Children with Special Health Care Needs (CSHCN)

DEFINITION:

• Handicapped children are those having certain physical, mental, social and dental conditions
that prevent them from achieving full potential when compared with other children.

• The term Children with Special Health Care Needs (CSHCN) could replace some terminologies
which were given to those children as: handicapped or disabled.

AAPD definition

• individuals with special health care needs (SHCN) 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.”

Classification

CSHCN

Dental Medical Mental

v
-Cleft lip and palate.
- Cardiovascular disorders
-Down syndrome
-Amelogenesis Imperfecta.
- Bleeding disorders e.g.
Hemophilia. -Cerebral palsy
-Dentinogenesis Imperfecta .
-Neuromuscular disorders -any disease
-Early Childhood Caries.
e.g. Epilepsy, Cerebral Palsy. accompanied by
-Sever Skeletal Malocclusion. mental retardation.
-Sensory Disorders e.g.
Hearing and visual -Intellectual disabilities
impairments (Deafness and -Mental retaedation
Blindness).

-Metabolic disorders e.g. à

Diabetes Mellitus.

-Respiratory disorders e.g.

à Asthma.

-Neoplasms.
 Rheumatic fever

Clinical picture
diagnosis confirmed with 2 major manifestation or 1 major and 2 minor

Major manifestation Minor manifestation

Arthritis • Fever

Carditis • Elevated ESR

Erythema marginatum • elevated CRP

Subcutaneous nodules Prolonged P-R interval on ECG

Chorea

TREATMENT
✓ Prophylactic : Penicillin 1,200000 U long life ( 21 yr )
✓ Curative : Bed rest- Aspirin - Cortisone
 infective endocarditis
• Infective bacterial endocarditis is one of the most serious infections of humans

• It is characterized by microbial infection of the heart valves or endocardium in proximity to

congenital or acquired cardiac defects.

• The acute form occurs as a result of microorganisms of high pathogenicity attacking a normal
heart causing erosive destruction of the valves.

• Subacute bacterial endocarditis usually develops in persons with preexisting congenital

cardiac disease or rheumatic valvular lesions.

• The subacute form is commonly caused by viridans streptococci

• Diagnosis
✓ Fever

✓ Pallor

✓ Osler's
nodes.

✓ Roth's
spots.

✓ Nail clubbing.

Dental consideration

• Consult the patient's cardiologist.

• In apprehensive patients prescribe sedative after medical consultation.

• If general anaesthesia is indicated hospitalize the patient.

• Pulp therapy in primary teeth is not recommended due to the possibility of producing infection.

• Endodontic treatment in permanent teeth can be done after careful selection.

• If extraction is indicated, give a prophylactic antibiotic to reduce the incidence of Sub-acute

Bacterial Endocarditis.

According to the American Heart Association the following can be given:

• Amoxicillin For children 50mg/ kg, Orally, one hour before the dental treatment

• In patients who are unable to take oral medications: Ampicillin 50mg/kg IM injectin 30 min.
before treatment.
 • In patients allergic to penicillin: Clindamycin e.g.Dalacin-C or Erythromycin orally one hour
before treatment

Dental Procedures requiring prophylactic antibiotic: (Procedures known to induce bleeding

&precipitate transient bacteremia) as:

• Extraction of a tooth.

• Scaling and Root planning.

• Endodontic treatment and instrumentation beyond the apex.

• Placement of orthodontic bands.

• Intraligamentary local anesthesia.

• Dental implants.

Dental Procedures not requiring prophylactic antibiotic:

• Filling and restoration

• Local anesthesia injection.

• Placement of rubber dam.

• Impressions.

• Removal of sutures.

• Shedding of primary teeth.

• Placement of orthodontic brackets.

• Taking radiographs.

Hemophilia
• It’s a blood coagulation disorder due to deficiency of one or more of the clotting factors which
results in severe bleeding.

• Hemophilia A is the most common bleeding disorders which results from deficiency of factor VIII
( antihemophilic factor).

• X- linked disease occurs in males while females act as carriers ( sex linked recessive trait)
transmitting the disease to males from one generation to another.

• Bleeding time is normal (1-3 min.), while coagulation time is prolonged (30min. or more).
*Oral manifestation
• Intra-oral hemorrhage due to trauma.

• Prolonged oozing from the gingiva during

shedding.

• Poor oral hygiene due to irregular tooth

brushing (fear from bleeding from his
gingiva).

• High caries incidence as the patient usually

eats soft carbohydrates.

*Dental management
• Consult patient's hematologist to know the severity of bleeding (Mild, Moderate, Severe).

Local Anesthesia :
• Nerve block anesthesia is contraindicated

• Infilteration anesthesia containing vasoconstrictor is recommended using finest gauge needle.

• General anesthesia may result in traumatic hemorrhage during induction and endo-tracheal
intubations.

Restorative treatment:
• - Rubber dam should be used to isolate the operating field & to protect the cheeks, lips and
tongue. Care should be taken during placement of rubber dam clamps, wedges and matrices.

• - Precautions should be taken during preparation of the teeth for crowns, while cavity
preparation can be done safely.

• - For taking an impression, the periphery of the tray should be lined with wax to prevent injury
of the soft tissues.

Pulp Therapy:
• Pulpotomy and pulpectomy are preferred over extraction and indirect pulp capping is preferred
over pulpotomy.

• If vital pulp is exposed, an intrapulpal anesthesia should be given to control pain. Bleeding from
the pulp champer doesn’t present a significant problem and could be controlled by pressure
with a cotton pellet.
• Periodontal Therapy: - Gingivitis can predispose to spontaneous gingival bleeding.
• - Supra-gingival calculus can be removed atraumatically with an ultrasonic scaler or hand
instrument

• Sub-gingival scaling and root planning could be performed only after factor replacement
therapy.

Oral Surgery: Consultation with the hematologist for pre-operative evaluation and post
operative emergencies.

Luekaemia
• Leukemia is a malignancy of the hematopoietic tissues in which there is
a disseminated proliferation of abnormal leukocytes in the bone
marrow

Leukemia
Acute Chronic
Myelocytic Myelocytic
lymphocytic Lymphocytic

Acute lukaemia
• The most common form of childhood leukemia.
• Acute onset
• Characterized by :
✓ Infection : as sore throat without pus formation – pneumonia
 ✓ Infiltration of lekaemic cells :
➢ bone marrow ( anemia- pancytopenia - )
➢ bleeding gingiva and hypertrophy
➢ C.N.S ( intercranial bleeding)
➢ Liver ( spontaneous bleeding)
Oral manifestation
The most frequently reported oral abnormalities attributed to the leukemic proccess
include regional lymphadenopathy,
• mscous membrane petechiae and
ecchymosis,
• gingival bleeding,
• gingival hypertrophy.
• pallor, and nonspecific ulcerations
• chin and lip parasthesias,
dental Management
• The primary objective of dental treatment should be the prevention, control
and eradication of oral inflammation, hemorrhage and infection.
• Consult the haematologist and oncologist about the state of disease,
adequency of coagulation, resistance to infection, liver function and patient
response to chemotherapy.
• Dental emergency : requires preparatory treatment to avoid bleeding and
infection.
• Comprehensive oral hygiene regimen at regular intervals.
• The use of ultra soft nylon toothbrush.
• Scaling and subgingival curettage should not necessarily be perceived in all
patients.
• If platelet counts are <20.000 cell/mm3), substitute the toothbrush by moist
gauze wipes supplemented by frequent warm saline rinses.
 • Pulp therapy on primary teeth are contraindicated
• Extraction of carious teeth with pulpal involvement to avoid systemic
infection.
• Endodontic treatment for permanent teeth is not recommended for patient
having chronic, intermit-tent suppression of granulocytes.
• An area of chronic inflammatory tissue may remain in the periapical tissue
acting as an anachoretic focus, with devastating sequelae.
• Palliative care for oral ulcerative lesions: - Topical obtundents for pain such
as: orabase with benzocaine,
• Local measures for bleeding lesions such as topical application of bovine
thrombin or Avitence, and the placement of an oral adhesive for protection.
• Fungal infection is treated by Nystatin oral suspension 100.000 units/m1.
Swish 5ml for 5 min and then swallow, repeat every 6 hours. Continue for
48 hours after lesions disappear

Epilepsy
Definition:
• It is a disease characterized by repeated attacks of unconsciousness which
may last for a moment or for a period of minutes. This loss of consciousness
may or may not be accompanied by muscular contractions or convulsions.
Etiology:
• Idiopathic: Genetic or acquired.
• Post traumatic – Post infectious
• Post toxic (Lead or Arsenic poisoning).
• Secondary to brain injury.
Types:
• Petit mal: characterized by loss of consciousness only for a few seconds,
there is no evidence of muscle spasm and the condition presents no difficulty
during dental treatment.
 • Grand mal: characterized by prolonged loss of consciousness, generalized
convulsions and severe muscular spasm, This may lead to:
• · Slipping of patient from the dental chair.
• · Hitting himself against any object.
• · Severe tongue biting.
• · Sudden closure of the mouth due to contraction of jaw muscles.m.
Oral Manifestations:
1. Tooth fractures, dental arch fractures and avulsion of teeth due to frequent falls.
2. Gingival hyperplasia which occurs in 32-84% of epileptic patients due to
Dilantin used to suppress seizures in those patients.
Dental Management:
• Give antianxiety drug if needed before dental treatment e.g. Valium.
• Keep the dental atmosphere relaxed. Dentist should avoid the precipitating
factors that may lead to convulsions as :
• a) Operating light (should be focused on the patient's eyes).
• b) Loud noise and high music.
• c) Insufficient sleeping hours before dental appointments.
• If an attack occurs, lower the dental chair and put the patient in a supine
position with the head tilted to one side to facilitate the exit of saliva or
vomitus.
• Use suction for any secretions to prevent aspiration.
• Use wrapped tongue blades to prevent tongue biting.
• Floss is attached to small objects introduced in the mouth to facilitate quick
withdrawal in case an attack occurs.
 Cerebral palsy
• Definition: It is a collection of neuromuscular disorders as a result of permanent brain
damage in the prenatal and perinatal periods during which time the CNS is still maturing.
The condition is usually associated with mental retardation.

Etiology:
Brain damage which may result from :
• Congenital brain defect.
• Trauma to the head.
• Infections of the brain.
• Anoxia (decreased oxygenation).
• Premature birth.
General Manifestations:
• Mental retardation in 60% of the cases.
• Seizures disorders and hyperirritability.
• Sometimes presented as hearing or visual impairments.
• Speech disorders as the patient cannot articulate because of lack of control
of speech muscles.
• Abnormal limb position and limited control of neck muscles.
Oral Manifestations:
Periodontal Diseases due to :
• a) Eating soft diet as the patient can't chew food because of poor muscular coordination.
• b) Neglection of the oral hygiene and tooth brushing due to lack of manual dexterity.
• c) Patients taking anticonvulsants (Dilantin) resulting in a degree of gingival hyperplasia.
Dental caries due to:

• a) Poor oral hygiene.

• b) Impaired chewing and swallowing will lead to poor eating habits as soft diet.
• c) Patients show higher incidence of enamel hypoplasia.
Malocclusion:
a) Protrusion of maxillary anterior teeth.
b) Excessive overbite and overjet.
c) Open bite.
d) Unilateral cross bite.
The most important causative factor of malocclusion may be:1. Disharmony between introral
and perioral muscles. 2. Uncoordinated and uncontrolled movement of the jaws, lips and tongue.

Bruxism which result in :

• a) Severe attrition of primary & permanent teeth.
• b) Loss of the vertical dimension.
• c) TMJ disorders.

Trauma to maxillary anterior teeth due to :

• a) Repeated fall accidents.
• b) Protrusion of maxillary teeth.
• C) Tongue trust and mouth breathing.

Dental Management:
1. Cough reflex is delayed with increased risk of aspiration of foreign objects, so:
• Use of rubber dam.
• -A piece of floss is attached to small objects e.g. files and clamps to
facilitate withdrawal.
2. Use of restraining devices due to involuntary movements such as :
• Pedi wrap which controls all the limbs.
• Safety belts to maintain the patient on the dental chair.
3. To stabilize the jaws opened by using :
• Molt mouth prop.
• Mckesson rubber bite blocks.
• Several wrapped tongue blade.
 • Stabilizing the head by plastic head positioned to avoid sudden movements.
• Treat patient while sitting in his wheel chair.
• During dental treatment, maintain patient's body in middle of dental chair
with his limbs as close as possible to his body.
• Elevate the back of the dental chair due to difficulty in swallowing.
• Fluoride exposure.
• Preventive restorations:
- Use pit and fissure sealants.
- Use long withstanding restorations e.g. Amalgam restorations.
- Use chrome steel crown for badly broken down teeth.
- Regular dental visits: every 2-4 months.
Sensory handicapped patients

Hearing impairment
• Oral Manifestations :
1. Deafness is usually accompanied by bruxism.
2. . Poor oral hygiene due to inability to perform oral hygiene instructions
in a correct manner
Dental Management :
Sign
Face Show/ do Hear aid Keep smile
language
The child can be Face the patient Employ Show In case of Keep smiling,
communicated and maintain a Do approach hearing aid, it be calm and
either by: Lip visual contact and allow the should be communicate
reading, Sign with him. patient to use turned off kindly.
language, other before dental
Writing notes sensations as procedure, as
or taste or touch those children
combinations. to are very
communicate. sensitive to
vibrations
coming from
the handpiece.
 Visual impairment (Blindness):
Oral manifestations:
• 1- Poor oral hygiene due to visual impairment.
• 2- Hypoplastic teeth.
• 3-Traumatic injury shows an increased incidence than normal child.
4-Early childhood caries due to prolonged bottle-feeding
Dental Management :

One
Describe Allow tell/ do Blind stick
operator
the dental the patient to and allow the Allow the Maintain a
office in details. ask questions patient to patient use it to relaxed
about the touch, taste and discover the atmosphere
Sit close to the treatment smell for dental office and limit the
patient and explaining the patient's dental
maintain treatment. . care to one
physical contact dentist.
with the child
e.g. holding his
hand.

Bronchial asthma
Generalized narrowing of the airway and attack of variable duration
Oral manifestations:
1- High caries rate due to:
• Repeated administration of medicines containing sugars.
• Also prolonged use of bronchodilators can lead to decreased salivary flow
rate.
2- Repeated use of corticosteroids can lead to:
• - Dry mouth.
 • - Oral candidiasis and sometimes tongue enlargement.
3- Gingivitis:
due to:
• Frequent inhalation of steroids.
• Mouth breathing.
• Impaired immunological factors.
4- Orofacial abnormalities due to:
• Impaired respiratory function.
• Mouth breathing.
• Studies showed that there is an increase in the facial height, high palatal
vault, greater overjet and high prevalence of posterior cross- bite.
Dental management
General consideration:
1- Oral hygiene instructions and fluoride supplements.
2- Instruct the patient to rinse his mouth after using the inhaler.
3- Prescribe antifungal drug for patients taking corticosteroids nebulizer.
*In the dental office:
1- to prevent the acute attack in the clinic. Therefore, the patient should
bring the inhaler (bronchodilator) at each visit.
2- Antihistaminics could be taken to minimize bronchoconstriction.
3- Avoid the factors that may predispose the attack during dental treatment
as:
• Improper positioning of suction tip, cotton rolls and fluoride trays
position.,
•Prolonged supine position.
•Any material with a strong odor as methyl acrylate, enamel or dentin dust
or rubber dam sheets…. Should be avoided
 Down syndrome
• It occurs in about 1 of every 660 live births. It is associated with an extra
chromosome 21, so each cell contains three number 21 chromosomes rather
than two. This syndrome is most common among first born infants of
women over 35 years of age.
Oral Manifestations:
• 1. Prognathic class III relationship, which lead to open bite.
• 2. Mouth breathing and xerostomia.
• 3. Protruded scrotal tongue.
• 4. Delayed eruption and exfoliation of the teeth.
• 5. Microdontia and partial anodontia.
• 6. Small conical roots.
• 7. Rapid destructive periodontal disease.
• 8. Lower caries index.
• 9. Hypodonia: decreased muscle tone of the lips and cheeks which may lead
to inefficient chewing.
Dental Management:
- Many children with Down syndrome are affectionate and cooperative, and
dental procedures can be provided if the dentist works at a slightly lower
rate.
- Light sedation and immobilization may be indicated in those children who
are moderately apprehensive.
- Severely resistant patients may require general anesthesia.