hope this will throw a light in understanding special children and dental management of the same particularly for pediatric dentistry PGs .children with genetic diseases and emotionally handicapped ( child abuse and neglect ) are not discussed here as they are separate topics. dr. aravindhan

1. Dental management of children
with Special Health Care Needs
Dr. Aravindhan A
JR-2
Dept. of Paediatric & Preventive Dentistry
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2. Introduction
• 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.”
American academy of pediatric dentistry. Definition of Special Health Care Needs.
2016;40(6):18-19.
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3. • Every child is unique
• Totally dependent on caregivers
• Some children require more attention and care-
children with special care needs
• WHO describes a child with special health care as
who, over an appreciable period of time, is
prevented by physical or mental conditions from
full participation in the normal activities of their
age groups including those of a social,
recreational, educational and vocational nature.
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4. Classification
• Frank al winters, 1974. ( 8 stages)
Blind or partially sighted
Deaf- (total/ partially)
Educably subnormal
epileptic
maladjusted
Physically handicapped
Speech abnormality
senile
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5. • Agerholm’s classification of handicap
conditions: ( 1975)
Intrinsic
category
Handicapping
conditions of the child
cannot be eradicated/
eliminated
Cerebral palsy, mental
retardation, down’s
syndrome
Extrinsic
category
Handicapping
conditions can be
improved with
meticulous care
Social deprivation
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6. • Nowak classification of special children
(1976)- 9 categories:
Category Example
Physically handicapped Kyphosis, scoliosis, poliomyelitis
Mentally handicapped Down’s syndrome, cerebral palsy,
mental retardation
Congenital defects Cardiac anomaly, cleft palate
Convulsive disorder Epilepsy
Communication disorder Sensory handicap ( deafness,
blindness)
Systemic disorders Hemophilia, hyperthyroidism
Metabolic disorders Juvenile diabetes
Osseous disorders Ricketts , osteogenesis imperfecta
Malignant disorders Rhabdomyosarcoma 6dr.aravindhan

7. accessibility
First dental
visit
Radiographic
examination
Preventive
dentistry
Diet and
nutrition
Home dental
care
Fluoride
exposure
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Factors considered in management of children
with SHCN

8. • 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.
Accessibility
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9. Accessibility guidelines
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10. 10dr.aravindhan

11. Accessible dental operatory design
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12. 12dr.aravindhan

13. First dental visit
• Establishment of “ dental home ”
• Role of the dental auxillaries.
• Initial examination.
• Management of parental anxieties.
• Informed consent
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14. AAPD recognizes a dental home should
provide
• Comprehensive, continuous, accessible, family-
centered, coordinated, compassionate, and culturally-
effective care for children.
• Comprehensive evidence-based oral health care
including acute care and preventive services .
• Comprehensive assessment for oral diseases and
conditions.
• Individualized preventive dental health program based
upon a caries risk assessment and a periodontal
disease risk assessment.
• Anticipatory guidance regarding growth and
development.
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15. • Information about proper care of the child’s teeth and
gingiva, 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.
• Dietary counselling.
• Referral, at an age determined by patient, parent, and
pediatric dentist, to a dentist knowledgeable and
comfortable with managing adult oral health care
needs.
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16. Initial examination
• May require physical restraints
• Proper history taking is needed.
• Early morning appointment should be given
for special children.
• Informed consent should be obtained from
caregivers.
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17. 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.
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18. • If radiographs 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.
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19. • 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.
American Academy Pediatric Dentistry. Oral health policy on dental
radiographs in children including those with SHCN . Pediatr Dent
2017;40(6):18. 19dr.aravindhan

20. • 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.
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21. Preventive dentistry
• Pit and fissure sealant application
• Mouth guard fabrication
• Oral prophylaxis
• Interim restoration
• Fluoride releasing restoration
• Anticipatory guidance about trauma
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22. 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.
• The dentist should teach the
parent or guardian to clean teeth
twice a day using correct tooth
brushing techniques.
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23. • 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.
• Horizontal scrub method of brushing is ideal for children with special health care needs23dr.aravindhan

24. Electronic tooth brush / suction tooth
brush
Suction toothbrush
Useful in children with mental retardation and cerebral palsy
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25. Tooth brushing position
• 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.
• 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. 25dr.aravindhan

26. • 3. 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.
• 4. 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.
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27. Diet and nutrition
• Proper assessment of the diet.
• Dietary modifications are made.
• Proper consultation with the patient’s primary
physician or dietician.
• Non cariogenic diet is emphasized.
• Caries risk assessment
• Early intervention and aggressive preventive
care based on the child’s caries risk.
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28. condition diet
Difficulty in swallowing
Eg. Cerebral palsy
Pureed diet
Autism Feingold diet
Epileptic patients Ketogenic diet
Metabolic disturbances
Eg. Phenyl ketonuria
Juvenile diabetes
Restriction of specific foods.
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29. Fluoride exposure
• Topical fluoride therapy
• Fluoridated tooth paste
• Mouth rinse with fluoride
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30. Recommendations
• 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.
• chronically poor oral hygiene and high
decay rates a daily regimen of rinsing
with 0.05% sodium fluoride solution is
recommended.
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31. • 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.
• SDF application in severe caries risk patients
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32. Recall of SHCN children
• Close observation of caries-susceptible
patients and regular dental examinations are
important in the treatment of patients with
SHCN
• Although most patients are seen semi-
annually for professional prophylaxis,
examination, and topical fluoride application,
certain patients can benefit from recall
examinations every 3, or 4 months.
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33. Physical restraints
• Needed for the patient with extreme motion of
extremities who is not a candidate for GA
1. Molt mouth prop
2. Rubber bite blocks ( McKesson mouth prop)
3. Finger guard/ inter occlusal thimble
4. Body : papoose board,
pedi wrap
triangular sheet ( mink’s)
5. Extremities: posey straps
velcro straps
6. Head : head positioner
plastic bowl
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34. Cerebral palsy head support
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35. Children with SHCN
( for the description purpose)
• Paediatric dentistry for special child - priya verma gupta
Intellectually
challenged
Learning
disabilities
Genetically
challenged
Medically
challenged
Physically
challenged
Emotionally
challenged
1.Mental
retardation
2.Cerebral
palsy
3.Epilepsy
4.Autism
1.Hearing
impairments
2.Visual
impairments
3.Speech
impairments
1.Cardiovascular
disorders
2.Respiratory
disorders
3.Liver disorders
4.Hematological
disorders
5.Endocrine/
metabolic disorders
6.Pediatric HIV
infection
1.Cleft lip
and palate
2. Down
syndrome
3. Klinefelter
syndrome
4. Treacher
collins
syndrome
5.Apert
syndrome
6. Crouzon
syndrome
1.Child
abuse and
neglect
1.ADHD
2.Dyslexia
7. Ectodermal dysplasia
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36. Mental retardation
• Can be defined by a collection
of symptoms, traits or
characteristics.
• Sheerenberger (1983) classifies
that disability of brain and
mind occurs due to brain
damage.
• Difficult to differentiate
between developmental delay
if there is no brain injury.
Three levels of impairment:
1 .idiot : development arrested at 2 yrs of age
2. imbecile: development equal to 2-7 yrs old
3. moron : development equal to 7-12 yrs old. 36dr.aravindhan

37. Classification
• Educable category
• IQ: 55-70
• 85% of mental retardation individuals
mild
• Trainable category
• IQ: 40- 55
• 10 % of individuals
moderate
• Lower functioning level
• IQ: 25- 40
• Fully dependent on caretakers for basic needs
severe
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38. • IQ : less than 25
• Mental age: below 2 yrs
• 1- 2% of individuals
profound
• Some children it is difficult to classify the MR
• Due to very young age and un cooperation
• Developmental delay is considered than MR
Unspecified
severity
According to
origin
Syndromic Non syndromic
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39. Clinical consideration- general
• MR with downs syndrome patients have OSA
• Aspiration and subsequent lung disease
• Difficulty in swallowing which may lead to
malnutrition and poor hydration
• Seizures ( more prone)
• Poor pain responders
• Neuromuscular scoliosis
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40. Oral manifestations- MR
• Early childhood caries as the medication is given
in syrup form for those patients.
( multifactorial- drug side effects like xerostomia,
tooth cleaning neglect)
• Trauma which may lead to fractured upper front
tooth, non vital tooth
• Early loss of tooth and subsequent malocclusion
• Poor oral hygiene- periodontal diseases
• Self inflicted habits.
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41. Dental management
General
consideration
• Mental age
• Need of
Antibiotic
prophylaxis
• Accessibility
issues
• Drug
interactions
• consent
Patient
assessment
• Mental
competency
• Co operation
level
• Possible use of
anaesthesia
Behaviour
management
• Desensitisation
• Restraints
• Oral sedation
• GA
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42. • Periodontal:
1. oral prophylaxis in every 3 months
2.proper oral hygiene instructions to caregivers
3. may need gingivectomy ( drug induced
enlargement)- electrosurgery/ laser preferred.
4. mouthrinse is not advisable. Sprays can be
prescribed.
5. electronic tooth brushes usage
• Restoration and endodontic management:
1. orthopantomogram is ideal for baseline
diagnosis
2. single visit pulp therapy is advisable
3. GIC restoration for caries than composite
4. SS crown for multisurface caries mangement
5. apex locators than radiographs
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43. Traumatic injuries:
• 1. managed as usual
• 2. sedation is needed in some situations
• 3. child abuse should be kept in mind during
diagnosis.
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44. Cerebral palsy
• Cerebral palsy is non progressive disorder of the
development of movement and posture, causing
activity limitations that are attributed to non
progressive disturbances that occurred in the
developing fetal or infant brains.
( American academy of cerbral palsy and developmental
medicine)
Epidemiology: 2- 2.5 cases/ 1000 live births
Etiology: prenatal
perinatal
post natal
prematurity
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45. Classification
Degree of affected
areas
• mild
• Moderate
• Severe
• No CP
Topography
• Monoplegia
• Diplegia
• Hemiplegia
• Triplegia
• Quadriplegia
• Tetraplegia
• paraplegia
Modified swedish
classification
• Spastic
-hemiplegia
-quadriplegia
-diplegia
• Ataxic
-diplegia
-simple
(congenital)
• Dyskinetic
-choreoathetotic
-dystonic
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46. 46dr.aravindhan

47. Clinical considerations- general
• Oral aversion
• Drooling
• GERD
• Constipation
• Dysphagia ( in some patients)
• Urinary tract infections ( highly frequent)
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48. Oral manifestations
• Spastic CP: hypertonicity of tongue, tongue
thrusting, cigar shaped tongue, flared anteriors,
hypotonic upper lip
• Athetoid CP: hyperactive tongue showing wave
like motions, TMJ dislocation is more common.
• Hypotonic CP: Tensely reclined head, flat large
protruded tongue, weak facial musculature,
inactive upper lip
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49. Other findings:
1. rumination ( rechewing already ingested food)
2. pica ( crave for non edible items)
3. pouching ( placing food in between cheek and
teeth- increases caries risk)
Dental management:
• Similar to MR patients
• Management of self inflicted habits
• Bruxism – soft splint/ mouth guard fabrication
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50. Epilepsy
• Epilambanein- greek word
• Definition: ( international league against epilepsy)
- “neurological disease and only applied in case of
2 unprovoked seizure more than 24 hours apart
or one unprovoked seizure along with probability
of another one after 2 unprovoked seizures over
a period of next 10 years”.
Non epileptic:
- no seizure for 10 years
- No medication for 5 years
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51. Etiology
• 1. idiopathic
• 2. traumatic
• 3. infections
• 4. progressive ( underlying cranial abnormalities)
Classification: 1. localised
2. generalised
Based on seizure type: 1. generalised (absence,
myoclonic, clonic, tonic, atonic, tonic-clonic)
2. focal
3. unknown ( epileptic spasm)
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52. Generalised seizure-Clinical presentation
•4- 14 yrs of age
•Lasts over 10- 25 seconds
•May occur many times a day
Absence seizure
•Brief contraction of muscles occur due to cortical discharge
•Without loss of consciousness
•More common is juvenile myoclonic epilepsy
Myoclonic seizure
•Seen in patients with neurological disease
•Seizure triggered when there postural loss
•Less severe ( simple twitch, head nodding)
Atonic seizure
• Bilateral clonic jerking will be there
Clonic seizure
• Muscle contraction of large parts with loss of consciousness
• Lasts for less than a minute with apnoea
• Tonic- clonic seizure is referred as grand mal epilepsy
• Post ictal phase is present and marked
Tonic seizures 52dr.aravindhan

53. Pediatric variants of gen. seizures
• 6 months – 5 yrs of age
• Accompanied With fever ( no cranial
abnormalities)
• Viral fever, Chicken pox, neonatal ICU patients
(> 28 days)
Febrile
seizures
(AAP,2008)
• Present in neonatal period
• May be occur up to 44 weeks of age
• LBW / preterm babies. ( possible cranial
damage)
Neonatal
seizures
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54. Oral manifestations
• Self injury to jaw / tooth structures due to
seizure
• Erythematous gingiva
• Gingival overgrowth ( drug induced)
• Mal occlusion
• Poor oral hygiene
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55. Dental management
Factors to Be Taken into Consideration While
Administering Treatment :
• The frequency of seizures;
• The date of the patient’s last seizure;
• The consciousness and respiratory state of the patient
during seizures;
• The physical condition of the patient after a seizure;
• Whether there is any aura before seizures;
• Whether experiencing an aura always leads to a seizure;
• The factors provoking seizures
• The existence of status epilepticus.
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56. General considerations
• Morning appointment
• Proper behaviour management as the stress may
provoke seizure
• Extreme noise, bright light should be avoided
• Treatment must be postponed if last seizure attack
occurred within one month (even if they are under
medication)
• During dental treatment, it has been suggested that
seizure development can be controlled by sedation
through nitrous oxide inhalation or intravenous
benzodiazepine sedation.
• GA is the ideal option for treating epileptic patients
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57. • Mouth guard for prevention of seizure induced
trauma.
• gingival hyperplasia caused by phenytoin should
be controlled by preventing the formation of
plaque .
• plaque removal would be ineffective unless
hyperplastic tissue is properly removed during
gingivectomy.
• Change the medication if gum hyperplasia recur
• protective methods such as the use of
chlorohexidine and fluoride, education regarding
oral hygiene, regular dental checkups, and
educating children to avoid sugary foods and
drinks are crucially important.
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58. • Restorative precedure should be done under rubber dam
(with floss secured files/ rubber dam clamp)
• Removable prosthetic/ orthodontic appliance is
contraindicated.
Management of epileptic attack in dental clinic:
• Treatment should be stopped
• Remove if any object is in mouth
• Place the patient supine position and turn to one side.
• Lift the chin
• Any tight clothing the patient is wearing should be
loosened
• If the seizure lasts more than 3 minutes and recurs, drug
administration is required.
• Buccal/ Intranasal midazolam (0.3 mg/kg) or intravenous
diazepam (0.5 mg/kg) / midazolam (0.25 mg/kg)
• Call for medical help 58dr.aravindhan

59. Autism
• Leo kanner “ a neurological disease that
occurs in first 3 years of life”
“ a developmental disorder causing
disturbance of behavioral development due to
multiple reasons and differernt levels of
severity”
• ASD ( Autism Spectrum Disorder)
Aspergers
syndrome Rett’s
disorder
Autistic
disorder
Pervasive
developmental
disoder
Childhood
disintegrated
disorder
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60. Theories
Pathological
parenting
Withdrawl of
child from
environment
Development of
autism
Emotionless mother
Parental rejection when
active development of
child behaviour
Development of autism
Deficiency state
of mind
Failure to read
what others
think
Social deficiency
and autism
Psycho dynamic theory Refridgerator mother theory Theory of mind
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61. Complicated
cognitive behaviour
Executive function (
organised motor co
ordination)
Any interruption
leads to dysfunction
of executive function
Inability to contest in
sequential manner/
cannot think wider
Poor understanding
capacity
Poor context
processing
Theory of executive dysfunction Weak central coherence theory
Kanner’s theory: biologically based defects are responsible for autism
Cognitive complexities and control theory: combination of all the above said theories
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62. • Incidence: 1 in 1000
• Male -female ratio . 3.5 : 1
• Etiology:
1. genetic
2. prenatal
3. postnatal
4. environmental
Repititive
and
sterotype
behavior
Communi
cation and
language
deficits
Diagnostic
alogarithm
Social
deficits
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63. Clinical features
• Social deficits
• Failure to respond properly
• Lack of eye contact
• Delayed speech
• Preference of isolation
• Unable to empathize with other
• Repetitive speech
• Mood fluctuations
• Abnormal motor behaviour
• Self injurious behaviour
• Mental retardation in 70% autistic child
• Positive qualities: Truthful, kind, straight forward, high pain
threshold
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64. Oral manifestations
• Dental caries
• Poor oral hygiene
• Bruxism
• Erosion due to regurgitation
• Tongue thrusting, non nutritive chewing
• Self injurious behaviour
• Prevalence of anterior open bite
• Delayed Tooth eruptions
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65. Dental management
Preventive protocol:
• Diet counselling
• Fluoridated tooth paste twice daily
• Frequent intake of water
• Usage of mouthguard
Management:
- Behavioural assessment and make the child
familiar with dental clinic
- Use behavioral shaping techniques
- Use of physical restraints
- Go for GA in very un co operative patients 65dr.aravindhan

66. Physically challenged
• Hearing impairment
•Visual impairment
•Speech impairment
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67. Hearing impairment
• Hearing impairment is clinical condition in which
individual is unable to detect or perceive the sound
frequencies in full/ partial capacity that can be
otherwise heard by people in surrounding.
Classification:
According to type:
1.conductive ( obstruction to the flow
of sound from the environment to the inner ear)
2.sensorineural ( reduced auditory
threshold sensitivity/dysfunction located in inner ear/
auditory nerve/ CNS auditory systems)
3.mixed ( combination)
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68. • According to the age of onset:
1. prelingual hearing loss
2. post lingual hearing loss
• According to severity ( WHO)
impairment Audible dB level
No impairment 25 dB or less
Slight impairment 26 – 40 dB
Moderate impairment 41 -60 dB
Severe impairment 61- 80 dB
Profound impairment 81 dB or more
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69. Etiology
• Genetic : usher syndrome, pendred syndrome
• Age:
• Disease: measles, mumps, adenoids, chlamydia
infection ( common in children), congenital syphilis,
fetal alcohol syndrome
• Drug induced: aminoglycoside, macrolide antibiotics.
Diuretics , chemotherapeutic agents.
• Noise induced
• Trauma
• Oto-toxic chemicals: heavy metal toxicity, pesticides.
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70. Clinical features ( general) Oral manifestations
Hearing with or without speech
impairment
Mouth breathing
Lack of social and emotional development xerostomia
Lack of learning Increased prevalence of dental caries
Low self esteem Increased risk of periodontal infection
Communication methods:
1. hand signs
2. lip reading
Dental considerations:
1. Gain trust with the child through commuunication
2. do all the behavioral modification technique
3. Early morning appointment
4. Avoid long appointments
5. Emphasize on preventive strategies
6. Avoid aspirin/ macrolide antibiotics
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71. Visual impairment
• Defn : “ the functional limitation of the eye due
to disorder or disease resulting in visual
handicap”.
• Classification: (WHO)
1. low vision: a. moderate visual impairment
b. severe visual impairment
2. blindness: a. profound visual impairment
b. near total visual impairment
c. total visual impairment
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72. • Etiology :
-albinism - moebius syndrome
-cataract - retinoblastoma
-CMV retinitis - traumatic brain injury
-glaucoma - diabetic retinopathy
Oral manifestations:
-no direct influence in oral cavity
-poor self care leads to poor oral hygiene and
related diseases
- xerostomia
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73. Management
• Establishing communication:
- Know the prefered way of communication of
patient
- Instruct slowly
- Braille method is useful
- Avoid strong lighting
- Do all the behavior shaping methods once the
communication is gained
- Use audio analgesIa
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74. Speech impairments
• Definition:
“ an impairment of speech or sound
production , fluency, voice or language which
significantly affects a child’s educational
performance or social , emotional or
vocational development”.
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75. Etiology:
• Functional :
- environment
- psychological development
- habit
• Organic ( structural variance):
a. primary organic voice disorder
- asymmetry of vocal fold
-neuromotor disorders
-trauma / pathologies of vocal fold
b. secondary organic voice disorder
-mucosal irritation
- recurrent laryngitis
-chronic hyperplastic laryngitis
Determinants of speech:
1. Vocal folds
2. Velum and the tongue
3. Tongue and palate
4. Lips and teeth
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76. Dental associated speech defects:
1. Cleft lip and palate
2. Rampant caries
3. Ankyloglossia
4. Open bite
5. Severe proclination of upper anteriors
6. Class 3 malocclusion
7. Abnormal oral habits
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77. Management
• Assess the level of impairment and analyse
whether it is impairment or delayed milestone
• Consult with speech therpaist
• Make use of non verbal communication
• pen, pencil, notebook should be handy for the
child to convey the doubts
• Do necessary behaviour shaping methods
• Treatment of potential malocclusion
• Release of ankyloglossia (if present)
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78. Medically challenged
• There are many medical conditions that can
directly affect the provision of dental care and
some where the consequences of dental disease,
or even dental treatment, can be life threatening.
• The definition of a “medically compromised”
patient is not precise and in this context, it is
interpreted as the presence of a medical factor
which may have implications for the provision of
dental care.
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79. Cardiovascular diseases
• Types
–Congenital
• ventricular septal defects, atrial septal defects,
pulmonary stenosis, patent ductus arteriosus,
tetralogy of Fallot,
–Acquired
• Rheumatic fever, diseases of the myocardium
and pericardium, secondary hypertension
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80. Dental management of cardiovascular
disorders
• Prevent dental disease:
OHI, diet counselling, fluoride therapy, fissure
sealants
• Any active dental disease must be treated
before cardiac surgery.
• Never give N2O inhalation sedation to the
patients with cyanotic congenital heart
disease
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81. • Antibiotic prophylaxis given before invasive
operative procedures
• Ideally short appointments in children for
maximal cooperation
• Check patient’s platelet count and prothrombin
time before tooth extraction.
• No child with symptomatic cardiac problems
should have any routine dental procedures until
details of the condition have been obtained and
the patient’s physician consulted.
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82. • Prefer Endodontic treatment only for teeth
with high probability of success like:
–Permanent incisors
–Straight canals
–Closed apices
–Single visit
• Antibiotic prophylaxis for indicated children.
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83. Infective endocarditis prophylaxis
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84. Dental procedures need IE prophylaxis
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85. Drug regimen
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86. 86dr.aravindhan

87. Blood disorders
1.Bleeding disorders
a. Hemophilia
b.Von Willebrand’s disease
c.Thrombocytopenia
2.Blood dyscrasias
a. RBC disorders
Anemia -Iron deficiency anemia, Glucose 6- Phosphate
dehydrogenase deficiency, Sickle cell
anemia,Thalassemia
b. WBC disorders
Leukemia ( AML, ALL, CML, CLL)
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88. 88dr.aravindhan

89. Dental management of bleeding
disorders
• Communicate with haematologist
• Find out the diagnosis/aetiology
• NSAIDS alter platelet function and should not be
used.
• Acceptable analgesics
For acute pain – Acetaminophen,
Propoxyphene hydrochloride
For severe pain – Narcotics – heroin, morphine,
hydroxycodone
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90. • Care taken while placing intraoral xrays
• Local anaesthesia infiltrations or
intraligamentous injections unlikely to cause
problems if given carefully
• Regional anaesthesia (mandibular block)
contraindicated as bleeding in
pterygomandibular region may cause asphyxia
• Rubber band extraction
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91. Pre op (Root stumps) After exfoliation by rubber band
Immediate post op
• Mean time of
exfoliation after
rubber band
application is 5.8
weeks
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92. • Pulp therapy preferred to extractions
• Dental extractions or surgery best managed in
hospital setting (use resorbable sutures if
needed)
• Antifibrinolytics – (e-aminocaproic acid,
tranexamic acid)
• Used as adjuvant to the factor
concentrate replacement to
prevent or control oral bleeding.
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93. • High speed vacuum and saliva ejectors used
with caution so that sublingual hematomas
don’t occur.
• Periphery wax used on impression tray
• Orthodontic treatment possible- be careful
wires don’t lacerate mucosa
Hygoformic suction tip93dr.aravindhan

94. Leukemia
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95. Dental management of leukemia
• Tendency to bleed after invasive dental
procedures
• Tests to be taken- Hb, Hematocrit, WBC,
Platelet cell count
• Prevent dental caries as these children at
high risk because of difficulty in taking care of
oral health due to mucositis.
• Preventive measures:
–Oral surveillance
–Topical fluoride therapy, toothbrushing
information
–Chlorhexidine mouthwash 0.12%
–Nystatin 500,000units ‘swish and swallow
–Diet control
–Relieve mucositis
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96. • All active dental foci of infection should be
eliminated before chemotherapy
• Unless dental emergency, no operative dental
treatment carried out until child in remission
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97. • Once the leukemia is in remission, and after consulting
child’s physician, routine dental care can be undertaken
with following protocol:
1. Hematological information required to assess
bleeding risks
2. Prophylactic antibiotics incase of depressed
neutrophil count.
3. Fungal infections treated with amphotericin B,
nystatin, or fluconazole and herpetic infections with
topical and/or systemic acyclovir
4. Regional block anaesthesia contraindicated
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98. Respiratory disorders
• Asthma
• Cystic fibrosis
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99. Dental management of asthma
• Dental treatment can cause emotional stress and
subsequent asthmatic attack
• Child may take puff of their inhaler before starting
dental treatment
• Use analgesics and sedatives with caution; opioids and
sedatives decrease respiratory drive.
• Recently a study has been published linking dental
erosion with asthma.
- Could be due to GERD in asthmatics
- Or acidic long term medication
- Or to increased consumption of erosive beverages
due to ‘drying’ of oral mucosa by inhalers
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100. Cystic fibrosis
100dr.aravindhan

101. Dental management of cystic fibrosis
• These children suffer from delayed dental
development, more commonly have enamel
opacities and are more prone to calculus
• They need to have higher caloric intake and
may have frequent refined carbohydrate
snacks – important priority group for dental
health education and care
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102. • May also have cirrhosis of liver
-> clotting defects ->
haemorrhaging , following
surgical procedures
• May be prescribed tetracycline
to prevent chest infections ->
intrinsic dental staining
• General anaesthesia should be
avoided. (Decreased
respiratory minute volume)
102dr.aravindhan

103. Endocrine and metabolic
disorders
• Diabetes mellitus
• Adrenal insufficiency
• Thyroid disease
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104. Type 1 DM
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105. Dental management of diabetes
• Preventive care
• Uncontrolled ->
Increased glucose concentrations in saliva,
decreased salivary flow -> dental caries
• Periodontal problems and susceptibility to
infections (Candida sp)
• Dental appointments arranged at times when
blood sugar levels well controlled; morning
immediately after their insulin injection and a
normal breakfast
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106. • Very un co-operative children may need GA/
sedation. And those patients face problem of
hypoglycemia due to NPO guidelines.
• So glucose level and insulin is managed via I/V
line before treatment under GA.
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107. 107dr.aravindhan

108. Dental management of adrenal
insufficiency
• In children, the risks of taking corticosteroids
are greater than in adults and should only be
used when specifically indicated, in minimal
dosage and for the shortest time possible.
• If child has adrenal insufficiency or on
steroids, any infection or stress may lead to
adrenal crisis. That time the oral steroid dose
should be increased.
• GA should be given under utmost caution as
there is tendency to develop hypotension.
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109. Liver diseases
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110. Dental management of liver disorders
• Preventive measures
• Strict cross-infection control
• Consult patient’s physician to
establish a safe and adequate treatment plan
• If invasive procedures to be done then prior
coagulation, antibiotic prophylaxis and
hemostasis tests required
• Be cautious when administering drugs.
• Do not administer general anaesthesia 110dr.aravindhan

111. Renal disorders
• Chronic kidney failure is common in children due to
developmental abnormalities.
• Other disorders: nephrotic syndrome, acute glomerular
nephritis, drug induced renal tubular injury.
• Dental features:
1. pale oral mucosa
2. salivary composition alteration
3. xerostomaia and dental caries
4. increased calculus formation
dr.aravindhan 111

112. Dental consideration
• Caution with prescribing drugs as may worsen
kidney disease.
• LA should be given cautiously
• Avoid NSAID ( specifically ibuprofen, diclofenac,
indomethacin, naproxen, aspirin), unless patient is
under dialysis
• INR should be assessed for patient under dialysis as
they are under anticoagulants.
• Prefer paracetamol and opioids .
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113. • Alfentanil is ideal opioid drug for renal failure patients.
• Don’t prescribe opioids ,if the GFR < 30 ml/ min
• Midazolam accumulate in renal tubules. Should be
avoided in sedation procedures.
• N20 is given with caution. (may cause homocysteinemia
and endothelial injury at prolonged usage)
• Dose reduction is needed (20% atleast ) and dose interval
should be increased for antibiotics.
• Benzyl penicillin found safe. And Cefepime is strictly
contra indicated.
( American kidney foundation, 2015)
dr.aravindhan 113

114. Paediatric HIV infection
• Most commonly due to vertical transmission
T and B cell appears in the
developing fetus at 10 weeks
I.U
HIV can be acquired at earlier
stage
Immature immune system leads
to severe infection and usually
child dies in first decade of life
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115. Mode of transmission to child
Vertical transmission (20% - 35%)
Pre natal Peri natal Post natal
As early as 9-
11 weeks I.U
•During
delivery
•Cervical
secretions
and ruptured
membranes
are source of
infection
•Through
breast
feeding.(21%)
•HIV is
present in
high titer in
colustrum
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116. • Other modes of spread in children:
1. Needle sharing (iatrogenic)
2. Blood transfusion ( thalassemia, hemophiliac)
3. Sexual abuse
• Risk factors:
1. Maternal viral load
2. Neutralising antibodies in mother
3. Mode of delivery ( duration of contact with
maternal blood)
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117. Clinical manifestations of pediatric HIV
infection
General features Oral features
Recurrent fever candidiasis
Failure to thrive Oral hairy leukoplakia
parotitis Herpes infection
anorexia ANUG/ NUP
cardiomyopathy Gingivitis (LGE), periodontitis
Progressive encephalopathy Kaposi sarcoma
Opportunistic fungal/ bacterial / viral
infections.
Recurrent apthous stomatitis
Persistent lymphadenopathy Salivary gland dysfunction
Saliva and HIV: less chance of transmission
presence of SLPI ( salivary leukocyte proteinase inhibitor)
infectious virions present less than 5% in saliva
less transmission via aerosol.
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118. Dental management
• Proper infection control
• Prior routine blood
investigations and viral load titre
in patient
• Pre procedural mouth rinse
(preferably hydrogen peroxide)
• Conservative management of
lesions.
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119. • Routine preventive
strategies and oral hygiene
instructions should be given
as usual
• Antibiotic prophylaxis for
the patients with CD4+
count less than 400/mm3.
• LA block should not be
given
• Scaling and periodontal
therapy is indicated only
when the CD4+ count is
more than 500/ mm3 119dr.aravindhan

120. Learning disabilities
ADHD (attention deficit hyperactivity disorder):
Defn: “ a family of related chronic neurobiological
disorders that interfere with an individual’s
capacity to regulate activity level (hyperactivity),
inhibit behaviour (impulsivity), attend to tasks (
inattention) in developmentally appropriate ways”
1918-1919: influenza pandemic left the survivors
with similar kind of hyperactivity disorder and
brain damage
1966: researchers changed the term from minimal
brain damage to minimal brain dysfunction
120dr.aravindhan

121. Subtypes: ( American Psychiatric Association-1994)
1. Predominantly hyperactive impulsive:
2. Predominanly inattentive
3. Combined hyperactive impulsive and inattentive (
most common).
Prevalence:
male : female= 3: 1
2- 20% prevalence in school children
Etiology :
• Still unknown
• Some hypothesis on abnormal brain function of
genetic origin is documented
• “ADHD is due to brain’s inability of producing
dopamine itself”- US Brookman national laboratory 121dr.aravindhan

122. Clinical features ( general) Oral manifestations
Inattention and restlessness High incidence Oro facial trauma
Short attention span Dento alveolar fractures
Social isolation Poor oral hygiene
Poor memory power Less salivary secretion than normal
Cognitive development is affected Caries in both primary and permanent
dentition
Be in constant motion, talk too much
Dental management:
•Early morning appointment
•Discontinuing the dose of stimulant
drug ( amphetamine/ bupropion)
•First , try for behaviour modification
and establish communication 122dr.aravindhan

123. • GA is better in extremely un co-operative
children rather than conscious sedation.
• Never use LA with levonordefrin in ADHD
patients as they may be under treatment of
TCA ( proper history is mandatory)
• Maximum dose of adrenaline will be 40 mcg
per child with ADHD. Excess adrenaline
dosage may precipitate cardiac arrhythmia.
• Salivary substitute can be prescribed.
123dr.aravindhan

124. Dyslexia
• is a specific reading disability that literally means inadequate of
verbal language.
• Definition: (2008)
“ dyslexia is a spectrum of specific learning difficulties and is evident
when accurate and/ or fluent reading and writing skills , particularly
phonological awareness, develop incompletely or with great
difficulty”
Types:
a. developmental dyslexia
b. acquired dyslexia (stroke /
neurological damage)
- visual dyslexia
- auditory dyslexia
- mixed dyslexia
124dr.aravindhan

125. Clinical features
• IQ level is in normal range
• Errors in reading
• Reads slowly and loss of orientation
• Unable to spell the word correctly
• Poor memory retention
• Distortion of text even when copying
• Cannot write properly
( directional confusion)
• Speech and language delay
• Highly creative
• Social isolation and stress
Pathophysiology:
•Distruptions in the
left hemisphere
posterior reading
system mainly in
the left
temporoparietal
occipital brain
region
•Along with
increased action of
frontal region125dr.aravindhan

126. • As dyslexia is a learning disability and
therefore child is trainable for executing basic
routine exercises.
• Nail biting and notching in central incisor is
common in dyslexic children.
Dental management:
• Children are more attentive , so not much
behavioral modification is needed.
• Oral hygiene instructions such as flossing and
brushing should be taught regularly as they
have poor memory retention
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127. Thank you!
127dr.aravindhan
Stay
safe!

128. References
• Textbook of Pediatric dentistry- 4th edition. Nikhil
marwah.
• Pediatric dentistry for special child- 1st edition. priya
verma gupta.
• Illustrated Pediatric dentistry- 1st edition. chockalingam.
• Paediatric Dentistry- 3rd Edition, by Richard Welbury and
Monty Duggal.
• Atraumatic Teeth Extraction in Bisphosphonate-Treated
Patients- Eran Regev et al., JOMFS , 2008.
• Management of Epileptic Patients in Dentistry- mehmet
et al., JO Surgical Science, 2012.
• Guidelines for the management of special children –
AAPD, 2015.
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129. Questions
• 1. Nowak classification of special children has how many
categories?
A. 8
B. 7
C. 9
D.10
• 2. which of the following diet is ideal for epileptic children
A. feingold diet
B. pureed diet
C. ketogenic diet
D. fatty diet
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130. • 3. most common seizure type in epileptic children
A. Generalised tonic clonic seizure
B. febrile seizure
C. absence seizure
D. myoclonic seizure
• 4. NOIS or GA is contra indicated in which group of
children
A. cerebral palsy
B. epileptic
C. cystic fibrosis
D. congenital heat disease
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131. • 5. HIV can be transmitted to developing fetus
as early as ( IU life)
A. 9- 11 weeks
B. 16 weeks
C. 27 weeks
D. 32 weeks
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