DENTAL CARE IN CHILDREN WITH SPECIAL NEEDS

Management of children with special needs could be a challenging affair for parents. About 13.6 million children in the US have special care needs, according to the National Survey of Children’s Health in 2017-2018. These children may have any form of physical, mental, behavioral, cognitive, or emotional impairments that require medical management. They usually have difficulties in performing daily activities including oral hygiene rituals. Dental care in such children is also neglected by parents due to lack of awareness, over-caring nature, or greater focus on more-urgent medical needs. These factors increase the risk of developing oral diseases throughout the child’s lifetime. 

If you are a parent of a special needs child, here are some of the things that you could consider for your child’s dental care. 

What are the most common disorders in children with special needs?

The dental status in children with special needs is related to their disabilities. These children are at increased risk of oral diseases during their lifetime. Below are common disorders observed in children with special needs:

• Behavioral disorders such as anxiety, attention deficit hyperactivity disorder (ADHD), autism
• Congenital disorders such as Down syndrome, congenital heart disease
• Developmental disorders such as Cerebral palsy
• Cognitive disorders such as intellectual disability
• Systemic diseases such as sickle cell diseases, cancer in children
• Orofacial defects such as Amelogenesis imperfecta, Dentinogenesis imperfecta, cleft lip, cleft palate, and oral cancers 

What are the barriers to dental care in children with special needs?

Dental care in children with special needs is often ignored by dentists and parents. Below are some of the barriers to dental care in these children: 

• A larger need for urgent medical care decreases the priority toward oral health
• Difficulty to find specialized dentists who are adequately trained to treat such children
• Limited understanding of parents regarding the importance of oral health
• Uncooperative behavior of children due to disabilities
• High cost of dental treatments 
• Inadequate availability of resources to deliver dental care to children with special needs 

What are commonly observed oral diseases in children with special needs?

Below are some of the oral problems in children with special needs that parents should be familiar with:

• Enamel hypoplasia: Enamel hypoplasia is a condition with the presence of a thin or no enamel on tooth surface (especially in the molar or upper front teeth). In this condition, teeth are characterized by white spots or yellow to brown stains, pits, grooves, and chipped enamel. Children with genetic syndromes, developmental defects, or low birth weight are at increased risk of developing enamel hypoplasia. 
• Dental defects: Children with special needs are prone to defects in the teeth during developmental stages. This results in variation in the size, shape, number of teeth present, or the arch form. Some children, especially with Down syndrome or other genetic disorders, may experience delayed eruption of teeth. These variations hinder aesthetics and functions in children. 
• Misaligned teeth: Misaligned or crowded teeth are common in children with mental disorders, cerebral palsy (abnormal muscle tone), or other craniofacial defects. Lack of harmony between the extraoral and intraoral muscle systems affect the relationship between upper and lower jaws. This results in crowded teeth, open bite (inability of upper and lower teeth to touch each other), crossbite (upper teeth fit inside the lower teeth), or spacing between teeth. 
• Gum diseases: Gum diseases are common in children with special needs. This is due to poor oral hygiene or the presence of misaligned teeth which limit the ability to brush teeth properly. Most children with special needs take medications to treat seizures which have a side effect that involves overgrowth of gums. Enlarged gums result in gingivitis (inflammation of gums), difficulty in chewing food, and aesthetic concerns. 
• Trauma: Children with special needs suffer from frequent seizures, delayed milestones, poor muscle coordination, and abnormal reflexes. These conditions may cause frequent falls which may damage oral and facial structures.
• Bruxism: Involuntary grinding of teeth during sleep is known as bruxism. It is common in children with cerebral palsy and mental disorders. Regularly grinding teeth causes loss of enamel, wearing of teeth, and gum diseases. Children often complain of sensitivity of teeth, headaches, pain, and difficulty while chewing food. 
•  Tooth decay: Children with misaligned teeth or with enamel hypoplasia are more prone to tooth decay. Limited dexterity in these children affects their ability to brush their teeth. Unhealthy eating habits (especially sugar-rich snacking) and dryness of the mouth due to medications increase the risk of decay. 

How to improve dental health in children with special needs?

Dental health in children with special needs can be improved by adopting preventive measures and by regularly visiting a pediatric dentist.

Preventive measures:

Below are some of the preventive measures that parents can consider:

• Wipe special need infant’s gums with a damped cloth or gauze from the third month of birth
• Avoid leaving a sleeping child with a bottle of milk to reduce the risk of developing early childhood decays
• Clean the baby’s teeth with a soft toothbrush with a small head
• Once teeth begin to erupt in the mouth, brush the child’s teeth twice daily using a pea-sized portion of toothpaste
• Use fluoridated toothpaste to reduce the incidence of cavities 
• Rinse the child’s mouth after every meal or snacks
• Check if the child can clean his/her own teeth. If not, help the child brush his/her teeth thoroughly
• If a child is unable to hold a toothbrush properly, improve the grasp of the handle of a toothbrush with the help of tape or use specially-shaped brushes
• Avoid transferring anything from one’s mouth to a child’s mouth as it may spread cavity-causing germs
• Give a healthy and balanced diet to the child
• Avoid giving junk foods or food rich in sugars (e.g., candy, sticky chocolates, soda) that increase the risk of decay
• Visit a dentist for regular check-ups

Visit the dentist for treatment:                                                     

Below are some of the things that parents could consider before taking their children to a pediatric dentist for treatment:

• Look for the dentist with additional training and specialized knowledge to treat and manage children with special needs
• Evaluate if the dentist and the clinical staff are friendly and able to communicate with the child 
• Check if the clinic is well-equipped to manage any kind of medical emergencies
• Choose an appointment with less waiting time, preferably an early morning appointment
• Familiarize the child with the dental clinic settings in the first visit to ensure a positive experience during the treatment

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References:

• https://www.childhealthdata.org/browse/survey?s=2&y=32&r=1
• https://www.aapd.org/media/Policies_Guidelines/BP_SHCN.pdf
• https://cchp.ucsf.edu/sites/g/files/tkssra181/f/OralHlthSpNeedsEN103006_adr.pdf
• https://www.colgate.com/en-in/oral-health/developmental-disabilities/dental-health-care-for-children-with-special-needs-0414
• Dharmani CK. Management of children with special health care needs (SHCN) in the dental office. Journal of medical society. 2018 Jan 1;32(1):1.
• Alkhabuli JO, Essa EZ, Al-Zuhair AM, Jaber AA. Oral Health status and treatment needs for children with special needs: A cross-sectional study. Pesquisa Brasileira em Odontopediatria e Clínica Integrada. 2020 Jan 13;19.
• Krishnan L, Iyer K, Madan Kumar PD. Barriers to utilisation of dental care services among children with special needs: A systematic review. Indian J Dent Res. 2020 May-Jun;31(3):486-493.  

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