Children with Special

Health Care Needs

PRESENTER:- Dr. Vedangi Mohite

III MDS
DEPT. OF PAEDIATRIC AND PREVENTIVE DENTISTRY
DATTA MEGHE INSTITUTE OF MEDICAL SCIENCES
MAHARAHTRA
GOOD MORNING
 CONTENTS

■ Dental access ■ Management of a child with

■ First dental visit ■ Special health care needs during

■ Radiographic examination dental treatment

■ Preventive dentistry

■ Home dental care

■ Diet and nutrition

■ Fluoride exposure
 CONTENTS

■ Intellectual disability ■ Respiratory diseases

■ Asthma (reactive airway disease)

■ Down syndrome (trisomy 21
■ Hearing loss
Syndrome)
■ Infective Endocarditis

■ Learning disabilities Disorder

■ Autism spectrum disorder

■ Cerebral palsy
 • Individuals with special health care needs (SHCN) as those with
“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.”

The American Academy of

Pediatric Dentistry

American academy of pediatric dentistry. Definition of Special Health Care Needs. 2016;40(6):18-19.
5
  21 million people in India as suffering
from one or the other kind of disability.

 Equivalent to 2.1% of the population.

 12.6 million are males

 9.3 million are females.

Office of the Registrar General & Census Commissioner, Ministry of Home Affairs,Government of India
The number of disabled persons is highest in the age group 10-19 years
(46.2 lakhs).
7
 ■ 20.42 lakhs children are disabled.

■ 1 in every 100 children.

DISABILITY PERCENTAGE
hearing 23%

seeing 30%

movement 10%

multiple disabilities. 7%
8
 “
Medical and Dental care of a child with
special healthcare needs.

9
 Multidisciplinary team

• Children with SHCN are best managed initially by a multidisciplinary team in

which a dentist is available to evaluate the child’s extraoral and intraoral
findings.

• A diagnosis is then established, and an impression is gained of the child’s

strengths and weaknesses and the team’s recommendations for future care.
10
Paediatric Dentist

• The child may then be

"mainstreamed” to a dental
practitioner.

• The team is available to help the

family practitioner or pediatric
dentist treat the child and prepare
the family for the child’s future
treatment needs.

• As oral health is a vital part of the

child’s well-being and general
health.
11
 7. Fluoride 1. Dental
exposure. Access.

“
6. Diet and Factors to be 2. First
nutrition. considered for dental visit.

complete Dental Care

3.
5. Home
Radiographic
dental care.
examination.
4.
Preventive
dentistry
 • Improving access to oral health care for those deprived of needed
services should be of great concern to the dental profession.

Children with SHCN, such as those who are chronically ill,

homebound, and have developmental disabilities and emotional
impairments, fall into large segments of the population who do not
have access to dental care.

DENTAL ACCESS

13
ACCESSIBILITY GUIDELINES
ACCESSIBILITY GUIDELINES
An accessible dental operatory floor plan design

16
17
 1. ESTABLISHMENT OF “ DENTAL HOME ”
2. ROLE OF THE DENTAL AUXILLARIES.
3. INITIAL EXAMINATION.
4. MANAGEMENT OF PARENTAL ANXIETIES.
5. INFORMED CONSENT

FIRST DENTAL VISIT

18
The dental home is inclusive

of all aspects of oral health

that result from the

interaction of :-

19
 ESTABLISHMENT OF THE DENTAL HOME

■ It is initiated by the identification and interaction of these individuals, resulting in

a heightened awareness of all issues impacting the patient’s oral health.

■ Many parents avoid dental treatment for their children because of their fear that
dental visits are routinely painful.

■ Dental professionals should use every opportunity to help patients or parents

overcome this barrier to the mainstream of effective dental care and establish a
“dental home” with them.
 The AAPD recognizes a dental home should provide:

1. Comprehensive, continuous, accessible, family- centered, coordinated,

compassionate, and culturally- effective care for children.

2. Comprehensive evidence-base oral health care including acute care and

preventive services .

3. Comprehensive assessment for oral diseases and conditions.

4. Individualized preventive dental health program based upon a caries-risk

assessment and a periodontal disease risk assessment

5. Anticipatory guidance regarding growth21and developement.

 The AAPD recognizes a dental home should provide:

6. Information about proper care of the child’s teeth and gingivae, and other
oral structures.
This would include the prevention, diagnosis, and treatment of disease of the
supporting and surrounding tissues and the maintenance of health, function,
and esthetics of those structures and tissues.

7. Dietary counseling.

8. Referral, at an age determined by patient, parent, and pediatric dentist, to a

dentist knowledgeable and comfortable with managing adult oral health care
needs.
22
THE ROLE OF THE DENTAL RECEPTIONIST

1. To should determine the presence and

nature of any child with SHCN

2. To identify the family’s medical provider.

3. To alert the dentist so that adequate time

can be allowed.
23
INITIAL DENTAL EXAMINATION

The names and addresses of medical

or dental personnel who have
previously treated the patient are
necessary for consultation purposes.

Consultation with these specialists is common; this

helps provide insight in case management and
planning and avoids unwanted outcomes.

24
24
MANAGING THE PARENTAL ANXIETY

By scheduling the patient at a designated time (early in the

day)

Allowing sufficient time to talk with the parents and the

patient before initiating any dental care, a practitioner can
establish an excellent relationship with them.

Sending a letter before the appointment explaining the first

visit to the family and sending another letter afterward letting
them know how helpful they were are beneficial.
25
 OBTAINING AN INFORMED CONSENT

Recognizes that informed consent is essential in the

The
delivery of health care.
American
Academy of The informed consent process allows the patient or the
custodial parent or, in the case of minors, legal
Pediatric guardian to participate in and retain autonomy over
the health care received.
Dentistry
Many times, dental treatment must be delayed until an
informed consent is obtained through a guardian.

A court petition must be filed when no parents are

legally accountable.
26
 When a practitioner utilizes an “informed consent” form, the following
should be included:

1. Name and date of birth of the pediatric patient.

2. Name and relationship to the pediatric patient/legal basis on which the

person is consenting on behalf of the patient;

3. Description of the procedure in simple terms

4. Disclosure of known adverse risk of the proposed treatment specific to that

procedure;

American academy of pediatric dentistry. Guideline on Informed Consent.

2009:32(6);10-11
27
 When a practitioner utilizes an “informed consent” form, the following
should be included:

5. Professionally-recognized or evidence-based alternative treatment to

recommended therapy and risk .

6. Place for custodial parent or legal guardian to indicate that all questions
have been asked and adequately answered.

7. Places for signatures of the custodial parent or legal guardian, dentist, and
an office staff member as a witness.

American academy of pediatric dentistry. Guideline on Informed Consent.

2009:32(6);10-11
28
COMMUNICATION

■ An attempt should be made to communicate directly with the patient and

when indicated, to supplement communication with gestures .

■A patient who does not communicate verbally may communicate in a

variety of non-traditional ways.

■ According to the requirements of the INDIAN DISABILITY ACT, if attempts

to communicate with a patient with SHCN are unsuccessful because of a
disability such as impaired hearing, the doctor must work with those
individuals to establish an effective means of communications

29
RADIOGRAPHIC EXAMINATION

■ Assistance from the parent and dental auxiliaries.

■ The use of immobilization devices may be necessary to obtain the films.

■ Better cooperation may be elicited from some children by delaying

radiographs until the second visit.

American Academy Pediatric Dentistry. Oral health policy on dental

radiographs in children including
30 those with SHCN . Pediatr Dent
 AAPD RECOMMENDATIONS

■ It recognizes that there may be clinical circumstances for which a

radiograph is indicated, but a diagnostic image can not be obtained.

■ If radio-graphs of diagnostic quality are unobtainable, the dentist should

confer with the parent to determine appropriate management techniques
(e.g., preventive/restorative interventions, advanced behaviour guidance
modalities, deferral, referral), giving consideration to the relative risks and
benefits of the various treatment options for the patient.

31
■ For patients with limited ability to control film position, intraoral films with
bitewing tabs are used for all bitewing and periapical radiographs.

■ An 18-inch (46- cm) length of floss is attached through a hole made in the
tab to facilitate retrieval of the film if it falls toward the pharynx.

32
■ Hardwired digital sensors have
reduced this risk, although they may
be difficult to tolerate by the patient.

■ The patient should wear a lead

apron with a thyroid shield

■ Operator who helps hold the patient

and the film or sensor steady should
wear a lead-lined apron and gloves.

33
 PREVENTIVE DENTISTRY

■ An effective preventive dentistry program is important for a child with

SHCN because of the predisposing factors that make restorative dental
care harder to obtain when it is necessary, and those who make preventive
dental visits will have fewer unmet needs.

■ Dental diagnosis and treatment planning will necessitate an accurate, up-

to-date medical history at each visit.

34
■ After the diagnosis, the dentist should determine :-

1. The patient’s needs .

2. Assume the responsibility for formulating an individual program for the

child .

3. Adequately communicate to the parents and patient how such a program

can be affected .

35
 HOME DENTAL CARE

■ Home dental care should begin in infancy; the dentist should teach the parents
to gently cleanse the incisors daily with a soft cloth or an infant toothbrush.

36
 HOME DENTAL CARE

■ For older children who are unwilling or physically unable to cooperate, the
dentist should teach the parent or guardian to clean teeth twice a day using
correct toothbrushing techniques, safely immobilizing the child when necessary.

37
HOME DENTAL CARE

■ Dental education of parents/guardians/caregivers is important to ensure

that children with SHCN do not jeopardize their overall health by
neglecting their oral health.

■ The parents (or the guardian) are initially responsible for establishing good
oral hygiene in the home.

38
■ Reinforcement of good home dental care is provided through :-

1) Mass media.
e.g., Newspapers, radio, television, and Internet

2) Communication with other people, and school activities.

e.g., Health classes, parent-teacher association meetings

39
■ This supplementary support relieves the dentist of having sole
responsibility for explaining the need for home dental care and reinforces
the receptivity of the parent and child to such a program .

■ The dentist or the hygienist is responsible for consulting with the caregiver
of the child with SHCN (i.e., parent, guardian, or nursing home attendant)
when continued oral hygiene problems occur .

■ Regular follow-up supervision at home and in the dental office is essential

for effective implementation of the preventive dental treatment plan .

40
TOOTH BRUSHING POSITIONS

■ There are several positions for toothbrushing that permit firm control and
support of the child, adequate visibility, and convenient positioning of the

adult, with reasonable comfort for both adult and child .

■ Positions most commonly used for children requiring oral care assistance
are as follows:-
41
1. The standing or sitting child is placed in

front of the adult so that the adult can

cradle the child’s head with one hand

while using the other hand to brush the

teeth.

42
2. The child reclines on a sofa or bed with the
head angled backward on the parent’s lap.

Again, the child’s head is stabilized with one

hand while the teeth are brushed with the other
hand.

The parents face each other with their knees

touching.

The child’s buttocks are placed on one parent’s

lap, with the child facing that parent while the
child’s head and shoulders lie on the other
parent’s knees; this allows the first parent to
brush the teeth.
43
The extremely difficult patient is isolated in an
open area and reclined in the brusher’s lap.

The patient is then immobilized by an extra

attendant while the brusher institutes proper
oral care.

If a child cannot be adequately immobilized

by one person, then both parents and perhaps
siblings may be needed to complete the home
dental care procedures.

44
 The standing and resistive child is

placed in front of the caregiver so

that the adult can wrap his or her legs

around the child to support the torso

while using the hands to support the

head and brush the teeth.

45
■ Some parents and health centres have encouraged children with SHCN to
assume the responsibility for their own oral hygiene, but the results are
usually poor.

■ Although independent brushing is not contraindicated, parents and staff

should be aware that, without their follow-up, unsupervised oral hygiene
procedures in children with SHCN can have serious dental consequences.

■ The amount of supervision and assistance provided by the parents or staff

should depend on the child’s willingness to cooperate and ability to
maintain good oral hygiene twice a day.

46
INSTITUTIONALIZED CHILDREN WITH SHCN .

■ If a child with SHCN is institutionalized, the staff should be instructed in the

proper dental care regimen for the child.

■ Wrapped tongue blades may be of benefit in helping to keep a child’s

mouth open while plaque is being removed.

47
INSTITUTIONALIZED CHILDREN WITH SHCN .

■ Stabilization of the child’s head prevents unnecessary trauma from sudden

movements.

■ Follow-up observation is carried out by the dentist or the hygienist, and it

is appropriate to offer in-service training sessions and to check with the
staff periodically to identify and solve the problems associated with an oral
hygiene program in the institution.

48
 Plaque control program

■ The brushing technique for patients with SHCN who have fine or gross
motor deficiencies limiting their ability to brush should be effective and yet
simple for the person performing the brushing.

■ Technique recommended is the horizontal scrub method because it is easy

to perform and can yield good results.

49
 TOOTH BRUSH DESIGNS

■ Modifications that may be made to a ■ Using the patient’s hand to custom-

toothbrush to help persons with design a handle has often had good
poor fine motor skills improve their results
brushing techniques.

50
 ELECTRIC TOOTHBRUSHES

■ They have been used effectively by

children with SHCN.

■ The vibration and noise tend to

desensitize the patient for future
dental appointments if followed by
positive reinforcement.

■ The design and colour are also

motivational for the child.

51 2200 /- 5000 /-
SUCTION TOOTH BRUSH

■ The suction is advantageous because of the excess saliva often found in

patients with SHCN.

1,300 /- 24,531 /-
52
VIDEO

53
Qualitative synthesis of three comparisons of powered, modified

toothbrushes versus conventional tooth brushes showed evidence of

greater effectiveness in dental plaque in favour of powered

toothbrushes .
54
A proper noncariogenic diet is essential to a good
preventive program for a child with SHCN.

DIET AND NUTRITION

DIET AND NUTRITION

■ Proper assessment of the diet.

■ Dietary modifications are made.

■ Proper consultation with the

patient’s primary physician or
dietitian.

■ Early intervention and aggressive

preventive care based on the child’s
caries risk.
56
 CONDITION DIET
Difficulty in swallowing:- Pureed diet

severe cerebral palsy

Metabolic disturbances or Restrict specific foods or total caloric
syndromes:- consumption

- Phenylketonuria
- Diabetes
- Prader-Willi syndrome

57
DENTAL CONSIDERATIONS

■ When a diet rich in carbohydrates is medically necessary (e.g., to increase

weight gain), the dentist should provide strategies to mitigate the caries
risk by altering frequency of and/or increasing preventive measures.

■ Other oral side effects (e.g., xerostomia, gingival overgrowth) of

medications should be reviewed .

58
 Special emphasis should be placed
on ensuring adequate systemic
fluoride for patients with
disabilities.

FLUORIDE EXPOSURE

59
FLUORIDE EXPOSURE

1 2
• Determine the concentration • If the level of fluoride is
of fluoride in the patient’s between 0.7 and 1 ppm:-
daily water supply or other No supplementation is
sources . normally required

4. 3
Once the level has been • Analysis is indicated if the
documented, a determination of fluoride level cannot be
the need for fluoride determined.
supplementation can be made
60
 Whether the patient lives in an area with a fluoridated or non-
fluoridated water supply, a topical fluoride should be applied after a
regularly scheduled professional prophylaxis.

Dentifrice containing a therapeutic fluoride compound should also be

used daily.

RECOMMENDATIONS
chronically poor oral hygiene and high decay rates a daily regimen of
rinsing with 0.05% sodium fluoride solution is recommended.

Nightly application of a 0.4% stannous fluoride or 1.1% sodium fluoride

brush-on gel has also been successfully used to decrease caries in
children.

61
 Interim therapeutic restoration (ITR), using materials such as glass
ionomers that release fluoride, may be useful as both preventive and
therapeutic approaches in patients with SHCN

PREVENTIVE STRATEGIES

62
■ Preventive strategies for patients with SHCN should address traumatic
injuries.

■ This would include :-

1. 2.

Anticipatory guidance about Mouthguard fabrication, and

risk of trauma what to do if dentoalveolar
- With seizure disorders or trauma occurs.
motor skills/coordination
deficits
CHILD ABUSE

■ Additionally, children with SHCN are more likely to be victims of :-

1. Physical abuse
2. Sexual abuse
3. Neglect when compared to children without disabilities.

■ Craniofacial, head, face, and neck injuries occur in more than half of the
cases of child abuse.

■ Because of this incidence, dentists need to be aware of signs of abuse and

mandated reporting procedures

64
 REGULAR PROFESSIONAL
SUPERVISION

65
1. Close observation of caries-susceptible patients and regular dental examinations are
important in the treatment of patients with SHCN

2. Although most patients are seen semi-annually for professional prophylaxis, examination,
and topical fluoride application, certain patients can benefit from recall examinations every
2, 3, or 4 months.

3. Transferring the “dental home” of an adult patient with SHCN to a knowledgeable general
dentist is recommended when dental care needs go beyond the scope of a pediatric dentist.

4. If necessary, the pediatric dentist may refer the patient for “specialized care” (e.g., oral
surgeon, orthodontist, periodontist).

66
 BARRIERS

67
■ Dentists should be familiar with community-based resources for patients
with SHCN and encourage such assistance when appropriate.

■ While local hospitals, public health facilities, rehabilitation services, or

groups that advocate for those with SHCN can be valuable contacts to help
the dentist/patient address language and cultural barriers.

■ Other community-based resources may offer support with financial or

transportation considerations that prevent access to care.
REFERRALS

■ A patient may suffer progression of his/her oral disease if treatment is not

provided because of age, behavior, inability to cooperate, disability, or
medical status.

■ Postponement or denial of care can result in unnecessary pain, discomfort,

increased treatment needs and costs, unfavorable treatment experiences,
and diminished oral health outcomes.

■ Dentists have an obligation to act in an ethical manner in the care of

patients.

69
• The goal is to maximize lifelong functioning and potential through
uninterrupted provision of high-quality, developmentally-appropriate health
care as the individual moves from adolescence into adulthood.

• The cornerstones of patient-centered health care are flexibility,

responsiveness, continuity, comprehensiveness, and coordination.

70
The policy statement articulated six critical steps to ensuring the successful
transition to adult-oriented care. They are:

1. To ensure that all young people with special health care needs have a health care
provider who takes specific responsibility for transition.

2. To identify the core competencies required by health care providers to render

developmentally appropriate oral health care transition.

3. To develop a portable, accessible, medical and dental summary to facilitate the

smooth collaboration and transfer of care among and between health care
professionals.

Chi DL. Medical care transition planning and dental care use for youth with special health care needs during
the transition from adolescence to young adulthood: A preliminary explanatory model. Matern Child Health
J 2014;18(4):778-88.
71
4. To develop an up-to-date detailed written transition plan, in collaboration
with young people and their families.

5. To ensure that the same standards for primary and preventive health care
are applied to young people with chronic conditions as to their peers.

Chi DL. Medical care transition planning and dental care use for youth with special health care needs during
the transition from adolescence to young adulthood: A preliminary explanatory model. Matern Child Health
J 2014;18(4):778-88.
72
 REFERENCES

■ Mcdonald and Avery .Dentistry for the child and the adolescent.10th
Edition.

■ Casamassimo.Pediatric Dentistry.Infancy Through Adolescence.5th Edition.

■ Shobha Tandon. Pediatric Dentistry.3rd Edition.

■ Glassman P, Subar P. Planning dental treatment for people with special

needs. Dent Clin North Am 2009;53 (2):195-205, vii-viii.

■ American academy of pediatric dentistry. Policy on the dental home. Oral

health policies .Reference manual v 4 073/ n o 6 1 8 / 19.
 REFERENCES

■ Office of the Registrar General & Census Commissioner, Ministry of

Home Affairs,Government of India

■ American Academy Pediatric Dentistry. Oral health policy on dental

radiographs in children. Pediatr Dent 2017;40(6):18.

■ American academy of pediatric dentistry. Policy on Transitioning from a

Pediatric-centered to an Adult-centered Dental Home for Individuals with
Special Health Care Needs 2016;4 0 (6):18-19

74
 REFERENCES

■ Chi DL. Medical care transition planning and dental care use for youth with
special health care needs during the transition from adolescence to young
adulthood: A preliminary explanatory model. Matern Child Health J
2014;18(4):778-88.

■ Rozier RG, Adair S, Graham F, et al. Evidence-based clinical

recommendations on the prescription of dietary fluoride supplements for
caries prevention: A report of the American Dental Association Council on
Scientific Affairs. J Am Dent Assoc 2010;141(12):1480-9.

75
 REFERENCES

■ American academy of pediatric dentistry. Policy on Transitioning from a

Pediatric-centered to an Adult-centered Dental Home for Individuals with
Special Health Care Needs 2016;4 0 (6):18-19.

■ Chi DL. Medical care transition planning and dental care use for youth with
special health care needs during the transition from adolescence to young
adulthood: A preliminary explanatory model. Matern Child Health J
2014;18(4):778-88.

■ Rozier RG, Adair S, Graham F, et al. Evidence-based clinical

recommendations on the prescription of dietary fluoride supplements for
caries prevention: A report of the American Dental Association Council on
Scientific Affairs. J Am Dent Assoc 2010;141(12):1480-9.
76
REFERENCES

■ American academy of pediatric dentistry. Definition of Special Health Care

Needs. 2016;4 0 (6):18-19.

■ American Academy of Pediatric Dentistry. Symposium on lifetime oral

health care for patients with special needs. Pediatr Dent 2007;29(2):92-152.

■ American academy of pediatric dentistry. Guideline on Informed Consent.

2009:32(6);10-11 .

77
INTELLECTUAL DISABILITY

■ It is a general term used when an individual’s intellectual development is

significantly lower than average and his or her ability to adapt to the environment
is consequently limited.

■ They were described using the terms (intelligence quotient ):-

below 25 25 to 50 50 to 70
idiot 1.imbecile moron

78
79
DIAGNOSIS

1. The Stanford-Binet Intelligence Scale .

2. The Wechsler Intelligence Scale .

■ Diagnosis of intellectual disability is not made based on IQ alone.

■ Both inadequate adaptive functioning and intellectual deficiency are required

to fulfil a diagnosis of intellectual disability.

80
 ORAL FINDINGS

■ Higher incidence of ■ Increase in severity typical oral signs of

poor oral hygiene following conditions also increases:-
1. Clenching
■ Gingivitis
2. Bruxing
■ Malocclusion 3. Drooling

4. Pica
■ Untreated caries.
5. Trauma

6. Missing teeth, and self-injurious behaviours

81
BEHAVIOUR CHARACTERISTICS

1. A short attention span .

2. Restlessness .

3. Hyperactivity .

4. Erratic emotional behaviour .

82
DENTAL IMPLICATIONS

■ Providing dental treatment for a person with intellectual disability requires

adjusting to :-

Emotional
delays.

Intellectual Social
Delay Delay

83
DENTAL IMPLICATIONS

■ The dentist should assess the degree of intellectual disability by consulting

the patient’s physician for frequent medical assessment and coordinate

care when appropriate.

84
The following procedures are beneficial in establishing dentist-patient-parent-staff
rapport and reducing the patient’s anxiety about dental care:

■ Give the family a brief tour of the office before attempting treatment.

■ Introduce the patient and family to the office staff.

■ Allow the patient to bring a favourite item (stuffed animal, blanket, or toy)
to hold for the visit.

■ Be repetitive; speak slowly and in simple terms. Make sure explanations

are understood by asking the patient if there are any questions.

85
The following procedures are beneficial in establishing dentist-patient-
parent-staff rapport and reducing the patient’s anxiety about dental care:

■ Give only one instruction at a time. Reward the patient with compliments
after the successful completion of each procedure.

■ Actively listen to the patient. People with intellectual disability often have
trouble with communication and the dentist should be particularly
sensitive to gestures and verbal requests.

■ Invite the parent into the operatory for assistance and to aid in
communication with the patient when helpful.

86
The following procedures are beneficial in establishing dentist-patient-
parent-staff rapport and reducing the patient’s anxiety about dental care:-

■ Keep appointments short. Gradually progress to more difficult procedures

(e.g., anesthesia and restorative dentistry) after the patient has become
accustomed to the dental environment.

■ Schedule the patient’s visit early in the day, on a lightly scheduled day,
when the dentist, the staff, and the patient will be less fatigued.

87
DOWN SYNDROME (TRISOMY 21 SYNDROME)

■ Down syndrome is a chromosomal disorder and is caused by the presence

of an extra copy of chromosome 21(trisomy 21).

■ Medical conditions that occur more frequently in infants and children with
Down syndrome include :-
Cardiac defects, leukaemia and upper respiratory infections.

■ The incidence of congenital cardiac defects is about 40%,

88
 EXTRA & INTRA ORAL FINDINGS

■ Underdeveloped midface.

■ Prognathic occlusal relationship.

■ Mouth breathing
■ Open bite
■ Macroglossia
■ Fissured lips and tongue
■ Angular cheilitis

89
 INTRA ORAL FINDINGS

■ Delayed eruption missing and malformed teeth, oligodontia, microdontia,

crowding, and a low level of caries.

■ High incidence of rapid, destructive periodontal disease,

90
■ Certain systemic factors are also believed to contribute to periodontal
disease including :-

Poor circulation Decreased cellular motility

of gingival fibroblasts
Decreased humoral General physical
response deterioration at an early age
Genetic influences

■ Bell and colleagues reported that severity of both attrition and erosion was
significantly greater in children with Down syndrome than in children
without the syndrome.

91
DENTAL TREATMENT

■ Many children with Down syndrome are affectionate and cooperative, and
dental procedures can be provided without compromise if the dentist
works at a slightly slower pace.

■ Emphasis should be placed on preventive dental care with frequent follow-

up visits to monitor oral hygiene. Comprehensive dental care is an overall
goal with alteration based on the individual’s level of functioning.

■ Light sedation and immobilization may be indicated in those children who

are moderately apprehensive. Severely resistive patients may require
general anesthesia.
92
93
 LEARNING DISABILITIES

■ Learning disabilities are neurological conditions that interfere with the

individual’s ability to store, process, or produce information.

■ They can affect a person’s ability to read, write, count, speak, or reason. In
addition, they may affect memory, attention, coordination, social skills,
and emotional maturity.

• NOT INCLUDED CONDITIONS • INCLUDED CONDITIONS

Intellectual disabilities Perceptual handicaps
Deafness Brain injury,
Behavioral disorders. Minimal brain dysfunction
Autism Dyslexia, and developmental aphasia
94
DENTAL MANAGEMENT

■ Most children with learning disabilities accept dental care and cause no
unusual management problems for the dentist.

■ If a child is resistant, behavioral management and conscious sedation

techniques may be used with success.

95
AUTISM SPECTRUM DISORDER

■ Autism spectrum disorder (ASD) includes three neurodevelopmental

disorders:
1. Autism disorder
2. Asperger syndrome
3. Pervasive development disorder (PDD).

■ The prevalence is estimated to be 6 per 1000 children.

■ The exact cause of ASD is not completely known, although genetic factors
and environmental factors may play a role.

96
 Three levels of impairment are noted

social communication, Repetitive behaviors.

• In some cases is • which can result in the • They may include

extreme. delay or complete lack staring, floppy hands,
of spoken language. an odd interest in or
• With lack of eye preoccupation with
contact and not • Children with Asperger specific objects.
responding to one’s syndrome do not have
name. a general delay in • There is great
language or cognitive variability in
development however, presentation in children
they often have with ASD.
communication
difficulties especially in
sustaining
conversations.
97
CHARACTERISTICS

■ Children with ASD have multiple medical and behavioural problems that
may make dental treatment difficult.

■ These children often have poor muscle tone, poor coordination, drooling, a
hyperactive knee jerk, and strabismus; 30% eventually develop epilepsy.

■ Children with ASD may have strict routines and prefer soft foods and
sweetened foods.

■ Because of poor tongue coordination, children with ASD tend to “pouch”

food instead of swallowing. This habit, combined with the desire for
sweetened foods, leads to increased susceptibility to caries.
98
DENTAL MANAGEMENT

■ Because of their tendency to adhere to routines, children with ASD may

require several dental visits to acclimate to the dental environment.

■ The use of a Papoose Board or Pedi-Wrap and preappointment conscious

sedation may be necessary and in some instances has a calming effect on
the child.

99
CEREBRAL PALSY

■ Cerebral palsy is one of the primary handicapping conditions of childhood.

■ The worldwide incidence of CP is approximately 2 to 2.5 cases per 1000 live

births.

■ In India, it is estimated at around 3 cases per 1000 live births.

■ Cerebral palsy is not a specific disease entity but rather a collection of

disabling disorders caused by insult and permanent damage to the brain in
the prenatal and perinatal periods, during which time the central nervous
system is still maturing.
100
■ This disability might involve :-
1. Muscle weakness
2. Stiffness
3. Paralysis
4. Poor balance
5. Irregular gait
6. Uncoordinated or involuntary
movements.

101
 ACCORDING TO THE TYPE OF NEUROMUSCULAR DYSFUNCTION

■ Spastic hemiplegia affects one third of all children with

cerebral palsy.

■ Hyperirritability of involved muscles, resulting in

exaggerated contraction when stimulated .

■ Tense, contracted muscles

The hand and arm are flexed and held in against the trunk.

■ The foot and leg may be flexed and rotated internally, which
results in a limping gait with circumduction of the affected
leg.
102
103
ACCORDING TO THE TYPE OF NEUROMUSCULAR DYSFUNCTION

Spastic (approximately 70% of cases)

Limited control of neck muscles, which results

in head rolling

Lack of control of the muscles supporting the

trunk, which results in difficulty in maintaining
upright posture

104
ACCORDING TO THE TYPE OF NEUROMUSCULAR DYSFUNCTION

Spastic (approximately 70% of cases)

Lack of coordination of intraoral, perioral, and
masticatory musculature
Impaired chewing and swallowing,
Excessive drooling
Persistent spastic tongue-thrust, and speech
impairments

105
 ACCORDING TO THE TYPE OF NEUROMUSCULAR DYSFUNCTION

■ Dyskinetic (athetosis and choreoathetosis) (approximately 15% of cases)

Constant and uncontrolled motion of involved
muscles.

Succession of slow, twisting, or writhing involuntary

movements (athetosis) or quick, jerky movements
(choreoathetosis)

Frequent involvement of neck musculature, which results in

excessive movement of the head
Hypertonicity of these muscles may cause the head to be held
back, with the mouth constantly open and the tongue
positioned anteriorly or protruded.
106
 ACCORDING TO THE TYPE OF NEUROMUSCULAR DYSFUNCTION

■ Dyskinetic (athetosis and choreoathetosis) (approximately 15% of cases)

Uncontrolled jaw movements, causing abrupt
closure of the jaws or severe bruxism

Frequent hypotonicity of perioral musculature with

mouth breathing,

Tongue protrusion

Excessive drooling

107
 ACCORDING TO THE TYPE OF NEUROMUSCULAR DYSFUNCTION

■ Ataxic (approximately 5% of cases)

Inability of involved muscles to contract
completely so that voluntary movements can be
only partially performed

Poor sense of balance and uncoordinated

voluntary movements (e.g., stumbling or
staggering gait or difficulty in grasping objects)

Possibility of tremors and an uncontrollable

trembling or quivering when attempting
voluntary tasks
108
 ACCORDING TO THE TYPE OF NEUROMUSCULAR DYSFUNCTION

■ Mixed (approximately 10% of cases)

Combination of characteristics of more than one type of cerebral

palsy (e.g., mixed spastic-athetoid quadriplegia)

109
In hypotonia:-
■ The muscles are flaccid.
■ There is an inability to elicit muscle
activity on volitional stimulation.
110
In rigidity:-
■ The muscles are in a constant state
of contraction.
■ The condition is characterized by
prolonged periods in which the
muscles of the extremities or trunk
remain rigid, resisting any effort to
move them.
 Asymmetric . Tonic
Startle
tonic neck labyrinthine
reflex
reflex reflex

Three common reactions, which a

dentist should recognize

111
1. Asymmetric tonic neck reflex.

■ If the patient’s head is suddenly

turned to one side, the arm and
leg on the side to which the face
is turned extend and stiffen.

■ The limbs on the opposite side

flex.

112
2. Tonic labyrinthine reflex.

■ If the patient’s head suddenly falls

backward while the patient is
supine, the back may assume the
position known as postural
extension; the legs and arms
straighten out, and the neck and
back arch.

113
3. Startle reflex

■ This reflex, which is frequently

observed in persons with cerebral
palsy, consists of sudden,
involuntary, often forceful bodily
movements.

■ This reaction is produced when the

patient is surprised by stimuli, such
as sudden noises or unexpected
movements by other people.
114
 ■ No intraoral anomalies are unique to persons with Cerebral palsy.

■ However, several conditions are more common or more severe than in the
general population. These conditions are as follows:

Periodontal • Periodontal disease and poor oral hygiene occur with great
disease frequency in persons with cerebral palsy.

• Often the patient will not be physically able to brush or

floss adequately.

115
Periodontal • Diet may also be significant; children who have difficulty
disease chewing and swallowing tend to eat soft foods, which are
easily swallowed and are high in carbohydrates.

• Patients with cerebral palsy and who take phenytoin to

control seizure activity will generally have a degree of
gingival hyperplasia.

116
Dental caries. • The data are conflicting regarding the incidence of
dental caries in patients with cerebral palsy compared
with its incidence in the general population.

• Except among institutionalized patients, the incidence of

caries does not seem to be significantly greater among
persons with cerebral palsy.

117
Malocclusions. • The prevalence of malocclusions in patients with cerebral
palsy is approximately twice that in the general population.

• Commonly observed conditions include noticeable

protrusion of the maxillary anterior teeth, excessive
overbite and overjet, open bites, and unilateral crossbites.

• A primary cause may be a disharmonious relationship

between intraoral and perioral muscles.

• Uncoordinated and uncontrolled movements of jaws, lips,

and tongue are observed with greater frequency in patients
with cerebral palsy.

• This may result in impaired chewing and swallowing,

excessive drooling,
118
tongue-thrust, and speech impairment.
Bruxism. • Bruxism is commonly observed in patients with athetoid
cerebral palsy. Severe occlusal attrition of the primary and
permanent dentition may be noted, with the resulting loss
of vertical interarch dimension.

• Temporomandibular joint disorders may be sequelae of

this condition in adult patients.

119
• Trauma • Persons with cerebral palsy are more susceptible to
trauma, particularly to the maxillary anterior teeth.

• This situation is related to the increased tendency to fall,

along with a diminished extensor reflex to cushion such
falls, and the frequent increased flaring of the maxillary
anterior teeth.

• Susceptibilities also include aspiration and ingestion of a

foreign body.

120
 TO AN UNINFORMED DENTIST

CONDITION MISCONCEPTION

1. A involuntary movements of the limbs An uncooperative and unmanageable

and head patient.

2. Unintelligible speech
Uncontrollable jaw movements Intellectually delayed.
Spastic tongue

• A clinician who is not knowledgeable about cerebral palsy and other physically and
intellectually disabling conditions may feel uncomfortable about treating such patients
and may refuse to do so.
121
DENTAL MANAGEMENT

In providing treatment for children with cerebral palsy, it is imperative that a

dentist evaluate each patient thoroughly in terms of :-

1. Personal characteristics

2. Symptoms and behaviour

3. Then proceed as conditions and needs dictate.

122
DENTAL MANAGEMENT

■ The dentist should never make assumptions about the degree of a child’s
physical or intellectual impairments without first acquiring the facts.

■ Taking a thorough medical and dental history is very important, and the
parent or guardian should be interviewed before the initiation of any
treatment.

■ It may also be beneficial to consult the patient’s physician regarding the

patient’s medical status.

123
■ A patient with cerebral palsy and who has involuntary head movements
may be cognizant of the need to minimize these movements while
receiving dental care.

■ Paradoxically the patient’s own endeavour's to control these movements

may only exacerbate the problem. Therefore all dental personnel be
empathic about the fears and frustrations that such a person experiences.

■ The importance of maintaining a calm, friendly, and professional

atmosphere cannot be overemphasized.

124
 The following suggestions are of practical significance in treating a patient
with cerebral palsy:

1.1. Consider treating a patient who uses a wheelchair in the wheelchair.

For a young patient, the wheelchair may be tipped back into the dentist’s
lap.

2. If a patient is to be transferred to the dental chair, ask about a

preference for the mode of transfer. If the patient has no preference, the
two-person lift is recommended.

3. Make an effort to stabilize the patient’s head throughout all phases of

dental treatment.

4. Try to place and maintain the patient in the midline of the dental chair,
with arms and legs as close to the body as feasible.

125
1.5. Keep the patient’s back slightly elevated to minimize
difficulties in swallowing. (It is advisable not to have the patient in
a completely supine position.)

1.6. When the patient has been placed in the dental chair,
determine the patient’s degree of comfort and assess the
position of the extremities. Do not force the limbs into unnatural
positions.
2.Consider the use of pillows, towels, and other measures for
trunk and limb support.

1.7. Use stabilization judiciously to control flailing movements of

the extremities.

126
1.To minimize startle reflex reactions, avoid presenting stimuli
such as abrupt movements, noises, and lights without
forewarning the patient.

1.Introduce intraoral stimuli slowly to avoid eliciting a

gag reflex or to make it less severe.

1.Consider the use of the rubber dam, a highly recommended

technique, for restorative procedures.

127
1.Work efficiently and quickly and minimize patient time in
the chair to decrease fatigue of the involved muscles.

1.Sedation or general anesthesia may be an option

for more complex patients.

128
1.- For control of involuntary jaw movements, choose from a variety of mouth props.

2.- Patient preference should weigh heavily because a patient with cerebral palsy may be
very apprehensive about the ability to control swallowing.

3.- Such appliances may also trigger the strong gag reflex that many of these patients
possess. Allow frequent time-outs for the patient to regroup, relax, and breathe normally.

129
ASTHMA (REACTIVE AIRWAY DISEASE)

■ Asthma is a chronic airway disease characterized by inflammation,

increased mucus production, and bronchial constriction.

■ It is caused by edema of the mucous membranes, increased mucous

secretions, and spasm of smooth muscle.

■ Asthma is a common childhood disease, affecting 1 in 10 children.

130
 Oral findings

■ Higher caries rates ■ High palatal vault

■ Decreased salivary rates ■ Posterior crossbites

■ Increased prevalence of oral ■ Increased overjet

mucosal changes characteristic of ■ increased facial height
chronic mouth breathers.

■ Increased levels of gingivitis.

131
■ A dental procedure constitutes an acute irritant to the airways of the asthmatic
child and may precipitate an attack

■ Before initiating dental treatment, the dentist should know :-

what are the frequency and what are the triggering agents
severity of the attacks

when the patient was hospitalized what medications the patient takes
and/or in the emergency department

when the last attack occurred what limitations on activity the

patient may have

132
Patients taking systemic corticosteroids

■ Those who were hospitalized or in the emergency department in the

preceding year should be treated with caution because they are at higher
risk of morbidity and mortality.

■ Sometimes, deferring the dental visit until the patient’s asthma is

controlled is the best approach.

133
 Patients using bronchodilators

■ should take a dose before their appointment, and they should bring their
inhalers or nebulizers into the dental office in case trouble arises.

■ Acute symptoms may be prevented by the use of the child’s bronchodilator

(inhaled β2 receptor agonist such as albuterol).

■ Behavioral methods are used to reduce anxiety, and nitrous oxide–oxygen

analgesia may be helpful.

134
Patients using bronchodilators

■ Hydroxyzine hydrochloride (Vistaril) and diazepam (Valium) have been

successful in alleviating anxiety.

■ Barbiturates and narcotics are not indicated because of their potential for
histamine release, leading to a bronchospasm.

135
NSAIDS

■ Aspirin compounds and nonsteroidal anti-inflammatory agents are

contraindicated because about 4% of patients experience wheezing after
taking these drugs.

■ Acetaminophen is recommended.

■ Positioning a child with mild asthmatic symptoms in an upright or semi

upright position for the dental procedure may be beneficial.

136
 DENTAL MANAGEMENT

■ Dental goals are similar to those for other patients, with care taken to
avoid the potential for dental materials and products to exacerbate the
asthma.

137
DENTAL MANAGEMENT

■ Emergency treatment for a person with asthma and who is in respiratory

distress requires discontinuing the dental procedure, reassuring the
patient, and opening the airway.

■ Staff should administer 100% oxygen while placing the patient in an

upright or comfortable position.

■ Keeping the airway open, administer the patient’s β2 agonist with an

inhaler or nebulizer.

■ If there is no improvement, administer subcutaneous epinephrine (0.01

mg/kg of 1:1000 solution) and obtain medical assistance immediately.
138
HEARING LOSS

■ In India, 63 million people (6.3%) suffer from significant auditory loss .

■ Four in every 1000 children suffer from severe to profound hearing loss .
■ With over 100,000 babies that are born with hearing deficiency every year .

139
■ Almost inevitably, speech is affected.

■ If an impairment is severe enough that dentist and child cannot

communicate verbally, the dentist must use sight, taste, and touch to

communicate and to allow the child to learn about dental experiences.

140
141
 CAUSES OF HEARING LOSS:

• Prenatal factors :- Congenital syphilis • Erythroblastosis fetalis

• Heredity disorders :- • Postnatal factors :-
• Viral infections :- Alport, Arnold-Chiari,
rubella and influenza Crouzon, • Viral infections, such as
Hunter, Klippel-Feil, Stickler, mumps, measles, chickenpox,
Treacher Collins, influenza, poliomyelitis,
• Ototoxic drugs :-
and Waardenburg syndromes meningitis
aspirin, streptomycin,
neomycin, kanamycin • Perinatal factors • Injuries
• Toxemia late in pregnancy
• Prematurity
• Birth injury
• Anoxia

142
DENTAL CONSIDERATIONS

1. Prepare the patient and parent before the first visit with a welcome letter
describing what is to be done and including a medical history form.

2. Let the patient and parent determine, during the initial appointment, how
the patient desires to communicate .

Through an interpreter, lip reading, sign language, note writing [for child who
can read], or a combination of these.

143
DENTAL CONSIDERATIONS

3. Look for ways to improve communication.

 It is useful to learn some basic sign language.

 Face the patient and speak slowly at a natural pace and directly to the
patient without shouting.

 Exaggeration of facial expressions and the use of slang make lip reading
difficult. Even the best lip-readers comprehend only 30% to 40% of what is
said.

144
 DENTAL CONSIDERATIONS

4. Assess speech, language ability, and degree of hearing impairment when taking
the patient’s complete medical history.

Identify the age of onset, type, degree, and cause of hearing loss, and determine
whether any other family members are affected

5. Enhance visibility for communication.

Watch the patient’s expression. Make sure the patient understands what the dental
equipment is, what is going to happen, and how it will feel.

Have the patient use hand gestures if a problem arises. If appropriate, write out and
display information.
145
 DENTAL CONSIDERATIONS

6. Reassure the patient with physical contact;

Hold the patient’s hand initially, or place a hand reassuringly on the patient’s
shoulder while the patient maintains visual contact.

Without visual contact, the child may be startled. Explain to the patient if you must
leave the room.

7. Use the tell-show-feel-do approach.

■ Use visual aids and allow the patient to see the instruments, and allow the patient
to see the instruments, and demonstrate how they work.
146
 DENTAL CONSIDERATIONS

8. Display confidence;
use smiles and reassuring gestures to build up confidence and reduce anxiety.
Allow extra time for all appointments.

9. Avoid blocking the patient’s visual field, especially with a rubber dam.

10. Adjust the hearing aid (if the patient has one) before the handpiece is in
operation
because a hearing amplifies all sounds. Many times the patient will prefer to have it
turned off

147
 DENTAL CONSIDERATIONS

10. Make sure the parent or patient understands explanations of diagnosis, treatment,
and payment.

Deaf persons have different levels of skill with English.

Use of an interpreter is extremely helpful.

148
INFECTIVE ENDOCARDITIS

■ It is characterized by microbial infection of the heart valves or

endocardium in proximity to congenital or acquired cardiac defects.

■ IE has been classically divided into acute and subacute forms.

No. ACUTE FORM SUBACUTE
1. Staphylococcus, Viridans streptococci

2. Pneumonococcus. Microorganisms
common to the flora of
the oral cavity.

3. Group A Streptococcus, 149

Cardiac Conditions Associated with the Highest Risk of Adverse Outcome from
Endocarditis for Which Prophylaxis with Dental Procedures Is Reasonable :-

5. Completely repaired congenital

1. Prosthetic cardiac valve or
prosthetic material used for
cardiac valve repair.
2. Previous infective endocarditis
3. Congenital heart disease
4. Unrepaired cyanotic CHD
150
heart defect with prosthetic material
or device, whether placed by surgery
or by catheter intervention, during
the first 6 months after the
procedure.
6. Repaired CHD with residual
defects at the site or adjacent to the
site of prosthetic patch or prosthetic
device
CLINICAL SYMPTOMS

■ Low, irregular fever (afternoon or evening peaks) with sweating

■ malaise,
■ Anorexia
■ weight loss and arthralgia
■ Inflammation of the endocardium increases cardiac destruction, and
murmurs subsequently develop.

■ Painful fingers and toes and skin lesions .

151
LABORATORY FINDINGS

1. Leukocytosis

2. Neutrophilia

3. Normocytic & normochromic anemia.

4. The erythrocyte sedimentation rate is rapid.

152
BEFORE INITIATING CARE

1. Obtain a thorough medical and dental history

2. Perform a physical examination

3. Formulate a complete treatment plan

4. Discuss the treatment with the child’s physician or cardiologist

153
INFECTIVE ENDOCARDITIS PROPHYLAXIS

■ Transient bacteremia is an important initiating factor in IE.

■ Procedures known to precipitate transient bacteremias prophylaxis for

dental procedures, even if such prophylactic therapy were 100% effective.

■ IE prophylaxis for invasive dental procedures involving the manipulation of

gingival tissue or the periapical region of teeth or perforation of the oral
mucosa is only for patients with the highest risk of adverse outcome.

■ Prophylaxis is not recommended.

154
DENTAL MANAGEMENT

■ Parents of patients with cardiac risks typically lack knowledge about IE

even after being informed during routine cardiology visits.

■ Hayes and Fasules et al report a deficiency of knowledge among dentists

regarding the indications for prophylaxis and the antibiotic regimen
required to prevent IE.

155
156
DENTAL MANAGEMENT

■ Behavior management technique , conscious sedation and nitrous oxide–

oxygen analgesia have also been proven beneficial in reducing anxiety in
such patients.

■ Conscious sedation monitoring and cardiopulmonary resuscitation

equipment should be readily available during the appointment.

■ If general anesthesia is indicated, the dental procedures should be

completed in a hospital setting, where adequate supportive care is
available if needed.

157
DENTAL CONSIDERATIONS

1. Pulp therapy is not recommended for primary teeth with a poor prognosis
because of the high incidence of associated chronic infection.

2. Extraction of such teeth with appropriate fixed-space maintenance is

preferred.

3. Endodontic therapy in the permanent dentition can usually be

accomplished successfully if the teeth to be treated are carefully selected
and the endodontic therapy is adequately performed.

4. A dentist who feels uncomfortable in treating patients who are susceptible

to IE has a responsibility to refer them
158 to someone.
CARDIAC SURGERY PATIENTS

■ Patients who are to undergo cardiac surgery should first have a careful
dental evaluation so that oral infection can be properly diagnosed and
treated.

■ Preventive dental program will decrease the incidence of postoperative IE

from oral sources, improve surgical outcomes, and improve the patient’
overall health.

■ After dental radiographs are obtained and an evaluation is performed, a

consultation with the patient’s cardiologist is in order to plan required
dental treatment before surgery.
159
CARDIAC SURGERY PATIENTS

■ The cardiologist will indicate the specific desired antibiotic prophylaxis

needed before the dental treatment.

■ Ideally, dental treatment should be completed within 3 or 4 weeks of the

planned surgery to allow for healing and the return of normal flora.

160
CONCLUSION

Children with SHCN may present challenges that require special preparation
before the dentist and office staff can provide acceptable care.

In addition, parental anxiety concerning the problems associated with a

child’s SHCN frequently delays dental care until significant oral disease has
developed.

If a dentist becomes familiar with the SHCN of a child and with the parents’
concerns, the dental management of the child can be gratifying.

161
 REFERENCES

■ Mcdonald and Avery .Dentistry for the child and the adolescent.10th
Edition.

■ Casamassimo.Pediatric Dentistry.Infancy Through Adolescence.5th Edition.

■ Shobha Tandon. Pediatric Dentistry.3rd Edition.

■ Glassman P, Subar P. Planning dental treatment for people with special

needs. Dent Clin North Am 2009;53 (2):195-205, vii-viii.

■ American academy of pediatric dentistry. Policy on the dental home. Oral

health policies .Reference manual v 4 0162/ n o 6 1 8 / 19.
■ US Department of Health and Human Services: Delivering on the promise: self-
evaluation to promote community living for people with disabilities: report to the
President on Executive Orde 13217, Washington, DC, 2002, US Department of
Health and Human Services.
■ American Academy of Pediatric Dentistry: Guideline on management of dental
patients with special health care needs, Pediatr Dent (Suppl Issue: Ref. Manual,
2013-14) 35:6, 2013.
■ American Academy of Pediatric Dentistry: Behavior guidance for the pediatric
dental patient, Pediatr Dent 36, 2014-1 (6 Suppl Issue: Ref. Manual 179–193).
■ Schalock RL, et al.: The renaming of mental retardation: understanding the
change to the term intellectual disability, Intellect Dev Disabil 45(2):116–124, 2007

163