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AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

Guideline on Management of Dental Patients with
Special Health Care Needs
Review Council
Council on Clinical Affairs
Latest Revision
2016

Purpose major life activity. Health care for individuals with special
The American Academy of Pediatric Dentistry (AAPD) recog- needs requires specialized knowledge, as well as increased
nizes that providing both primary and comprehensive preven- awareness and attention, adaptation, and accommodative mea-
tive and therapeutic oral health care to individuals with special sures beyond what are considered routine.”3
health care needs (SHCN) is an integral part of the specialty Individuals with SHCN may be at an increased risk for oral
of pediatric dentistry.1 The AAPD values the unique qualities diseases throughout their lifetime.2,4-6 Oral diseases can have
of each person and the need to ensure maximal health attain- a direct and devastating impact on the health and quality of
ment for all, regardless of developmental disability or other life of those with certain systemic health problems or condi-
special health care needs. This guideline is intended to educate tions. Patients with compromised immunity (e.g., leukemia or
health care providers, parents, and ancillary organizations other malignancies, human immunodeficiency virus) or car-
about the management of oral health care needs particular to diac conditions associated with endocarditis may be especially
individuals with SHCN rather than provide specific treatment vulnerable to the effects of oral diseases.7 Patients with men-
recommendations for oral conditions. tal, developmental, or physical disabilities who do not have
the ability to understand, assume responsibility for, or coop-
Methods erate with preventive oral health practices are susceptible as
This guideline was originally developed by the Council on well.8 Oral health is an inseparable part of general health and
Clinical Affairs Committe and adopted in 2004. This docu- well-being.4
ment is a revision of the previous version, last revised in 2012. SHCN also includes disorders or conditions which manifest
This update of the previous guideline revised is based on a only in the orofacial complex (e.g., amelogenesis imperfecta,
review of the current dental and medical literature related to dentinogenesis imperfecta, cleft lip/palate, oral cancer). While
individuals with SHCN. An electronic search was conducted these patients may not exhibit the same physical or commu-
®
via PubMed using the terms: special needs, disability, disabled nicative limitations of other patients with SHCN, their needs
patients/persons/children, handicapped patients, dentistry, den- are unique, impact their overall health, and require oral health
tal care, and oral health; fields: all; limits: within the last 10 care of a specialized nature.
years, human, English, and clinical trials. Papers for review were According to the U.S. Census Bureau, approximately 37.9
chosen from the resultant list of articles and from references million Americans have a disability, with about two-thirds of
within selected articles. When data did not appear sufficient or these individuals having a severe disability.9 The proportion
were inconclusive, recommendations were based on expert and/ of children in the U.S. with SHCN is estimated to be 18 per-
or consensus opinion by experienced researchers and clinicians, cent, approximately 12.5 million.10 Because of improvements
including papers and workshop reports from the AAPD- in medical care, patients with SHCN will continue to grow in
sponsored symposium “Lifetime Oral Health Care for Patients number; many of the formerly acute and fatal diagnoses have
with Special Needs” (Chicago, Ill.; November, 2006).2 become chronic and manageable conditions. The Americans
with Disabilities Act (AwDA) defines the dental office as a
Background place of public accommodation.11 Thus, dentists are obligated
The AAPD defines special health care needs as “any physical, to be familiar with these regulations and ensure compliance.
developmental, mental, sensory, behavioral, cognitive, or emo-
tional impairment or limiting condition that requires medical
management, health care intervention, and/or use of special- ABBREVIATIONS
ized services or programs. The condition may be congenital, AAPD: American Academy of Pediatric Dentistry. SHCN: Special
health care needs. AwDA: Americans with Disabilities Act.
developmental, or acquired through disease, trauma, or envi-
HIPAA: Health Insurance Portability and Accountability Act. ITR:
ronmental cause and may impose limitations in performing Interim therapeutic restoration.
daily self-maintenance activities or substantial limitations in a

CLINICAL PRACTICE GUIDELINES 171

10 SHCN and. When scheduling patients with SHCN.. discriminatory treatment. It is important to educate and prepare oral health care for patients with SHCN as they transition the patient and parent on the value of transitioning to a dentist beyond the age of majority. who is knowledgeable in adult oral health needs. This presents difficulties for pediatric comfortable with managing that patient’s specific health care dentists providing care to adult SHCN patients who have not needs.28 It should be noted that unmet dental care needs of individuals with SHCN. but it still provides incomplete protection. for hearing impaired patients/parents.13 Financing and reimbursement have been cited as needs of patients with SHCN. Pediatric hos.14.30 common barriers for medically necessary oral health care. care. can be accom.29.19 Lack of preventive Along with the child’s name. and lip-reading. The dental between oral health and general health is not well understood.REFERENCE MANUAL V 38 / NO 6 16 / 17 Failure to accommodate patients with SHCN could be con. as children with disabilities reach adult-hood. At a time pediatric SHCN patients could be challenging. the pitals. which preventable dental/oral disease. Regulations require practitioners to provide physical access tives. may adversely impact the frequency of dental visits and. agreed upon by the patient. and chief complaint. private insurance for health care services. In cases where this is not possible or desired. medical care provider(s). the re- and timely therapeutic care may increase the need for costly ceptionist should determine the presence and nature of any care and exacerbate systemic health issues. that the dentist be familiar and comply with Health Insur- and difficulty locating providers who accept Medicaid. for general dentists to obtain hospital privileges.31 experience of the caregiver.19. Structural barriers include tran. Patients with SHCN who have a dental home33 are more likely portant than dental health.27. thus making it difficult referrals for specialized dental care should be recommended when needed. and past dental at each subsequent visit. Because of the ility of caring for SHCN patients. parent. Dental home tive dental care. Outpatient sidered discrimination and a violation of federal and/or state surgery centers and in office general anesthesia may be alterna- law. to a lack of trained providers willing to accept the responsib- penditures than required for healthy children. should determine the need for an increased length cess to oral health care. and pediatric dentist.25 Finding a dental home for non. tomized services should be documented so the office staff is ated with access for patients with SHCN include oral health prepared to accommodate the patient’s unique circumstances beliefs. and cultural considerations may interfere with ac. can create another barrier patient should be transitioned to a dentist knowledgeable and to care for these patients.20 allows both parties an opportunity to address the child’s pri- Many individuals with SHCN rely on government funding mary oral health needs and to confirm the appropriateness of to pay for medical and dental care and lack adequate access to scheduling an appointment with that particular practitioner. school absence policies.34 172 CLINICAL PRACTICE GUIDELINES . ance Portability and Accountability Act (HIPAA) and AwDA munity-based health services. coordinated services Dental Association introduced an accreditation standard re- should be established.22 Other health conditions may seem more im.16-18 Scheduling appointments Furthermore. the dental yet transitioned to adult primary care. The need for increased dentist and team time as well as cus- written materials. When patients with SHCN reach adulthood. plished through a variety of methods including interpreters. although they may not be appropriate to treat patients to an office (e.32 HIPAA insures grams.24 health care needs may extend beyond the scope of the pedi- Pediatric dentists are concerned about decreased access to atric dentist’s training.11. the name(s) of the child’s Nonfinancial barriers such as language and psychosocial.17.21 that the patient’s privacy is protected and AwDA prevents dis- Priorities and attitudes can serve as impediments to oral crimination on the basis of a disability. disabled-parking spaces). individuals with SHCN can face many barriers to Transitioning to a dentist who is knowledgeable and com- obtaining oral health care. sub. may assist dentists and their patients with SHCN. fortable with adult oral health care needs often is difficult due Families with SHCN children experience much higher ex. Some pediatric hospitals home can remain with the pediatric dentist and appropriate require dentists to be board certified. under the guidance of structural. it is imperative sportation. with special needs due to medical complexity. the dentist. age. The office staff. regulations applicable to dental practices. norms of caregiver responsibility. Parental and physician lack of awareness and knowledge may hinder an individual with SHCN from seeking preven.14 Com. their oral sequently.18 Effective communication is essential of appointment and/or additional auxiliary staff in order to and.g. emphasis the Commission on Dental Accreditation of the American on a dental home and comprehensive.23 home provides an opportunity to implement individualized Persons with SHCN patients may express a greater level of preventive oral health practices and reduces the child’s risk of anxiety about dental care than those without a disability. The parent’s/patient’s initial contact with the dental practice health insurance coverage may be restricted. when appropriate. accommodate the patient in an effective and efficient manner.12 Optimal health of children is more quiring dental schools to ensure that curricular efforts are likely to be achieved with access to comprehensive health care focused on educating their students on how to assess treatment benefits. by imposing age restrictions. especially when the relationship to receive appropriate preventive and routine care. Psychosocial factors associ. wheelchair ramps. with educational and social pro.15 Insurance plays an important role for families with children Recommendations who have SHCN.26 however. oral health.

At times. and changes in medications cal examination and any additional diagnostic procedures should be documented. nurses. if attempts to communicate immunization status. Significant medical conditions should be identified in a conspicuous yet confidential manner in the Informed consent patient’s record. psychological. consultation with the caregiver progresses through several steps. Because of dental anxiety or a lack of understanding of needs. When appropriate. sedation. therefore. these diseases further jeopardize the patient’s health. AMERICAN ACADEMY OF PEDIATRIC DENTISTRY Patient assessment ment. Information regarding the chief complaint. to supplement commu- creasing the risk of aggravating a medical condition while ren. with a patient with SHCN/parent are unsuccessful because tories. oral health ging. If the patient/parent is unable The process of developing a dental treatment plan typically to provide accurate information. ly should be emphasized to help prevent caries and gingivitis.11 include such considerations during the history intake and be prepared to modify the traditional delivery of dental care to Planning dental treatment address the child’s unique needs. institutional re- classifying caries risk at a point in time and. newly behavioral. Protective stabilization can be helpful in of any significant findings. A caries-risk assessment should provide this service for them. to the requirements of the AwDA. An individualized preventive Behavior guidance program. anesthesia. At each patient visit. when indicated. of dental professionals should develop an individualized oral developmentally-appropriate communication is critical. The examination also should include assessments of trauma and periodontal risk. non-traditional ways. and oral examinations should for dental treatment or have someone present who legally can be completed on all patients. a parent. social workers) should be informed in the dental office. be developed and presented to the patient and/or caregiver. and special restrictions or preparations that may be required to ensure the safe delivery of oral health care.g. family member. caretaker may need to be present to facilitate communication medical care providers. including a dental recall schedule. and up-to-date cation during the provision of dental care. haviors. These behaviors can interfere with the safe delivery of ommendations should be provided to the patient and parent/ dental treatment. patients for whom traditional behavior guidance techniques are not adequate. family and social his. comprehensive. An accurate. an out-patient should be consulted regarding medications. nication with gestures and augmentive methods of communi- dering dental care. All patients must be able to provide signed informed consent Comprehensive head.. Individuals with SHCN may be at increased risk for oral ical emergency.8 An attempt should be made to communicate directly Familiarity with the patient’s medical history is essential to de.3 Education of parents/caregivers is critical for ensuring appro- Patient communication priate and regular supervision of daily oral hygiene.39 When protective stabilization is not feas- Medical consultations ible or effective. neck. current medications. updated. general surgical care facility might be necessary. Recent medical attention for illness or injury.36 Caries-risk assessment provides a means of comply with state laws and. allergies/sensitivities. diseases. dental care. similar to any other child. Informed consent should be well documented in be applied periodically to assess changes in an individual’s risk the dental record through a signed and witnessed form. A patient who does medical history is necessary for correct diagnosis and effective not communicate verbally may communicate in a variety of treatment planning.35 As of a disability such as impaired hearing. the patient’s other care providers patients with physical and mental disabilities can be managed (e. CLINICAL PRACTICE GUIDELINES 173 . should quirements. social. the history should be consulted and information regarding medical. Before a treatment plan can or with the patient’s physician may be required. or history of present illness. sedation or general anesthesia is the behavioral The dentist should coordinate care via consultation with the guidance armamentarium of choice.38 status. When in-office sedation/ patient’s other care providers. The team When treating patients with SHCN. at each recall visit. anesthetic and/or provide information that the patient cannot. When appropriate. and thorough dental history should be obtained. A written update should be obtained completed. the physician general anesthesia is not feasible or effective. Informed consent/assent must be performed. physical. most caregiver. the dentist must work many children with SHCN may have sensory issues that can with those individuals to establish an effective means of make the dental experience challenging. Behavior guidance of the patient with SHCN can be challen- mended after evaluation of the patient’s caries risk. and abilities. when applicable. hospitalizations/surgeries. hygiene program that takes into account the unique disability information provided by a parent or caregiver prior to the of the patient. According experiences. The Preventive strategies dentist and staff always should be prepared to manage a med. Brushing with a fluoridated dentifrice twice dai- patient’s visit can assist greatly in preparation for the appoint. the dentist should communications. children with disabilities may exhibit resistant be- A summary of the oral findings and specific treatment rec. should be recom. Often. and dental histories must be gathered37 and clini- diagnosed medical conditions. medical conditions and/or illnesses. review of systems. physicians. with the patient and. With the parent/caregiver’s assistance.

gingival over.g. mouthguard fabrication. behavior.34 Manual Overview: Definition and scope of pediatric dentistry. acquired orofacial conditions necessitate special considerations. head.49 Dentists should work with motor skills/coordination deficits).46 Develop- brush their own teeth. the practitioner must be sensitive to the psychosocial well-being dentist should provide strategies to mitigate the caries risk by of the patient.45 Because of ment is not provided because of age.41 In cases of genesis imperfecta. Pediatr Dent 2007.41 Topical fluorides may be in. public health facilities. children with SHCN are more likely to be victims of physical abuse. This would include anticipatory prostheses (including complete dentures or over-dentures) and/ guidance about risk of trauma (e. Those patients with by third party payors between congenital anomalies involving progressive periodontal disease should be referred to a perio. with seizure disorders or or implants may be indicated. Patients ital disorders. other oral side effects (e.g. For patients who might swallow a rinse.42 Interim therapeutic services by the various health care providers can be crucial to restoration (ITR). that release fluoride. a the oral manifestations are intrinsic to the genetic and congen- toothbrush can be used to apply the chlorhexidine. Congenital oral conditions may As well. to increase weight gain). ectodermal dysplasia. disability. Electric toothbrushes and floss holders mental defects such as hereditary ectodermal dysplasia. Although may be useful.. may be useful as both preventive and Patients with oral involvement of conditions such as osteo- therapeutic approaches in patients with SHCN.REFERENCE MANUAL V 38 / NO 6 16 / 17 If a patient’s sensory issues cause the taste or texture of fluor. Toothbrushes can be associated with children having SHCN.48 For children with Preventive strategies for patients with SHCN should ad. Sealants ditions such as ectodermal dysplasia. chlorhexidine mouth rinse bullosa often present with unique financial barriers. Caregivers should provide most teeth are missing or malformed.4 From the first adequately. the orofacial complex and those involving other parts of the dontist for evaluation and treatment. the dentist should make necessary referrals in order to rehabilitation services. inability to co- this incidence. body is often arbitrary and without merit. removable or fixed dress traumatic injuries. unfavorable treatment experiences. Symposium conditions on lifetime oral health care for patients with special The oral health care needs of patients with developmental or needs. Reference considerations that prevent access to care. entail therapeutic intervention of a protracted nature.45 of care can result in unnecessary pain. discomfort. dentists need to be aware of signs of abuse and operate.. ciplinary team approach to their care. and neck injuries A patient may suffer progression of his/her oral disease if treat- occur in more than half of the cases of child abuse. While these individuals usually do not require longer appoint- idated toothpaste to be intolerable. contact with the child and family. justification for such treatment in these cases. management of their modified to enable individuals with physical disabilities to oral conditions presents other unique challenges. Coordinating delivery of dicated when caries risk is increased. Patients with con- Patients with SHCN may benefit from sealants. a fluoridated mouth rinse ments or advanced behavior guidance techniques commonly may be applied with the toothbrush.38(special issue):2.40 When a diet rich in carbohy. While local hospitals. as well as the effects of the condition on growth. tioner.29(2):92-152. Dentists have an obli- Dentists should be familiar with community-based resources gation to act in an ethical manner in the care of patients. Pediatr Dent 2016. American Academy of Pediatric Dentistry. 50 for patients with SHCN and encourage such assistance when Once the patient’s needs are beyond the skills of the practi- appropriate.43 using materials such as glass ionomers successful treatment outcomes. hereditary hypodontia and/or oligodontia. the insurance industry to recognize the medical indication and and what to do if dentoalveolar trauma occurs. and oral cancer frequently require an interdis- primary and permanent teeth. or groups that advocate for those with ensure the overall health of the patient. every effort must be made A non-cariogenic diet should be discussed for long term to assist the family in adjusting to and understanding the com- prevention of dental disease. altering frequency of and/or increasing preventive measures. SHCN can be valuable contacts to help the dentist/patient ad- dress language and cultural barriers.47 The dental drates is medically necessary (e. function.g. to coincide with developmental milestones. Postponement or denial mandated reporting procedures. sexual abuse. epidermolysis bullosa.44. or medical status. Additionally. xerostomia. 174 CLINICAL PRACTICE GUIDELINES . increased treatment needs and costs. other community-based References resources may offer support with financial or transportation 1. cause lifetime problems the appropriate oral care when the patient is unable to do so that can be devastating to children and adults. and appearance. and neglect when compared to children Referrals without disabilities. where may improve patient compliance. and epidermolysis gingivitis and periodontal disease.. timed growth) of medications should be reviewed. Patients with developmental or acquired orofacial 2. The distinction made three months or more often if indicated. American Academy of Pediatric Dentistry. face. Barriers and diminished oral health outcomes. reduce the risk of caries in susceptible pits and fissures of cleft lip/palate. medical health benefits often do not provide having severe dental disease may need to be seen every two to for related professional oral health care. plexity of the anomaly and the related oral needs.44 Craniofacial.

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