Special Care Patient Report

Paige Humphries

DH222B Clinical Dental Hygiene

March 30th, 2024

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Description

For the special care client requirement, I will be providing dental hygiene services to a

22-year-old patient with severe autism spectrum disorder, attention deficient hyperactivity

disorder (ADHD), and Tourette’s syndrome. Neurological and developmental conditions often

present during adolescence and persist throughout the lifetime of the patient. The symptoms of

each of these conditions may be controlled by certain medications, but the conditions will not be

eliminated by medications. The patient whom I will be providing dental hygiene treatment for

has no additional systemic medical considerations and the medications that this patient is taking

include risperidone, paroxetine, and fluvoxamine. Risperidone is a second-generation

antipsychotic and antimanic agent. The patient is taking this medication for the antimanic

effects, to reduce irritability associated with autism. The local anesthesia considerations for this

medication include a low risk for drug-induced torsades de pointe with the use of

vasoconstrictors (Lexicomp, n.d.). When a patient is taking this medication, it may be

recommended to have a medical consult before the use of vasoconstrictors. The effects of

risperidone on dental treatment include drooling, dysgeusia, orthostatic hypotension,

sinusitis/congestion, tardive dyskinesia, tongue paralysis/spasm, toothache, trismus, and

xerostomia (Lexicomp, n.d.). This medication has no listed effects on bleeding. The patient is

also taking paroxetine, which is a selective serotonin reuptake inhibitor (antidepressant).

Paroxetine is taken for mood regulation and has no reported effects when used with

vasoconstrictors and local anesthetic solutions. The effects that this medication has on dental

treatment may include abnormal taste, xerostomia, orthostatic hypotension, and bruxism

(Lexicomp, n.d.). This medication may also impair platelet aggregation, resulting in an increased

risk of bleeding. Fluvoxamine is also listed on this patient’s medical history and is a selective

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serotonin reuptake inhibitor (antidepressant). The patient is taking this medication for the

treatment of obsessive-compulsive disorder-like symptoms. Fluvoxamine has the same

considerations associated with paroxetine.

The patient presents with a neurological and developmental disorder known as autism

spectrum disorder, which is described as a “complex developmental disability that impairs

communication and social, behavioral, and intellectual functioning” (Practical Oral Care for

People with Autism). Autism spectrum disorder can vary in symptoms and severity, and

research has shown that autism has comorbidity with other conditions, such as Tourette’s

syndrome and attention deficit hyperactivity disorder (ADHD). The symptoms associated with

autism spectrum disorder may include repetitive behaviors, aloofness, unpredictable movements,

and obsessive routines (Practical Oral Care for People with Autism). In addition to autism

spectrum disorder, the patient also has a disorder known as attention deficient hyperactivity

disorder (ADHD), which is a common neurodevelopmental disorder (What is ADHD?).

Symptoms associated with attention deficient hyperactivity disorder (ADHD) include

hyperactivity, impulsiveness, and a lack of attention (Begnini et al., 2019). The symptoms that

are associated with attention deficient hyperactivity disorder (ADHD) may also be associated

with autism spectrum disorder. Due to hyperactivity and impulsive behaviors, patients with

attention deficient hyperactivity disorder (ADHD) are often at an increased risk for dental and

oral trauma from actions such as bruxism and lip biting. Lastly, the patient presents with

Tourette’s syndrome, also known as Gilles de la Tourette’s syndrome, which is a neurological

condition that presents with vocal and motor tics (Vivanti & Canitano). Tics are described as

unintentional and uncontrollable movements or sounds. Both motor and vocal tics can affect

dental treatment, with the possibility of causing unintentional injury to both the patient and the

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clinician. Motor tics can affect the oral cavity directly by causing irregular and sudden

movements of the lips and tongue. In addition to this, patients with Tourette’s syndrome often

present with hyposalivation, increasing the patient's risk for dental caries and periodontal disease

(Friedlander & Cummings).

Treatment Modifications

Autism spectrum disorder, attention deficient hyperactivity disorder (ADHD), and

Tourette’s syndrome all present the need for adaptations in dental hygiene treatment. When a

patient has any of these conditions, diligent care and understanding is required to provide the

highest quality of care. These patients often have a higher risk for caries and periodontal disease

and show signs of poorer overall oral health.

Patients with neurological and developmental disorders often have an increased risk for

dental caries and periodontal disease due to an inability to maintain adequate home care and

plaque removal techniques. These patients require increased support and assistance with oral

hygiene habits, and depending on the severity of the condition, a caregiver may be responsible

for providing oral hygiene homecare to the patient. Because of this, it is important to provide

thorough and interactive homecare instructions to both the patient and the caregiver. To improve

overall oral hygiene, an electric toothbrush may be beneficial for patients who can tolerate the

vibrations. The encouragement of visual aids and videos can help increase the patient's

understanding and receptiveness to homecare efforts and dental hygiene treatment. In addition to

this, sensory-friendly toothbrushes and toothpaste may be required from homecare interventions

(Curbow, 2023). Overall, adaptive and thorough homecare instructions adjusted to the needs of

the patient are extremely important in reducing a patient's risk for caries and periodontal disease.

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 Other factors that may increase a patient's risk for caries include consuming a diet high in

sugar and taking medications that cause xerostomia. Due to the increased caries risk, it is also

important to encourage the application of fluoride. To increase acceptance of fluoride therapy,

fluoride varnish may be the most tolerable method of application for these patients. Overall, due

to the challenge of maintaining adequate oral hygiene for patients with neurological and

developmental disorders, and an increased risk for caries and periodontal disease, a 3-month

recall is often required for dental hygiene treatment.

Effective communication can be a concern when treating patients with neurological and

developmental disorders. Patients with autism spectrum disorder may have decreased mental

capabilities and may be unable to comprehend the information presented by the dental hygienist.

The clinician should talk to the caregiver before the appointment to develop an understanding of

the patient's intellectual abilities before making assumptions about the patient. When caring for

patients with neurological disabilities, it is important to communicate with the patient on a level

that they can understand. The tell-show-do method and the use of visual aids are often effective

tools that may help reduce unpredictable behaviors. In addition to using the tell-show-do

method, positive reinforcement for good behavior should be implemented in all aspects of dental

hygiene treatment.

For patients with neurological and developmental disorders, it is not uncommon for

behavioral issues to arise. When these problems occur during dental treatment, it is important to

attempt to calm the patient in a safe manner, which may require the assistance of the caregiver.

Many patients with special needs can be seen in a general dental office with a calm and

consistent environment, but if individuals cannot tolerate dental care, sedative dentistry may be

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required. The caregiver may be knowledgeable of methods that work to calm the patient and

limit behavioral problems.

Dental hygiene appointments should be short, and the patients may require specific

appointments to desensitize the patient to the dental office environment (Curbow, 2023). These

appointments may involve the dental hygienist showing the patient the operatory and allowing

them to look around to become comfortable and familiar with the environment. During these

appointments, it is important to build a relationship with the patient and show interest in the

things that they enjoy. With a calm and consistent environment, the patient may grow more

comfortable and receptive to dental hygiene treatment. Although many adaptations to dental

hygiene treatment may be required when treating patients with neurological and developmental

disorders, comprehensive dental hygiene treatment can be achieved with patience and flexibility.

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Citations

American Psychiatric Association. (n.d.). What is ADHD? https://www.psychiatry.org/patients-

families/adhd/what-is-adhd

Begnini, G. J., Brancher, J. A., Guimarães, A. T., de Araujo, M. R., & Pizzatto, E. (2019). Oral
Health of children and adolescents with attention deficit hyperactivity disorder.
International journal of clinical pediatric dentistry.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7229396/

Curbow, L. (2023, June 27). Dental Care for Patients with Autism: Strategies for Home and
Office Care. Today’s RDH. https://www.todaysrdh.com/dental-care-for-patients-with-
autism-strategies-for-home-and-office-care/

Friedlander, A. H., & Cummings, J. L. (1992). Dental treatment of patients with Gilles de la
Tourette’s syndrome. Oral surgery, oral medicine, and oral pathology.
https://pubmed.ncbi.nlm.nih.gov/1532057/

Hours, C., Recasens, C., & Baleyte, J. M. (2022). ASD and ADHD Comorbidity: What Are We
Talking About? Frontiers in psychiatry, 13, 837424.
https://doi.org/10.3389/fpsyt.2022.837424

Lexicomp. (n.d.). Lisdexamfetamine: Drug information. UpToDate. Retrieved March 19, 2024,
from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/lisdexamfetamine-
drug-information

National Institute of Dental and Craniofacial Research. (n.d.). Practical Oral Care for People
with Autism. https://www.nidcr.nih.gov/sites/default/files/2017-09/practical-oral-care-
autism.pdf

Vivanti, G., & Canitano , R. (n.d.). Tics and Tourette syndrome in autism spectrum disorders.
Autism: The International Journal of Research and Practice.
https://pubmed.ncbi.nlm.nih.gov/17175571/