Guideline:
Clinical guideline on management of persons with special health care needs
Bibliographic Source(s)
- American Academy of Pediatric Dentistry. Clinical guideline on management of persons with special health care needs. Chicago (IL): American Academy of Pediatric Dentistry; 2004. 4 p. [24 references]
Guideline Status
Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.
Guideline Category
Counseling
Evaluation
Management
Treatment
Intended Users
Dentists
Guideline Objective(s)
To address the management of oral health care particular to persons with special health care needs (SHCN) rather than provide specific treatment recommendations for oral conditions
Target Population
Pediatric patients with special health care needs (SHCN)
Note: The American Academy of Pediatric Dentistry (AAPD) defines persons with special health care needs as individuals who "have a 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. The condition may be developmental or acquired and may cause limitations in performing daily self-maintenance activities or substantial limitations in a major life activity. Health care for special needs patients is beyond that considered routine and requires specialized knowledge increased awareness and attention and accommodation."
Interventions and Practices Considered
- Scheduling appropriate length of appointment and complying with the Health Insurance Portability and Accountability Act (HIPAA) and the Americans with Disability Act (AwDA)
- Establishing a dental home
- Patient assessment
- Obtaining medical history
- Performing comprehensive head neck and oral examination
- Caries-risk assessment (CAT)
- Recommending an individualized preventive program
- Providing a summary of oral findings and specific treatment recommendations
- Consulting with physician when necessary
- Establishing good communication
- Obtaining informed consent
- Behavior management
- Protective stabilization
- Sedation or general anesthesia
- Provision of care in a hospital or outpatient surgical care facility
- Preventive strategies
- Education of parents/caregivers to ensure appropriate and regular supervision of daily oral hygiene
- Demonstrating oral hygiene techniques
- Stressing the need to use a fluoridated dentifrice daily and to brush and floss daily
- Use of electric or modified toothbrushes and floss holders
- Dietary counseling
- Sealant application
- Use of topical fluorides (e.g. brush-on gels mouth rinses fluoride varnish professional application during prophylaxis)
- Alternative restorative treatment (ART)
- Use of chlorhexidine mouth rinse
- Referral to periodontist when necessary
- Encouraging assistance from community-based resources
- Making appropriate referrals when the patient's needs are beyond the skills of the practitioner
Major Outcomes Considered
Not stated
Methods Used to Collect/Select Evidence
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
This guideline is based on a review of the current dental and medical literature related to special health care needs (SHCN) patients. A MEDLINE search was conducted using the terms "special needs" "disabled patients" "handicapped patients" "dentistry" and "oral health".
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Not stated
Rating Scheme for the Strength of the Evidence
Not applicable
Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
The oral health policies and clinical guidelines of the American Academy of Pediatric Dentistry (AAPD) are developed under the direction of the Board of Trustees utilizing the resources and expertise of its membership operating through the Council on Clinical Affairs (CCA).
Proposals to develop or modify policies and guidelines may originate from 4 sources:
- the officers or trustees acting at any meeting of the Board of Trustees
- a council committee or task force in its report to the Board of Trustees
- any member of the AAPD acting through the Reference Committee hearing of the General Assembly at the Annual Session
- officers trustees council and committee chairs or other participants at the AAPD's Annual Strategic Planning Session
Regardless of the source proposals are considered carefully and those deemed sufficiently meritorious by a majority vote of the Board of Trustees are referred to the CCA for development or review/revision.
Once a charge (directive from the Board of Trustees) for development or review/revision of an oral health policy or clinical guideline is sent to the CCA it is assigned to 1 or more members of the CCA for completion. CCA members are instructed to follow the specified format for a policy or guideline. All oral health policies and clinical guidelines are based on 2 sources of evidence: (1) the scientific literature; and (2) experts in the field. Members may call upon any expert as a consultant to the council to provide expert opinion. The Council on Scientific Affairs provides input as to the scientific validity of a policy or guideline.
The CCA meets on an interim basis (midwinter) to discuss proposed oral health policies and clinical guidelines. Each new or reviewed/revised policy and guideline is reviewed discussed and confirmed by the entire council.
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation
Once developed by the Council on Clinical Affairs (CCA) the proposed policy or guideline is submitted for the consideration of the Board of Trustees. While the board may request revision in which case it is returned to the council for modification once accepted by majority vote of the board it is referred for Reference Committee hearing at the upcoming Annual Session. At the Reference Committee hearing the membership may provide comment or suggestion for alteration of the document before presentation to the General Assembly. The final document then is presented for ratification by a majority vote of the membership present and voting at the General Assembly. If accepted by the General Assembly either as proposed or as amended by that body the document then becomes the official American Academy of Pediatric Dentistry (AAPD) oral health policy or clinical guideline for publication in the AAPD's Reference Manual and on the AAPD's Web site.
Major Recommendations
Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.
Scheduling Appointments
The parent's/patient's initial contact with the dental practice (usually via telephone) allows both parties an opportunity to address the child's primary oral health needs and to confirm the appropriateness of scheduling an appointment with that particular practitioner. Along with the child's name age and chief complaint the receptionist should determine the presence and nature of any special health care needs (SHCN) and when appropriate the name(s) of the child's medical care provider(s). The office staff under the guidance of the dentist also should determine the need for an increased length of appointment and/or additional auxiliary staff in order to accommodate the patient in an effective and efficient manner. The need for a higher level of dentist and team time as well as customized services should be documented so the office staff is prepared to accommodate the patient's unique circumstances at each subsequent visit.
When scheduling patients with SHCN it is imperative that the dentist be familiar and comply with Health Insurance Portability and Accountability Act (HIPAA) and Americans with Disabilities Act (AwDA) regulations applicable to dental practices. The Health Insurance Portability and Accountability Act ensures that the patient's privacy is protected and the Americans with Disabilities Act prevents discrimination on the basis of a disability.
Dental Home
Patients with SHCN who have a dental home are more likely to receive appropriate preventive and routine care. The dental home provides an opportunity to implement individualized preventive oral health practices and reduces the child's risk of preventable dental/oral disease. When SHCN patients reach adulthood their oral health care needs may go beyond the scope of the pediatric dentist's training. It is important to educate and prepare the patient and parent/legal guardian on the value of transitioning to a dentist who is knowledgeable in adult oral health needs. At a time agreed upon by the patient parent/legal guardian and pediatric dentist the patient should be transitioned to a dentist knowledgeable and comfortable with managing that patient's specific health care needs. In cases where this is not possible or desired the dental home can remain with the pediatric dentist and appropriate referrals for specialized dental care should be recommended when needed.
Patient Assessment
Familiarity with the patient's medical history is essential to decreasing the risk of aggravating a medical condition while rendering dental care. An accurate comprehensive and up-to-date medical history is necessary for correct diagnosis and effective treatment planning. Information regarding the chief complaint history of present illness medical conditions and/or illnesses medical care providers hospitalizations/surgeries anesthetic experiences current medications allergies/sensitivities immunization status review of systems family and social histories and thorough dental history should be obtained. If the patient/parent is unable to provide accurate information consultation with the caregiver or with the patient's physician may be required. At each patient visit the history should be consulted and updated. Recent medical attention for illness or injury newly diagnosed medical conditions and changes in medications should be documented. A written update should be obtained at each recall visit. Significant medical conditions should be identified in a conspicuous yet confidential manner in the patient's record.
Comprehensive head neck and oral examinations should be completed on all patients. A caries-risk assessment (CAT) should be performed. CAT provides a means of classifying caries risk at a point in time and therefore should be applied periodically to assess changes in an individual's risk status. An individualized preventive program including a dental recall schedule should be recommended after evaluation of the patient's caries risk oral health needs and abilities.
A summary of the oral findings and specific treatment recommendations should be provided to the patient and parent/caregiver. When appropriate the patient's other health care providers should be informed.
Medical Consultations
The dentist should coordinate care via consultation with the patient's other care providers including physicians nurses and social workers. When appropriate the physician should be consulted regarding medications sedation general anesthesia and special restrictions or preparations that may be required to ensure the safe delivery of oral health care. The dentist and staff always should be prepared to manage a medical emergency.
Patient Communications
When treating patients with SHCN an assessment of the patient's mental status or degree of intellectual functioning is critical in establishing good communication. Often information provided by a parent or caregiver prior to the patient's visit can assist greatly in preparation for the appointment. An effort should be made to communicate directly with the patient during the provision of dental care. A patient who does not communicate verbally may communicate in a variety of non-traditional ways. At times a parent family member or caretaker may need to be present to facilitate communication and/or provide information that the patient cannot. According to the requirements of the Americans with Disabilities Act (AwDA) if attempts to communicate with the SHCN patient/parent are unsuccessful because of a disability such as impaired hearing the dentist must work with those individuals to establish an effective means of communications.
Informed Consent
All patients must be able to provide appropriate signed informed consent for dental treatment or have someone who legally can provide it for them. Informed consent/assent must comply with state laws and when applicable institutional requirements. Informed consent should be well documented in the dental record through a signed and witnessed form.
Behavior Management
Behavior management of the patient with SHCN can be challenging. Demanding and resistant behaviors may be seen in the person with mental retardation and even in those with purely physical disabilities and normal mental function. These behaviors can interfere with the safe delivery of dental treatment. With the parent/caregiver's assistance most patients with physical and mental disabilities can be managed in the dental office. Protective stabilization can be helpful in patients for whom traditional behavior management techniques are not adequate. When protective stabilization alone will not allow delivery of comprehensive oral health care appropriate sedation or general anesthesia is the behavioral management armamentarium of choice. When in-office behavior management including sedation/general anesthesia is not feasible a hospital or outpatient surgical care facility may be the most appropriate setting to provide treatment.
Preventive Strategies
Individuals with SHCN are at increased risk for oral diseases; these diseases further jeopardize the patient's health. Education of parents/caregivers is critical for ensuring appropriate and regular supervision of daily oral hygiene. Dental professionals should demonstrate oral hygiene techniques including the proper positioning of the person with a disability. They also should stress the need to use a fluoridated dentifrice daily to help prevent caries and to brush and floss daily to prevent gingivitis. Toothbrushes can be modified to enable individuals with physical disabilities to brush their own teeth. Electric toothbrushes may improve patient compliance. Floss holders may be beneficial when it is difficult to place hands into the mouth. Caregivers should provide the appropriate oral care when the patient is unable to do so adequately.
Dietary counseling should be discussed for long term prevention of dental disease. Dentists should encourage a non-cariogenic diet and advise patients/parents about the high cariogenic potential of oral pediatric medications rich in sucrose and dietary supplements rich in carbohydrates. As well other oral side effects (e.g. xerostomia gingival overgrowth) of medications should be reviewed.
Patients with SHCN may benefit from sealants. Sealants reduce the risk of caries in susceptible pits and fissures of primary and permanent teeth. Topical fluorides (e.g. brush-on gels mouth rinses fluoride varnish professional application during prophylaxis) may be indicated when caries risk is increased. Alternative restorative treatment (ART) using materials such as glass ionomers that release fluoride may be useful as both preventive and therapeutic approaches in patients with SHCN. In cases of gingivitis and periodontal disease chlorhexidine mouth rinse may be useful. For patients who might swallow a rinse a toothbrush can be used to apply the chlorhexidine. Patients having severe dental disease may need to be seen every 2 to 3 months or more often if indicated. Those patients with progressive periodontal disease should be referred to a periodontist for evaluation and treatment.
Barriers
Dentists should be familiar with community-based resources for patients with SHCN and encourage such assistance when appropriate. While local hospitals public health facilities rehabilitation services or groups that advocate for those with SHCN can be valuable contacts to help the dentist/patient address language and cultural barriers other community-based resources may offer support with financial or transportation considerations that prevent access to care.
Patients with Developmental or Acquired Orofacial Conditions
The oral health care needs of patients with developmental or acquired orofacial conditions necessitate special considerations. While these individuals usually do not require longer appointments or advanced behavior management techniques commonly associated with SHCN patients management of their oral conditions presents other unique challenges. Developmental defects such as hereditary ectodermal dysplasia where most teeth are missing or malformed cause lifetime problems that can be devastating to children and adults. From the first contact with the child and family every effort must be made to assist the family in adjusting to the anomaly and the related oral needs. The dental practitioner must be sensitive to the psychosocial well-being of the patient as well as the effects of the condition on growth function and appearance. Congenital oral conditions may entail therapeutic intervention of a protracted nature timed to coincide with developmental milestones. Patients with conditions such as ectodermal dysplasia epidermolysis bullosa cleft lip/palate and oral cancer frequently require an interdisciplinary team approach to their care. Coordinating delivery of services by the various health care providers can be crucial to successful treatment outcomes.
The distinction made by third party payers between congenital anomalies involving the orofacial complex and those involving other parts of the body is often arbitrary and unfair. For children with hereditary hypodontia removable or fixed prostheses (including complete dentures or overdentures) and/or implants may be indicated. Dentists should work with the insurance industry to recognize the medical indication and justification for such treatment in these cases.
Referrals
A patient may suffer progression of his/her oral disease if treatment is not provided because of age behavior inability to cooperate disability or medical status. Postponement or denial of care can result in unnecessary pain discomfort increased treatment needs and costs unfavorable treatment experiences and diminished oral health outcomes. Dentists have an obligation to act in an ethical manner in the care of patients. When the patient's needs are beyond the skills of the practitioner the dentist should make appropriate referrals in order to ensure the overall health of the patient.
Clinical Algorithm(s)
None provided
Type of Evidence supporting the Recommendations
All oral health policies and clinical guidelines are based on 2 sources of evidence: (1) the scientific literature; and (2) experts in the field.
Potential Benefits
Appropriate management of pediatric oral health needs in patients with special health care needs (SHCN)
Potential Harms
Not stated
Qualifying Statements
The American Academy of Pediatric Dentistry (AAPD) recognizes that persons with special health care needs (SHCN) are an integral part of the specialty of pediatric dentistry. The American Academy of Pediatric Dentistry values the unique qualities of each person and the need to ensure maximal health attainment for all regardless of their development or other special health care needs. By developing these guidelines the American Academy of Pediatric Dentistry accepts its responsibility to assist the dental profession in meeting the unique oral health care concerns of this patient population.
Description of Implementation Strategy
An implementation strategy was not provided.
Implementation Tools
Chart Documentation/Checklists/Forms
Resources
For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.
IOM Care Need
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Bibliographic Source(s)
- American Academy of Pediatric Dentistry. Clinical guideline on management of persons with special health care needs. Chicago (IL): American Academy of Pediatric Dentistry; 2004. 4 p. [24 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
American Academy of Pediatric Dentistry
Guideline Committee
Council on Clinical Affairs
Composition of Group that Authored the Guideline
Not stated
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.
Guideline Availability
Electronic copies of the updated guideline: Available from the American Academy of Pediatric Dentistry Web site.
Print copies: Available from the American Academy of Pediatric Dentistry 211 East Chicago Avenue Suite 700 Chicago Illinois 60611
Availability of Companion Documents
Information about the American Academy of Pediatric Dentistry (AAPD) mission and guideline development process is available on the AAPD Web site.
The following implementation tools are available for download from the AAPD Web site:
- Dental growth and development chart
- American Academy of Pediatric Dentistry Caries-Risk Assessment Tool (CAT)
Patient Resources
None available
NGC STATUS
This NGC summary was completed by ECRI on March 3 2005. The information was verified by the guideline developer on April 18 2005.
COPYRIGHT STATEMENT
This summary is based on the original guideline which is subject to the guideline developer's copyright restrictions.
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