet for Head Start Staff: Working with Parents to Improve Access to Oral Health Care

Holt K, Cole S. The Oral Health Tip Sheet for Head Start Staff: Working with Parents to Improve Access to Oral Health Care. Washington DC: National Maternal and Child Oral Health Resource Center, 2003.


This tip sheet is intended to help Head Start staff working with health professionals ensure that pregnant women, infants, and children enrolled in Head Start receive oral care.
http://www.mchoralhealth.org/PDFs/HSOHTipParent.pdf

Special Health Care Needs



Dental Education in Care of Persons with Disabilities (DECOD)

Dental Education in Care of Persons with Disabilities (DECOD) is a special program of the UW School of Dentistry that treats persons with severe disabilities and prepares dental professionals to meet their special oral health needs. Includes several special clinics: pediatric, for children with disabilities; rehabilitation for those in vocational training and independent living program; geriatric, for elderly with disabilities; mobile dental service, for residents of long-term care facilities and the homebound. Training programs include short-term fellowships, extended fellowships, research training, staff training, and self-directed modules. The series of self-directed modules are for dental professionals who would like to treat patients with special needs. They include information about transfers from wheelchair to dental chair, and special dental concerns with specific conditions.


http://www.dental.washington.edu/departments/oralmed/decod/
Special Care Resources – Developmental Disabilities Practical Oral Care Series

National Institute of Dental and Craniofacial Research. Practical oral care for people with developmental disabilities: Making a difference [Dental provider’s kit]. Bethesda, MD: National Institute of Dental and Craniofacial Research, 2004.


This series of publications is designed to equip dental professionals with information on delivering quality oral health care to people with special health care needs. Strategies for care, covering topics such as mobility, neuromuscular and behavioral problems, sensory impairment, and other treatment considerations are discussed in the context of the general dentist office setting. Individual booklets offer practical guidelines on adapting standard practices for people with autism, cerebral palsy, Down syndrome, and mental retardation. A guide for caregivers has also been provided to detail the important role they play at home in maintaining good oral health. No charge for single copies. Continuing education for dental providers offered.
National Oral Health Information Clearinghouse http://www.nidcr.nih.gov/HealthInformation/SpecialCareResources/default.htm
National Institute of Dental and Craniofacial Research (NIDCR): Oral Health Information Index

The National Institute of Dental and Craniofacial Research (NIDCR) is a resource for health professionals and patients that gathers and disseminates information, including fact sheets, brochures, and information packets. The Oral Health Information Index includes bibliographic citations, abstracts, and availability information for a wide variety of print and audiovisual materials.


http://www.nidcr.nih.gov/HealthInformation/OralHealthInformationIndex/default.htm
Preventing Dental Diseases in Children with Disabilities

Preventing Dental Diseases in Children with Disabilities. The Arc, Johnson & Johnson Dental Care Co., the American Dental Hygienists’ Association and the Academy of Dentistry for the Handicapped. Preventing Dental Diseases in Children with Disabilities. 1990. This 10-page folder is designed for parents and other caregivers. Positioning tips, toothbrush modifications, and tips for planning dental visits are included.


Available for download or order from The Arc website (http://thearc.org): http://209.183.228.233/. (publication 10-8)
Inequalities in access: Oral health services for children and adolescents with special health care needs

National Maternal and Child Oral Health Resource Center. Inequalities in access: Oral health services for children and adolescents with special health care needs. Arlington VA: National Center for Education in Maternal and Child Health. 2000.


This fact sheet presents general information on the status of oral health services for children and adolescents with special health care needs, focusing on legal requirements, availability, and use.
http://www.mchoralhealth.org/PDFs/OHCSHCNfactsheet.pdf
Medicaid/EPSDT

Information about the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) service is available online. EPSDT is Medicaid’s preventive health program for individuals under the age of 21. EPSDT services include dental services and health education.


http://www.cms.hhs.gov/medicaid/epsdt/
Title V of the Social Security Act: Maternal and Child Health Services Block Grant

US states and jurisdictions use funds allocated by Title V of the Social Security Act of 1935 for a wide range of maternal and child health programs. Programs and services vary, however the overall goal is the same, to improve the health of all mothers and children. Thirty percent of Title V funding is reserved for children with special health care needs. In some areas, this funding provides direct service (or reimbursement for service), including dental and nutrition care.


More information about Title V in general can be found online: http://mchb.hrsa.gov/programs/blockgrant/overview.htm. Links to state and regional contacts are also available: https://performance.hrsa.gov/mchb/mchreports/link/state_links.asp.
Oral development and oral conditions in young children with special health care needs

Isman B, Newton RN. Oral development and oral conditions in young children with special health care needs: A guide for medical professionals. Los Angeles CA: California Connections, 1998.


This guide describes and illustrates 11 types of oral development and oral conditions in young children with special health care needs. With each section, there is a recommendation to medical professionals for counseling of parents, referral, or treatment.
http://www.mchoralhealth.org. Available for loan; single copies available at no charge, or through the HRSA Clearinghouse, http://www.ask.hrsa.gov, Document number MCHL018
Special Smiles: A guide to good oral health for persons with special needs

Perlman SP, Friedman C, Kaufhold GH. Special Smiles: A guide to good oral health for persons with special needs. Boston, MA: Special Athletes, Special Smiles; Boston University. 1996.


This information is designed to help families and caregivers develop and maintain an oral hygiene program, including brushing, using fluoride rinses, and flossing. It has tips for adapting a toothbrush and using different body positions to make brushing easier and includes an oral hygiene evaluation checklist to be completed by the dentist. http://www.specialolympics.org/Special+Olympics+Public+Website/English/Initiatives/Healthy_Athletes/Special+Smiles/Oral_Health_Guide/default.htm
Special Olympics Special Smiles

Special Olympics Special Smiles a core component of the Special Olympics Healthy Athletes initiative. The mission of Special Smiles is to increase access to dental care for Special Olympics athletes, as well as all people with intellectual disabilities.


Dental screenings increase awareness of the state of the athletes' oral health for the athletes themselves, as well as their parents and/or caregivers. The athletes are provided with hygiene education to help ensure they are doing an adequate job of brushing and flossing, as well as nutrition education to understand how their diet affects their total health. The athletes also are provided with a list of dentists/clinics in their area who will treat patients with special needs, should they have difficulty finding a dentist. At most locations, free mouth guards are provided for athletes competing in contact or high-risk sports.
The Special Smiles website includes the Local Clinical Director’s Handbook, with information to implement Special Olympics Special Smiles events and the Training Manual for Standardized Oral Health Screening, with information to become a standardized oral health screener.
http://www.specialolympics.org/special+olympics+public+website/english/initiatives/healthy_athletes/special+smiles/default.htm
Healthy Smiles for Children with Special Needs

American Academy of Pediatric Dentistry. Healthy Smiles for children with special needs. Chicago, IL: Teletech video, 1998. 1 videotape (12:02 minutes, VHS). $9.95.


This videotape describes devices and techniques that can assist parents in helping their children with special health care needs establish an oral health care routine. Topics addressed include the basics of oral health care, the best age for a child’s first dental visit, dental sealants, and oral sensitivity. The videotape also features interviews with three parents.
American Academy of Pediatric Dentistry http://www.aapd.org
Head Start and Early Head Start

Head Start is a program with an overall goal of promoting school readiness for children from low-income families and children with special health care needs. In addition, Head Start provides social health services (including medical, dental and nutrition). Early Head Start is a similar program, started in 1994, which provides services to pregnant women with low incomes and children 0 to 3 years of age from families with low incomes. Federal law reserves 10% of enrollment slots for children with disabilities.


More information about Head Start can be found at: http://www2.acf.dhhs.gov/programs/hsb/. More information about Early Head Start can be found at: http://www.ehsnrc.org/
Critical Elements of Care

From The Center for Children with Special Needs, booklets are available for cerebral palsy, sickle cell, Duchenne muscular dystrophy, cleft lip and palate, cystic fibrosis, juvenile rheumatoid arthritis. Guidelines include anticipatory guidance for oral health and nutrition.


http://www.cshcn.org/resources/cec.cfm

Local, State, and Regional Resources



Access to Baby and Child Dentistry Extended (ABCDE)

ABCD focuses on preventive and restorative dental care for Medicaid-eligible children from birth to age six, with emphasis on enrollment by age one. It is based upon the premise that starting dental visits early will yield positive behaviors by both parents and children, thereby helping to control the caries process and reduce the need for costly future restorative work. The first ABCD program opened for enrollment in Spokane, Washington in February 1995 as a collaborative effort between several partners in the public and private sectors. Its success has led other county dental societies and health districts in Washington to adopt the program, as well as prompted interest from other states. This website was created to assist others in replicating the ABCD model or in using some of its components in existing dental practices or oral health programs.


http://abcd-dental.org/ Also, described in Milgrom P, et al. Making Medicaid child dental services work: a partnership in Washington state. J Am Dent Assoc. 1997; 128: 1440-6.

Initiatives and Projects



Promoting Oral Health of Children with Neurodevelopmental Disabilities and Other Special Health Care Needs: A meeting to develop training and research agendas

Mouradian W, et al, eds. Promoting Oral Health of Children with Neurodevelopmental Disabilities and Other Special Health Care Needs. May 4-5, 2001. Seattle, WA.


This May 2001 meeting of health care professionals, educators, policy makers, researchers and parents was convened to develop training agendas related to oral health promotion for children with neurodevelopmental disabilities and other special health care needs and to consider oral health research, service, and policy needs.
Proceedings available on-line: http://depts.washington.edu/ccohr/resource/LEND_2001.pdf


Nutrition and Oral Health for Children

Self-study curriculum

http://depts.washington.edu/pwdlearn



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