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Dental Management of Special Needs Patients: A Literature Review

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 Global Journal of Oral Science, 2016, 2, 33-45 33

Dental Management of Special Needs Patients: A Literature Review

Virgínia Annett Polli, Mariane Beatriz Sordi, Mariah Luz Lisboa, Etiene de Andrade Munhoz*
and Alessandra Rodrigues de Camargo

Department of Dentistry, Health Science Centre, Federal University of Santa Catarina, 88040-900,
Florianópolis, Brazil
Abstract: The dental management of special needs patients creates doubt and anxiety among dentists. The theme is
underexplored throughout the undergraduate course and the dentists have not enough theoretical foundation to work on
this field. Special needs patients are those individuals who have permanent or transitory mental, physical, organic social
and / or behavioral impairments. Thus, the aim of this study was to assist dentists in the best dental management choice
for special needs patients. It was revised and more specifically detailed the management on dental base office, the
management under sedation and under general anesthesia, and home care treatments for patients with special needs,
with the aim of developing guidelines on management of dental patients with special health care needs to facilitate the
execution of dental treatment of these patients. From this literature review, we proposed a guideline to assist the dentist
in choosing the best therapeutic approach for the dental treatment of patients with special needs.

Keywords: Therapeutic approach, Sedation, General anesthesia, Home care.

1. INTRODUCTION the patient who is not to be subjected to general

Once the expectation of population lifetime has
increased, the demand for dental treatment for patients
with intellectual disability, physical limitations, social
and / or emotional deficit also grew. In dentistry, the
planning therapy of the special needs patients (SNP)
requires an extensive vision of the dentist, often
leading to a multidisciplinary approach [1].
However, many professionals still find difficulty
while providing such assistance. Such difficulties can
range from a lack of professional training, insecurity,
possible ergonomic limitations, changes in the routine
of the consulting room requiring physical adaptations
and special equipment, to the lack scientific knowledge
[2,3]. Moreover, it is common for patients with different
levels of cooperation, a difficulty or even an impedi-
ment of the dental treatment in an outpatient setting.
Thus, the health care professionals can reduce barriers
using different techniques [1].
Clinical care of the SNP should be based on risk
assessment, in which the general health status is
correlated to the level of collaboration level with the
dental treatment, versus the dental needs. Thereafter,
techniques for behavioral management must be initially
used, but in case of failure, sedation is an alternative to
anesthesia [1].
From the moment that the patient's clinical condition
derails the attempt of sedation, the dental treatment
should be performed by general anesthesia technique
in a hospital setting. This approach offers the possibility
of total oral readjustment in only one session, including
prophylaxis of the entire oral cavity, dental restorations,
pulp therapy, extractions, coronary reconstruction and
preventive procedures [4].
In the context of dentistry directed to the support of
SNP, the modality of home dental care proposes to
take care of all bedridden patient or those with limited
mobility and developmental disabilities. In this modality,
we can consider patients in palliative care, patients with
a dementia, or even patients in several post surgical
that show a dental emergency setting, for example [5].
The scientific literature is not concise in addressing
all these therapies and organizes them on an increas-
ing scale in order to direct professionals to the best
treatment choice. This study aims to conduct a litera-
ture review directed to dentists who are not familiar
with this area and intend to learn about different
management techniques for the dental care of SNP.
2. MATERIALS AND METHODS

*
Address correspondence to this author at the Department of
Dentistry, Health Science Centre, Federal University of Santa
Catarina, s/n, Delfino Conte Street, Trindade, Florianópolis, 88040-
900, Brazil; Tel: +55 (48) 3721-9520; E-mail: etiamfob@yahoo.com
Author Contributions: All authors equally contributed to this paper
with conception and design of the study, literature review and
analysis, drafting and critical revision and editing, and final approval
of the final version.
In order to conduct the proposed literature review, a
bibliographic research was performed in the database
PubMed / Medline with the following descriptors: “Dent-
istry/Special needs/Sedation”; “Dentistry/Special needs/
General anesthesia”; “Dentistry/Special needs/Home
care”; “Special patients/Dental treatment”; “Risks/

© 2016 Revotech Press

34 Global Journal of Oral Science, 2016, Vol. 2
Sedation/Dentistry”; “Domiciliary care/Dentistry”; and
“Risks/General anesthesia/Dentistry”. The article search
was restricted to the years 1999-2015. Systematic and
non-systematic reviews, studies on series of cases and
research articles were considered to structure this
study.
3. LITERATURE REVIEW
The Commission on Dental Accreditation (CODA)
defines SNP as every individual with a medical, physi-
cal, psychological and / or social condition that requires
individualization of the dental treatment [6].
Once it is a general concept, the theme 'special
patient' comprises a heterogeneous group of genetic
and / or acquired diseases, which in practice can be
divided into: neurological motor disorders (Down synd-
rome, cerebral palsy, etc.), chronic systemic diseases
(diabetes, heart diseases, hypertension), onco-hemato-
logical malignancies (leukemia, lymphoma), infectious
diseases (HIV, hepatitis B or C), physical disability
(paraplegia, hemiplegia), sensory impairments (hearing
impairment, visual disability), acquired diseases
(rubella, tuberculosis) [7]. This classification helps the
dentist to choose the best therapeutic approach while
analyze the underlying disease of the patient and the
consequent physical and / or mental impairment.
The dentist must to adapt to the psychological
approach, the surgical techniques and the choice of
dental materials for every type of individual and for
every need [8]. In this context, the identification of the
dental problems and implementation of the treatment
plan may change dramatically from one case to an-
other, since the general health status will influence this
behavior.
3.1. Management of the Patients with Special Needs
For patients with neurological motor disorders, the
initial clinical assessment requires three steps:
A. Evaluation of General Health: The first step starts
with a complete health questionnaire to be fulfilled
by the parents of the SNP. The medical history must
explore physician reports, including any hospital
treatment, medications in use, health problems,
warning situations, alimentary habits and other
important medical information.
B. Evaluation of Oral Health: The evaluation of oral
health status starts considering prior treatments and
the reasons of consultation, before performing the
Polli et al.
clinical examination. If possible, any dental, gingivo-
periodontal and soft tissue pathology must be
noted. At least one panoramic X-ray must be taken
as complementary exame. If necessary for the
diagnosis, additional periapical and/or occlusal X-
rays must be taken as well.
C. Evaluation of Behavior: For the dental treatment,
we consider the evaluation of behavior the most
relevant aspect in this protocol. In this matter, we
suggest that the behavioral analysis is based on the
amended Frankl scale [9] (Table 1), which consider
the level of cooperation; and the scale developed by
Houpt and co-workers [10] (Table 2), based on
movement during examination (whether or not asso-
ciated with shouting, crying, and other manifestation
of non-cooperative behavior). We believed that the
application of the scales might be a good indicator
as to whether outpatient care can be performed or
not [11].
Table 1: Frankl Scale [9] for Evaluating Behavior
Modified by De Nova Garcia, 2007 [11]
Category 1 Clearly Negative
Total lack of cooperation
Category 2 Negative
Signs of lack of cooperation
Category 3 Positive
Accepts treatment with caution. May require
reminders (open mouth, hands down, etc.)
Category 4 Very Cooperative
No sign of resistance. Very cooperative
Table 2: Scale for Evaluating Movement (Houpt and Co-
Workers 1985) [10], Modified by De Nova
Garcia, 2007[11]
1. Violent movement constantly interrupting examination
2. Constant movements that hinder examination
3. Controllable movements that do not interfere with the procedure
4. Lack of movement
After completing the three steps of the clinical assess-
ment, the most appropriate treatment plan for each
patient must be drawn and classified by quadrants/
sextants. Prioritization of therapeutic needs (preventive,
conservative, surgical) must be performed as follows:

Preventive treatment, which includes systematic
scaling/cleaning and fluor application, also the
placement of sealants;
Dental Management of Special Needs Patients Global Journal of Oral Science, 2016, Vol. 2, 35

Restorative treatment, which includes endodontic

and restorative treatment in both primary and
permanent teeth.

Surgical treatment, which includes tooth extrac-

tions, gingivectomies, biopsies and other minor
oral surgery.

Some conditioning techniques or even physical

support can be suggested and necessary, so that the
dental treatment elapses uneventfully [8]. Some of
these recommend to limitate the movement and must
be used in order to prevent that the patient movement
difficults the dental assistance. Also, this technique
avoids "escape attempts" of the patient, while protects
the work team of possible trauma and accidents, as
bites. Based on authors clinical experience, below are
some suggestions:

The “holding therapy” is a physical support

technique suitable for children, that remain in the
lap of the responsible person, who stabilizes
trunk and arms while embrace the patient
(Figure 1);

The “knee to knee” position is suitable for child-

ren of 1-3 years old. The technique consists to
lay the child supported on the legs of the dentist
Figure 1: Holding therapy.
and the responsible person, both touching knees
to each other and forming a kind of hammock
The technique where the auxiliary holds the pat-
(Figure 2); ient's head can be applied to patients of all ages.

Figure 2: Knee to knee position.

36 Global Journal of Oral Science, 2016, Vol. 2
Figure 3: Auxiliary sustaining the patient’s head.
The aid sustains the patient's head in order to
stabilizes or support it (Figure 3);
These techniques may be employed to short dental
visits, in which preventive, restorative, and/or surgical
treatments - as described above - can be performed
before the attempted pharmacological restraint.
Sedation obtained through oral medication - mild or
moderate - may be an important and very useful option
in dental treatment of SNP, since the sedatives are a
safe and effective way to contain the patient, with the
advantage of being prescribed by the dentist for
outpatient use [12]. According to the American Dental
Association [13], sedation represents a minimal depre-
ssion of levels of consciousness that keeps the pat-
ient's ability to maintain independently and continuous-
ly his airway, responding appropriately to physical
stimulation or verbal communication. The loss of con-
sciousness levels is produced by pharmacological or
non-pharmacological method, or a combination of both
[8,13].
The sedation procedure can be performed using an
evolutionary scale for choice of drug, namely: benzo-
diazepines, nitrous oxide, antihistamines and hypnotics
(barbiturics and non-barbiturics). It is also possible to
prescribe opioids for ambulatorial use, although with
some more caution. For deep sedation, the drugs used
are propofol and the neuroleptics, but these medica-
tions should be used in a hospital setting [14]. Table 3
Polli et al.
shows the different types of medication that may be
used in an outpatient setting by the dentist in order to
perform mild and / or moderate sedation for implement-
ing dental treatment. The table also presents the side
effects of each sedative [12,14].
The guideline developed by the Australian and New
Zealand College of Anesthesiologists [15], indicates the
risks involved in this technique, such as: depression of
protective airway reflexes and loss of airway perme-
ability; breath depression; depression of the cardiovas-
cular system; drug interactions or adverse reactions,
including anaphylaxis; unexpected high sensitivity to
drugs used for sedation and / or procedural analgesia
that could result in inadvertent loss of consciousness,
respiratory depression and / or cardiovascular depre-
ssion; individual variations in response to medicines
used, particularly in the children, the elderly and those
with pre-existing disease [15].
In order to minimize or avoid these risks, the dentist
must have a basic service support emergency kit,
composed of Ambu (manual ventilator), stethoscope
and sphygmomanometer, oxygen cylinder, Guedel
cannula, insulin syringe, scalpel, oximetry, epinephrine,
antihistamines, Captopril 12.5 mg, Hydrochlorithiazide
25 mg, Dimenhydrinate 50 mg and Pyridoxine Hydro-
chloride 10 mg, physiological saline, children's aspirin,
Isosorbide Dinitrate 5mg and sachet of carbohydrate or
glucose 50%. The dentist also must have the course of
Dental Management of Special Needs Patients Global Journal of Oral Science, 2016, Vol. 2, 37

Table 3: Medications, Indications, Contraindications and Side Effects of Different Drugs Used for Mild, Moderate and
Deep Sedation in the Dental Treatment

Dosage and Mode of

Medication
Administration
Diazepam: 5-10
mg/day, orally.
Benzodiazepines
Midazolam: 3,5-7,5
mg, intravenous.
Sedative
Phenobarbital: 2-3
hypnotics
mg/kg/day, orally.
(barbiturates)
Sedative
hypnotics (non-
… allergic to barbiturates and
barbiturates) -
Chloral Hydrate
Promethazine: 50-150
Antihistamines
mg/day, orally.
Meperidine: 25-150
mg, intramuscular; 25-
100 mg, intravenous.
Codeine: 90-360
Opioids
mg/day, orally.
Fentanyl: 1 a 2 mL
(0,05 a 0,1mg),
intramuscular.
Chlorpromazine: 25-
1.600 mg/day, orally.
Neuroleptics
Haloperidol: 2,5-5 mg,
intramuscular.
Propovan/Propotil: 1,5-
Propofol 2,5 mg/kg,
intravenous.
* Might be indicated with caution and under medical supervision.
** Might be used with caution.
Indications
Anxiety, apprehension and
fear; preanesthetic
medication; used in diabetic
and cardiac patients with
controlled disease.
Induction of general
anesthesia.
Pediatric patients; patients
benzodiazepines.
Pediatric patients; conscious
sedation; premedication for
deep sedation and general
anesthesia; treatment of
anaphylactic reactions.
Meperidine: outpatient
sedation and anesthesia;
Codeine: analgesia and
alleviation of pain; Fentanyl:
Intravenous supplement
during general anesthesia.
Deep sedation in patients
with high levels of anxiety
(hospital use).
Induction and maintenance of
general anesthesia or
conscious sedation.
Contraindications
st
Pregnant women (1
trimester)*, patients with
glaucoma or myasthenia gravis,
children with severe mental
impairment, alcoholics, and
patients with hypersensitivity to
benzodiazepines.
st
Pregnant women (1 trimester);
elderly patients, patients with
impaired liver function, sleep
apnea**.
Patients with liver failure,
severe kidney disease, gastritis
or gastric ulcers, severe heart
disease or intermittent
porphyria.
Taking care not to potentiates
the depressant effects of other
drugs on the CNS.
Meperidine: patients using
MAOIs or amphetamines, and
asthmatics.
---
Care to elderly patients,
hypovolemic, or with limited
cardiac reserve.
Side Effects
Drowsiness, ataxia,
confusion, double vision,
headache, changes in
libido, incoordination,
dysarthria,
pharmacodependence.
Chronic use causes
dependence.
Adverse dose-dependent
effects. At high doses
orally: excessive
depression of the central
nervous system (CNS),
gastrointestinal
disorders, cardiac
arrhythmias and
respiratory depression.
Drug interaction
potentiates depressant
effects on the CNS.
Drug interactions with
other depressant drugs
CNS.
Tremors, akathisia,
dyskinesia, orthostatic
hypotension, changes in
cardiac function and
body temperature, dry
mouth, nasal obstruction,
constipation, increased
body weight.
Nausea and vomiting
after surgery.

Basic Life Support (BLS), so that in any situation, the
professional knows how to handle emergency situa-
tions that endanger the life and physical and / or mental
integrity of the patient [16].
Due to severe health impairments and the less
cooperative level of some patients with the dental
treatment, procedures under general anesthesia are
very useful in some clinical situations [17] The ADA
(2009) considers general anesthesia as a procedure
that causes loss of consciousness where the individual
does not respond to painful stimuli and losses the abi-
lity to maintain ventilatory and neuromuscular function
independently. Mandatorily, this approach should be
performed in a hospital setting, with the assistance of
the anesthesiologist [13].
In dentistry there is not a determining classification
that helps the dentist in the choice of general anes-
thesia. Thus, the SNP risk analysis indicated for gene-
38 Global Journal of Oral Science, 2016, Vol. 2
ral anesthesia must be directed to the American Society
of Anesthesiologists (ASA), based on the physical
condition of each patient [18]: ASA I - Patients without
organical, physiological, biochemical and / or psychol-
ogical alterations. There are no systemic changes; ASA
II - Patients with mild or moderate systemic disease
caused by pathophysiological phenomenon or by the
condition to be treated surgically; ASA III - Patients with
very intense organical changes or pathological dis-
orders of any cause, even if it is not possible to define
the degree of the organical incapacity; ASA IV – Pat-
ients with severe general disorders, endangering their
lives, not able to be corrected by surgery; ASA V -
Moribund patient, with few chances to survive, they
undergo surgery as a last resort; and ASA VI - Patient
with declared cerebral death [18].
According to the World Health Organization (WHO),
approximately 8% of people with disabilities present
indication of dental treatment under general anes-
thesia. In a dental context, systemic health condition
should be evaluated together with the anesthesiology
team and the costs and benefits of the therapeutic ap-
proach discussed between both teams and family [19].
Among the contraindications of the technique is the
old age, decompensated systemic diseases, physical
limitations that may interfere with physiological func-
tions, specific syndromes with psychological and ana-
tomical abnormalities, pediatric patients with congenital
heart disease and / or physical disabilities, mental
illness or cognitive disorder, and other complex medical
conditions [20]. Absolute contraindications are also
mentioned, so the professional should be aware of febr-
ile conditions, colds, respiratory infections or decom-
pensated heart failure that compromise the general
anesthesia execution [21]. Table 4 shows the advan-
Table 4: Advantages e Disadvantages About the Use of General Anesthesia
Advantages
The cooperation of the patient
is not absolutely essential
The patient is unconscious during treatment
The therapy does not cause pain
The drugs used cause anterograde amnesia
--- The need for a professional team (not just the dentist) for conducting the proposed treatment
--- Must necessarily be performed in a hospital environment, including post-operative monitoring
Complications in the trans-surgical and post-operative are more common in procedures
---
Polli et al.
tages and disadvantages of this anesthesic modality in
dentistry [22].
Different than other therapies, home care aims to
target the dental approach for those bedridden indi-
viduals or unable to get around their homes [23].The
purpose of home care is to provide differentiated dental
service, offering specific care by a qualified profess-
ional, including the participation of relatives or guard-
ians. The procedures performed in the home setting
aim at removing odontogenic infection, in addition to
performing preventive procedures such as hygiene
instructions to the patient, carers and guardians [24].
Although the home dental care might be a challenge
for the dentist - due to space limitations, inadequate
posture, insufficient lighting, reduced access to imaging
exams, less control over unforeseen events, emergen-
cies and lack of biosecurity –it is an extremely import-
ant activity for the care of the SNP [5].
There are four main types of home care, according
to the physical and cognitive status of the patient: 1)
Required emergency treatment: aims to treat pain or
diseases that severely influence the general health of
the patient. In these cases, the treatment is performed
independently of the patient's collaboration; 2) Nece-
ssary treatment - Severe: aims to preserve oral and
general health of the patient, the latter being able and /
or aware of receiving dental treatment; 3) Necessary
treatment - Moderate: the patient may have restrictions
to cooperate and may require prior medication (sedat-
ives) to the dental care, in this case it is evaluated the
benefit of the treatment in relation to the stress that the
patient might have; and 4) No need for treatment: in
this case, the patient may be in a persistent vegetative
state, or may have a good oral function, not presenting
oral diseases [25].
Disadvantages
The unconsciousness of the individual during the procedure
(it is considered advantage and disadvantage at the same time)
The patient's protective reflexes are depressed
Vital signs are depressed
It requires advanced training for administration of general anesthesia (medical team)
performed under general anesthetic induction
Dental Management of Special Needs Patients
3.2. Decision-Making About Treatment Modality –
Behavior Scales
The indications described below were based on our
clinical experience, the amended Frankl scale (Table 1)
[9] and the scale developed by Houpt and co-workers
(Table 2) [10]. This should not be used systematically
for the convenience of the dental team, but rather should
be seen as the last resource for protocol treatment.
The proposed protocols were classified in three main
groups:
- Conditions Techniques and / or Physical
Support: Patients in categories 3 and 4 (Tables 1 and
2) [9,10] who are cooperative with dental treatment but,
eventually, do not show clear signs of interacting verb-
ally with the dentist. Many patients are collaborative
even though they are not able to carry out interactive
communication with the dentist because their special
conditions;
- Sedation Technic: For patients in category 2
(Tables 1 and 2) [9,10], and in cases of failure in the
use physical support techniques, the dentist may use
ambulatory care with sedation [26]. Selecting the most
appropriate drug for sedation should take into consi-
deration the dental need, the underlying disease of the
Figure 4: Sedation sequence. Materials used: Midazolam, distilled water, disposable syringe, 2 ml of gooseberry juice. Mixture
of the macerated sedative with the distilled water, and addition of 2 ml of the gooseberry juice. Sedative administration.
Global Journal of Oral Science, 2016, Vol. 2, 39
patient, and the advantages and disadvantages of
using each of them (Table 3) [12,14]. The outpatient
sedation technique should only be performed by quali-
fied professionals. All support for any complications
must be available and ready for use at the dental ap-
pointment. Regarding the assessment of the underlying
disease, it is suggested this technique for patients ASA
I and ASA II.
- General Anesthesia: We advocated that general
anesthesia must be considered for patients classified in
categories 1 and 2 (Tables 1 and 2) [9,10]. The use of
the technique requires the participation of a multidisci-
plinary team in a hospital setting. The hospital routine
must be respected. The cooperation of the patient is
not required in this modality. Regarding the assess-
ment of the underlying disease, it is suggested this
technique for patients ASA I to ASA IV.
3.3. Guidelines of Service
3.3.1. Mild / Moderate Sedation
The sequence of service proposed by this work
builds on the guidelines of the American Dental Asso-
ciation [13], the Australian and New Zealand College of
Anesthetists [15]. Figure 4 presents a sequence for use
of sedation by the oral route in SNP.
40 Global Journal of Oral Science, 2016, Vol. 2
Step 1 - Initial Assessment of the Patient: Comple-
tion of a health questionnaire, including medical history,
physician reports, hospital treatments, medications in
use, health problems, alimentary habits and behavior.
Patients included in category 2 (Tables 1 and 2) are
potential for intervention.
Step 2 - Preoperative Evaluation: Medical assess-
ment by the team which manage the patient; request of
laboratory exams about the clinical state; verbal and
written instructions to the patient and / or guardian
about the pre, intra and postoperative procedures;
informed consent form of the patient and / or guardian;
dietary restrictions of 4 hours without ingesting solids
and liquids; evaluation of the patient's vital signs (blood
pressure and respiratory rate).
Step 3 - Professionals and Equipment: At least one
person, besides the dentist, with training in BLS must
be present, and monitoring equipment of vital signs and
resuscitation equipment must be easily accessible.
This professional will be responsible for monitoring the
patient's vital signs. For the accomplishment of the
dental procedure, it is required the presence of an
auxiliary on oral health and / or another dentist.
The room should be wide and equipped in order to
deal with cardiopulmonary emergencies [15] and must
contain at least: 1) stethoscope to auscutate the breath-
ing (check every five minutes); 2) oximeter to monitor-
ate peripheral perfusion; 3) non-invasive monitor to
check the blood pressure (sphygmomanometer or auto-
matic cuff device); 4) supply and administering of 100%
oxygen source; 5) supply for intravenous medication
(must be performed by a qualified professional) [12].
Step 4 - Patient Monitoring: Oxygenation: Colora-
tion of mucosal, skin or blood should be evaluated
continuously; oxygen saturation by peripheral oximetry
may be considered clinically useful.
Ventilation: The dentist and / or the qualified pro-
fessional should observe elevations of the chest and
check breathing continuously. Maintain airway perme-
ability.
Circulation: Blood pressure and heart rate should
be evaluated preoperatively and monitored intra and
postoperatively [12].
Step 5 – Dental Treatment: The most favorable
cases are those in which the dental needs are small
and easily resolved with short appointments. Prevent-
Polli et al.
ive, restorative and surgical treatment can be per-
formed and concluded in different approaches.
Step 6 - Documentation: All the procedures should
be documented, reporting the sedative drugs and the
local anesthetics administered, as well as the doses
and the pre / postoperative medications. The description
of the dental procedure performed is also part of this
description.
Step 7 - Patient Discharge: It is necessary that the
patient is capable to walk with minimal assistance.
Postoperative pain and bleeding should be minimal or
absent. The patient should be accompanied by a res-
ponsible person who will receive verbally and written
postoperative orientations [12].
3.3.2. General Anesthesia
The assistance sequence proposed by the present
study takes as reference the guidelines of the Ameri-
can Dental Association [13] and the Australian and
New Zealand College of Anesthetists [15].
Step 1 - Initial Assessment of the Patient: Com-
pletion of a health questionnaire, including medical his-
tory, physician reports, hospital treatments, medica-
tions in use, health problems, alimentary habits and
level of cooperation. Patients included in categories 1
and 2 (Tables 1 and 2) are potential for intervention.
Step 2 - Preoperative Evaluation: Medical assess-
ment by the team which manage the patient; request of
laboratory exams (urea, creatinine, complete blood
count, complete coagulation exams, X-ray of the chest,
electrocardiogram for patients older than 50 years or
for patients who have pre-existing cardiac abnormal-
ities) [18]; verbal and written instructions to the patient
and / or the responsible person about the procedures
before, during and after surgery; informed consent form
of the patient / guardian; dietary orientations (absolute
fasting of 10 hours).
Step 3 - Professionals and Equipment: Among
professionals, it is necessary an anesthesiologist, the
nursing team and the dental team. Among the equip-
ment, a complete surgical center is requested. Figure 5
presents the dental materials for the treatment of SNP
under general anesthesia and Figure 6 presents dental
procedures performed with the patient under general
anesthesia.
Step 4 - Patient Monitoring: Responsibility of the
anesthesiologist team.
Dental Management of Special Needs Patients Global Journal of Oral Science, 2016, Vol. 2, 41

A B C

D E F

G H I

Figure 5: Materials used for general anesthesia. A) Surgical center. B) Anesthesia and monitoring device. C) Portable
compressor for micro motor. D) Photopolymerizer. E) Ultrasound. F, G and H) Dental instruments. I) Sterile gauze.

A B C

D E F

G H I

Figure 6: Dental procedures performed in hospital. A and B) Approximated and extended view of the prepared patient to
receive dental care. C) Prevention procedure using ultrasound. D) Patient receiving local anesthesia for local tissue ischemia. E,
F and G) Endodontic procedures. H, I) Restorative procedures.

Step 5 – Dental Treatment: The use of general ment. Preventive, restorative and surgical treatment
anesthesia is indicated for cases of more complex can be performed and concluded in a single appoint-
dental problems, which involve extensive dental treat- ment.
42 Global Journal of Oral Science, 2016, Vol. 2
Step 6 - Documentation: The whole procedure
must be documented, reporting the name of the admin-
istered inducing drugs and anesthetics (local and gene-
ral), the doses and the pre and postoperative medi-
cations.
Step 7 - Recovery Room: Postoperative care relat-
ed to the type of the dental procedure performed. Drug
prescription must be maintained as used in the operat-
ing room. The patient care is responsability of the hos-
pital nursing team.
Step 8 - Hospital Liberation: For dental procedures
without complications, patient will be released between
1-2 days. Anesthetic liberation is liability of the res-
ponsible anesthesiologist.
3.3.3. Home Care
The sequence of assistance for home care is based
on the guideline proposed by the British Society for
Disability and Oral Health [24]. Figure 7 illustrates a
home care sequence.
Step 1 - Initial Assessment of the Patient: Com-
pletion of a health questionnaire, including medical his-
Figure 7: Illustrative sequence of home care. A) House layout to receive the dental team. B) Portable equipment before
installing. C) Dental assistance. D) Portable equipment installed and ready for use (equipment consists of portable compressor,
outputs for micro motor, multifunction syringe and aspirator).
Polli et al.
tory, physician reports, hospital treatments, medica-
tions in use, health problems, alimentary habits and
level of cooperation. Patients included in categories 3
and 4 (Tables 1 and 2) are potential for intervention.
Step 2 - Preoperative Evaluation: Medical assess-
ment by the team which manage the patient; request of
laboratory exams linked to the clinical state; verbal and
written instructions to the patient and / or guardian
about the pre, intra and postoperative procedures;
informed consent form of the patient and / or guardian;
dietary restrictions according to the underlying disease.
Step 3 - Professionals and Equipment: It is re-
quested two dentists. The necessary equipments are
presented in Table 5.
Step 4 - Patient Monitoring: Constant cardiac and
respiratory monitoringalong the dental appointment is
only necessary in cases of bedridden patients pre-
viously monitored by the medical team. Blood pressure,
oxygen and random blood glucose monitoring will be
performed routinely according to the underlying
disease of the patient. In these situations, the behavior
will be the same done in the dental office.
A B
C D
Dental Management of Special Needs Patients
Table 5: List of Necessary Equipments for Home Care Approach
General Equipments Administratives Materials
Portable light
Portable equipment with dental aspirator, General recommendations
X-ray and ultrasound equipment (surgical and oral hygiene)
IPE (Individuale Protective Equipment):
gloves, mask and protective eyewears.
Forms laboratories
Biosecurity materials
Desinfectant solution
Liquid soap Photographic camera in order to record cases
Dental instruments Illustrative material on health
Step 5 – Dental Treatment: The most favorable
cases are those in which the dental needs are small
and easily resolved with short appointments. Prevent-
ive, restorative and surgical treatment can be perform-
ed and concluded in different approaches.
Step 6 - Documentation: Every procedure should
be documented, reporting each drug used (ie. admin-
istered local anesthetics and pre / postoperative medi-
cations).
4. DISCUSSION
In the scientific literature there are no studies that
address the use of different techniques directed to the
management of special needs patients, from outpatient
clinic approach - with the help of conditioning and
physical support techniques – to general anesthesia,
placing them at an increasing scale choice.
This scarcity exists by the magnitude of the subject
involved. The area of special needs patients has as
object of study heterogeneous subgroups of patients,
whose classification ranges from oncological, infec-
tious, psychiatric, chronic, systemic diseases to genetic
disorders in adults and children. Thus, in order to focus
this subject, it is necessary initially to define the study
subgroup to which it is addressed.
Behavioral management, physical constraint and
sedation techniques are more described in pediatric
dentistry specialty [19]. However, they do not take into
consideration many of the anatomical and neurological
changes that occur in patients with neuro-psychomotor
disturbances that might difficult the use of such tech-
niques. It is based on this prerogative that profe-
ssionals end up basing their behavior on the clinical
experience acquired throughout their lives. In this
Global Journal of Oral Science, 2016, Vol. 2, 43
Consumables / Instrumentals
Medical records Vary according to the dental procedure
Rigid plastic box for transporting the
contaminated material (instruments and
consumables)
Rigid plastic box for transporting and proper
disposal of needlesticks, sharps in the office.
Consent forms --
--
--
matter, we consider that the use of proposed on the
amended Frankl scale [9] and scale developed by
Houpt and co-workers [10], can be useful tool to
analyze behavior as a basis for dental treatment [11].
The main aim of this study was to perform a litera-
ture review targeted at dentists who are unfamiliar with
this area, in order to learn about different management
techniques considered for dental care of patients with
special needs. As to facilitate the access and the
understanding of the subject addressed, the goal was
to elaborate guidelines of dental care for different tech-
niques based on the available literature. The theoretical
basis necessary to develop this literature review was a
challenge for the small amount of published works on
the subject.
As a starting point, we tried to facilitate the identifi-
cation of primary signals to be recognized on each pat-
ient, so that the dentist might choose the best thera-
peutic approach. For the preparation of the protocols
presented in this work, we based our review on manu-
als of the American Dental Association [13], Australian
and New Zealand College of Anaesthetists [15] and on
our clinical experience, which were reinforced with
images of cases performed by the authors. The seda-
tion and general anesthesia guidelines proposed by
this study differ from the above protocols once they
present a more dynamic and practical profile, with
simplified topics.
Furthermore, the guideline presented here com-
prises additional information, such as references to the
medication used for sedation, in addition to risks and
directions on their use. Maybe this could be the differ-
ential of this study since, when compared to other
protocols, it was observed that not all authors cite this
particular content or gather the information of the three
44 Global Journal of Oral Science, 2016, Vol. 2
afore mentioned assistance options [5,8,13,15,17,19,
20,26,27].
Glassman et al. (2009) reviewed several guidelines
about sedation and general anesthesia, concluding that
despite the large amount of available protocols in the
literature, few are specific to patients with special
needs [8]. Thus, this guideline becomes a specific
working tool. Differently from the elaborated assistance
protocols for the modalities of sedation and general
anesthesia, we found difficulty in developing a dental
care protocol for home care technique. The major rea-
son was the lack of scientific articles published on this
subject to the date [5,27]. Among the selected articles,
only one scientific paper has proposed the develop-
ment of a practical protocol that based the formulation
of the guideline of this work [5].
The ideal would be to elaborate an evolutionary
scale to choose the best therapeutic approach, based
solely on the underlying disease of the patient. In this
matter, patients with Down syndrome, for example,
might be potential targets for an outpatient approach
under conditioning and / or physical stabilization, as
well as autistic patients might be directly indicated for
general anesthesia and so on. Facing such imposs-
ibility, we believe that the development of the proposed
guideline could assist in the decision-making.
In homecare subject, the studies are more related to
oral health in patients living in institutions, paliative care
units or nursing homes [5,24,27].
Searching the professional dental performance in
the home care area is of considerable importance to
improve the technique and to enrich the access to
health services. According to the American Academy of
Pediatric Dentistry [28], the home care reduces the risk
of illness from preventable diseases, once only in this
way the dental care can be performed on bedridden
patients, not just to eliminate foci of pain, but also for
prevention of diseases [27].
5. FINAL CONSIDERATIONS
The conducted literature review coupled with our
clinical experience, has allowed us to develop an evo-
lutionary guideline destined to a better therapy – seda-
tion, general anesthesia or home care - for dental treat-
ment of special needs patients with neuro psychomotor
disorders. This was the first time in the literature that a
scientific work discussed and compared the different
therapeutic modalities involved in the dental treatment
of special needs patients. We hope this guide could be
Polli et al.
used by dentists that are not familiar with this area on
the professional clinical routine.
ACKNOWLEDGMENTS
The authors thank Doctor Claudia Barbosa Pereira
who kindly donated the home care images.
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Published on 19-04-2016