Guideline on Management of Patients with Special Health Care Needs

Resident: Swan
Article Title: Guideline on Management of Dental Patients with Special Health Care Needs
Main Purpose: educate health care providers, parents, and ancillary organizations about the management of oral health care needs particular to individuals with SHCN.
Methods: A MEDLINE search of the current medical and dental literature related to individuals with SHCN using the terms “special needs,” “disabled,” “handicapped,” “dentistry,” and “oral health.”
Background:
The AAPD defines SHCN as “any physical, developmental, mental, sensory, behavioral, cognitive, or emotional impairment or limiting condition that requires medical management, health care intervention, and/or use of specialized services or programs…health care for individuals with special needs requires specialized knowledge, increased awareness and attention, adaptation, and accommodative measures beyond what are considered routine.”
The term SHCN applies not only to patients who suffer from limiting systemic conditions, but also to disorders which manifest only in the orofacial complex (eg amelogenesis/dentinogenesis imperfect, cleft lip/palate, oral cancer). The number of Americans with some type of disabling condition is 52 million, a number which will only increase with improvements in medical care. Today, many of these patients are seeking care from private practitioners as opposed to nursing homes or state-operated institutions. Failure to accommodate patients with SHCN could be considered discrimination and a violation of federal/state law.
These patients face many potential barriers to care, including financial (lack of insurance, high costs to families), language barriers, psychosocial issues (oral health beliefs, norms of caregiver responsibility, positive caregiver dental experience), structural (transportation, school absence policies, difficulty finding providers who accept Medicaid), priorities and attitudes (lack of importance given to oral health), increased anxiety about dental treatment.
Recommendations:
Scheduling appointments: When scheduling a patient with SHCN, the dental team should be very aware of any special considerations needed. Prior to the patient’s first visit, and after talking with the parent/caregiver on the phone to obtain the patient’s name/age/CC, name of medical care provider(s), the office should determine the need for additional appointment time or staff needed to accommodate the patient.
Dental Home: Establishment of a dental home is critical for these patients to ensure they receive appropriate preventive and routine care. If and when the patient’s needs exceed the scope of a pediatric dentist’s practice, it is important to transition smoothly to care with a dentist comfortable in the management of such a patient.
Patient Assessment: Special care should be given to ensure an accurate and comprehensive medical/dental history, with subsequent updates at each appointment. Individual treatment plans should be created based on each patient’s individual unique needs. All necessary consultations with other physicians or social workers need to be made in advance of providing treatment. As far as the actual appointment goes, much preparation can be done prior to the visit. Preferred communication methods, patient likes and dislikes can all be communicated by a parent or caregiver.
Behavior Guidance: This can be very hard with these patients. Help from parent’s/caregivers, protective stabilization, sedation, and GA are all options to consider as adjuncts.
Preventive Strategies: Because patients with SHCN are at increased risk for oral diseases, proper education of parents and caregivers is critical to ensure regular supervision of daily oral hygiene. Dentists should demonstrate oral hygiene techniques, including proper positioning of the patient. Twice daily brushing, daily flossing, dietary counseling (non-cariogenic diet, high cariogenic risk of sucrose-containing pediatric medications, carb-loaded dietary supplements), preventive measures (sealants, topical fluoride, ITR, etc.) should all be discussed. Dentists should be familiar with community based resources available to these patients.
Patients with developmental or acquired orofacial conditions: Patients with oral involvement of conditions such as OI, Ectodermal dysplasia, and Epidermolysis Bullosa often have unique financial barriers. Although oral manifestations are intrinsic to the disorder, medical health benefits often don’t provide for oral health care needs. Dentists should work with the insurance industry to recognize the medical indication and justification for such treatment.