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

© 2016 Revotech Press

Dental Management of Special Needs Patients: A Literature Review

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

Department of Dentistry, Health Science Centre, Federal University of Santa Catarina, 88040-900, Florianópolis, Brazil

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

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

1. INTRODUCTION

Once the expectation of population lifetime has increased, the demand for dental treatment for patients with intellectual disability, physical limitations, social and / or emotional deficit also grew. In dentistry, the planning therapy of the special needs patients (SNP) requires an extensive vision of the dentist, often leading to a multidisciplinary approach [1].

However, many professionals still find difficulty while providing such assistance. Such difficulties can range from a lack of professional training, insecurity, possible ergonomic limitations, changes in the routine of the consulting room requiring physical adaptations and special equipment, to the lack scientific knowledge [2,3]. Moreover, it is common for patients with different levels of cooperation, a difficulty or even an impedi- ment of the dental treatment in an outpatient setting. Thus, the health care professionals can reduce barriers using different techniques [1].

Clinical care of the SNP should be based on risk assessment, in which the general health status is correlated to the level of collaboration level with the dental treatment, versus the dental needs. Thereafter, techniques for behavioral management must be initially used, but in case of failure, sedation is an alternative to

*Address correspondence to this author at the Department of Dentistry, Health Science Centre, Federal University of Santa Catarina, s/n, Delfino Conte Street, Trindade, Florianópolis, 88040-900, Brazil; Tel: +55 (48) 3721-9520; E-mail: [email protected]

Author Contributions: All authors equally contributed to this paper with conception and design of the study, literature review and analysis, drafting and critical revision and editing, and final approval of the final version.

the patient who is not to be subjected to general anesthesia [1].

From the moment that the patient's clinical condition derails the attempt of sedation, the dental treatment should be performed by general anesthesia technique in a hospital setting. This approach offers the possibility of total oral readjustment in only one session, including prophylaxis of the entire oral cavity, dental restorations, pulp therapy, extractions, coronary reconstruction and preventive procedures [4].

In the context of dentistry directed to the support of SNP, the modality of home dental care proposes to take care of all bedridden patient or those with limited mobility and developmental disabilities. In this modality, we can consider patients in palliative care, patients with a dementia, or even patients in several post surgical that show a dental emergency setting, for example [5].

The scientific literature is not concise in addressing all these therapies and organizes them on an increasing scale in order to direct professionals to the best treatment choice. This study aims to conduct a literature review directed to dentists who are not familiar with this area and intend to learn about different management techniques for the dental care of SNP.

2. MATERIALS AND METHODS

In order to conduct the proposed literature review, a bibliographic research was performed in the database PubMed / Medline with the following descriptors: “Dent- istry/Special needs/Sedation”; “Dentistry/Special needs/ General anesthesia”; “Dentistry/Special needs/Home care”; “Special patients/Dental treatment”; “Risks/

34 Global Journal of Oral Science, 2016, Vol. 2 Polli et al.

Sedation/Dentistry”; “Domiciliary care/Dentistry”; and “Risks/General anesthesia/Dentistry”. The article search was restricted to the years 1999-2015. Systematic and non-systematic reviews, studies on series of cases and research articles were considered to structure this study.

3. LITERATURE REVIEW

The Commission on Dental Accreditation (CODA) defines SNP as every individual with a medical, physical, psychological and / or social condition that requires individualization of the dental treatment [6].

Once it is a general concept, the theme 'special patient' comprises a heterogeneous group of genetic and / or acquired diseases, which in practice can be divided into: neurological motor disorders (Down syndrome, cerebral palsy, etc.), chronic systemic diseases (diabetes, heart diseases, hypertension), onco-hemato- logical malignancies (leukemia, lymphoma), infectious diseases (HIV, hepatitis B or C), physical disability (paraplegia, hemiplegia), sensory impairments (hearing impairment, visual disability), acquired diseases (rubella, tuberculosis) [7]. This classification helps the dentist to choose the best therapeutic approach while analyze the underlying disease of the patient and the consequent physical and / or mental impairment.

The dentist must to adapt to the psychological approach, the surgical techniques and the choice of dental materials for every type of individual and for every need [8]. In this context, the identification of the dental problems and implementation of the treatment plan may change dramatically from one case to another, since the general health status will influence this behavior.

3.1. Management of the Patients with Special Needs

For patients with neurological motor disorders, the initial clinical assessment requires three steps:

A. Evaluation of General Health: The first step starts with a complete health questionnaire to be fulfilled by the parents of the SNP. The medical history must explore physician reports, including any hospital treatment, medications in use, health problems, warning situations, alimentary habits and other important medical information.

B. Evaluation of Oral Health: The evaluation of oral health status starts considering prior treatments and the reasons of consultation, before performing the

clinical examination. If possible, any dental, gingivo- periodontal and soft tissue pathology must be noted. At least one panoramic X-ray must be taken as complementary exame. If necessary for the diagnosis, additional periapical and/or occlusal X-rays must be taken as well.

C. Evaluation of Behavior: For the dental treatment, we consider the evaluation of behavior the most relevant aspect in this protocol. In this matter, we suggest that the behavioral analysis is based on the amended Frankl scale [9] (Table 1), which consider the level of cooperation; and the scale developed by Houpt and co-workers [10] (Table 2), based on movement during examination (whether or not asso- ciated with shouting, crying, and other manifestation of non-cooperative behavior). We believed that the application of the scales might be a good indicator as to whether outpatient care can be performed or not [11].

Table 1: Frankl Scale [9] for Evaluating Behavior Modified by De Nova Garcia, 2007 [11]

Category 1 Clearly Negative Total lack of cooperation

Category 2 Negative Signs of lack of cooperation

Category 3 Positive Accepts treatment with caution. May require reminders (open mouth, hands down, etc.)

Category 4 Very Cooperative No sign of resistance. Very cooperative

Table 2: Scale for Evaluating Movement (Houpt and Co-Workers 1985) [10], Modified by De Nova Garcia, 2007[11]

1. Violent movement constantly interrupting examination

2. Constant movements that hinder examination

3. Controllable movements that do not interfere with the procedure

4. Lack of movement

After completing the three steps of the clinical assessment, the most appropriate treatment plan for each patient must be drawn and classified by quadrants/ sextants. Prioritization of therapeutic needs (preventive, conservative, surgical) must be performed as follows:

Preventive treatment, which includes systematic scaling/cleaning and fluor application, also the placement of sealants;

Dental Management of Special Needs Patients Global Journal of Oral Science, 2016, Vol. 2, 35

Restorative treatment, which includes endodontic and restorative treatment in both primary and permanent teeth.

Surgical treatment, which includes tooth extractions, gingivectomies, biopsies and other minor oral surgery.

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

The “holding therapy” is a physical support technique suitable for children, that remain in the lap of the responsible person, who stabilizes trunk and arms while embrace the patient (Figure 1);

The “knee to knee” position is suitable for children of 1-3 years old. The technique consists to lay the child supported on the legs of the dentist and the responsible person, both touching knees to each other and forming a kind of hammock (Figure 2);

Figure 1: Holding therapy.

The technique where the auxiliary holds the patient's head can be applied to patients of all ages.

Figure 2: Knee to knee position.


The aid sustains the patient's head in order to stabilizes or support it (Figure 3);

These techniques may be employed to short dental visits, in which preventive, restorative, and/or surgical treatments - as described above - can be performed before the attempted pharmacological restraint.

Sedation obtained through oral medication - mild or moderate - may be an important and very useful option in dental treatment of SNP, since the sedatives are a safe and effective way to contain the patient, with the advantage of being prescribed by the dentist for outpatient use [12]. According to the American Dental Association [13], sedation represents a minimal depression of levels of consciousness that keeps the patient's ability to maintain independently and continuously his airway, responding appropriately to physical stimulation or verbal communication. The loss of consciousness levels is produced by pharmacological or non-pharmacological method, or a combination of both [8,13].

The sedation procedure can be performed using an evolutionary scale for choice of drug, namely: benzodiazepines, nitrous oxide, antihistamines and hypnotics (barbiturics and non-barbiturics). It is also possible to prescribe opioids for ambulatorial use, although with some more caution. For deep sedation, the drugs used are propofol and the neuroleptics, but these medications should be used in a hospital setting [14]. Table 3

shows the different types of medication that may be used in an outpatient setting by the dentist in order to perform mild and / or moderate sedation for implement- ing dental treatment. The table also presents the side effects of each sedative [12,14].

The guideline developed by the Australian and New Zealand College of Anesthesiologists [15], indicates the risks involved in this technique, such as: depression of protective airway reflexes and loss of airway perme- ability; breath depression; depression of the cardiovascular system; drug interactions or adverse reactions, including anaphylaxis; unexpected high sensitivity to drugs used for sedation and / or procedural analgesia that could result in inadvertent loss of consciousness, respiratory depression and / or cardiovascular depression; individual variations in response to medicines used, particularly in the children, the elderly and those with pre-existing disease [15].

In order to minimize or avoid these risks, the dentist must have a basic service support emergency kit, composed of Ambu (manual ventilator), stethoscope and sphygmomanometer, oxygen cylinder, Guedel cannula, insulin syringe, scalpel, oximetry, epinephrine, antihistamines, Captopril 12.5 mg, Hydrochlorithiazide 25 mg, Dimenhydrinate 50 mg and Pyridoxine Hydro- chloride 10 mg, physiological saline, children's aspirin, Isosorbide Dinitrate 5mg and sachet of carbohydrate or glucose 50%. The dentist also must have the course of

Figure 3: Auxiliary sustaining the patient’s head.


Basic Life Support (BLS), so that in any situation, the professional knows how to handle emergency situations that endanger the life and physical and / or mental integrity of the patient [16].

Due to severe health impairments and the less cooperative level of some patients with the dental treatment, procedures under general anesthesia are very useful in some clinical situations [17] The ADA (2009) considers general anesthesia as a procedure

that causes loss of consciousness where the individual does not respond to painful stimuli and losses the ability to maintain ventilatory and neuromuscular function independently. Mandatorily, this approach should be performed in a hospital setting, with the assistance of the anesthesiologist [13].

In dentistry there is not a determining classification that helps the dentist in the choice of general anesthesia. Thus, the SNP risk analysis indicated for gene-

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

Medication Dosage and Mode of Administration Indications Contraindications Side Effects

Benzodiazepines

Diazepam: 5-10 mg/day, orally.

Midazolam: 3,5-7,5 mg, intravenous.

Anxiety, apprehension and fear; preanesthetic

medication; used in diabetic and cardiac patients with

controlled disease.

Pregnant women (1st trimester)*, patients with

glaucoma or myasthenia gravis, children with severe mental impairment, alcoholics, and

patients with hypersensitivity to benzodiazepines.

Drowsiness, ataxia, confusion, double vision,

headache, changes in libido, incoordination,

dysarthria, pharmacodependence.

Sedative hypnotics

(barbiturates)

Phenobarbital: 2-3 mg/kg/day, orally.

Induction of general anesthesia.

Pregnant women (1st trimester); elderly patients, patients with impaired liver function, sleep

apnea**.

Chronic use causes dependence.

Sedative hypnotics (non-barbiturates) -

Chloral Hydrate

… Pediatric patients; patients allergic to barbiturates and

benzodiazepines.

Patients with liver failure, severe kidney disease, gastritis or gastric ulcers, severe heart

disease or intermittent porphyria.

Adverse dose-dependent effects. At high doses

orally: excessive depression of the central nervous system (CNS),

gastrointestinal disorders, cardiac arrhythmias and

respiratory depression.

Antihistamines Promethazine: 50-150 mg/day, orally.

Pediatric patients; conscious sedation; premedication for deep sedation and general

anesthesia; treatment of anaphylactic reactions.

Taking care not to potentiates the depressant effects of other

drugs on the CNS.

Drug interaction potentiates depressant

effects on the CNS.

Opioids

Meperidine: 25-150 mg, intramuscular; 25-100 mg, intravenous.

Codeine: 90-360 mg/day, orally.

Fentanyl: 1 a 2 mL (0,05 a 0,1mg), intramuscular.

Meperidine: outpatient sedation and anesthesia; Codeine: analgesia and

alleviation of pain; Fentanyl: Intravenous supplement

during general anesthesia.

Meperidine: patients using MAOIs or amphetamines, and

asthmatics.

Drug interactions with other depressant drugs

CNS.

Neuroleptics

Chlorpromazine: 25-1.600 mg/day, orally.

Haloperidol: 2,5-5 mg, intramuscular.

Deep sedation in patients with high levels of anxiety

(hospital use). ---

Tremors, akathisia, dyskinesia, orthostatic

hypotension, changes in cardiac function and

body temperature, dry mouth, nasal obstruction, constipation, increased

body weight.

Propofol Propovan/Propotil: 1,5-

2,5 mg/kg, intravenous.

Induction and maintenance of general anesthesia or conscious sedation.

Care to elderly patients, hypovolemic, or with limited

cardiac reserve.

Nausea and vomiting after surgery.

* Might be indicated with caution and under medical supervision. ** Might be used with caution.


ral anesthesia must be directed to the American Society of Anesthesiologists (ASA), based on the physical condition of each patient [18]: ASA I - Patients without organical, physiological, biochemical and / or psychological alterations. There are no systemic changes; ASA II - Patients with mild or moderate systemic disease caused by pathophysiological phenomenon or by the condition to be treated surgically; ASA III - Patients with very intense organical changes or pathological disorders of any cause, even if it is not possible to define the degree of the organical incapacity; ASA IV – Pat- ients with severe general disorders, endangering their lives, not able to be corrected by surgery; ASA V - Moribund patient, with few chances to survive, they undergo surgery as a last resort; and ASA VI - Patient with declared cerebral death [18].

According to the World Health Organization (WHO), approximately 8% of people with disabilities present indication of dental treatment under general anesthesia. In a dental context, systemic health condition should be evaluated together with the anesthesiology team and the costs and benefits of the therapeutic approach discussed between both teams and family [19].

Among the contraindications of the technique is the old age, decompensated systemic diseases, physical limitations that may interfere with physiological func- tions, specific syndromes with psychological and anatomical abnormalities, pediatric patients with congenital heart disease and / or physical disabilities, mental illness or cognitive disorder, and other complex medical conditions [20]. Absolute contraindications are also mentioned, so the professional should be aware of febr- ile conditions, colds, respiratory infections or decompensated heart failure that compromise the general anesthesia execution [21]. Table 4 shows the advan-

tages and disadvantages of this anesthesic modality in dentistry [22].

Different than other therapies, home care aims to target the dental approach for those bedridden individuals or unable to get around their homes [23].The purpose of home care is to provide differentiated dental service, offering specific care by a qualified professional, including the participation of relatives or guardians. The procedures performed in the home setting aim at removing odontogenic infection, in addition to performing preventive procedures such as hygiene instructions to the patient, carers and guardians [24].

Although the home dental care might be a challenge for the dentist - due to space limitations, inadequate posture, insufficient lighting, reduced access to imaging exams, less control over unforeseen events, emergencies and lack of biosecurity –it is an extremely important activity for the care of the SNP [5].

There are four main types of home care, according to the physical and cognitive status of the patient: 1) Required emergency treatment: aims to treat pain or diseases that severely influence the general health of the patient. In these cases, the treatment is performed independently of the patient's collaboration; 2) Nece- ssary treatment - Severe: aims to preserve oral and general health of the patient, the latter being able and / or aware of receiving dental treatment; 3) Necessary treatment - Moderate: the patient may have restrictions to cooperate and may require prior medication (sedatives) to the dental care, in this case it is evaluated the benefit of the treatment in relation to the stress that the patient might have; and 4) No need for treatment: in this case, the patient may be in a persistent vegetative state, or may have a good oral function, not presenting oral diseases [25].

Table 4: Advantages e Disadvantages About the Use of General Anesthesia

Advantages Disadvantages

The cooperation of the patient is not absolutely essential

The unconsciousness of the individual during the procedure (it is considered advantage and disadvantage at the same time)

The patient is unconscious during treatment The patient's protective reflexes are depressed

The therapy does not cause pain Vital signs are depressed

The drugs used cause anterograde amnesia It requires advanced training for administration of general anesthesia (medical team)

--- The need for a professional team (not just the dentist) for conducting the proposed treatment

--- Must necessarily be performed in a hospital environment, including post-operative monitoring

--- Complications in the trans-surgical and post-operative are more common in procedures performed under general anesthetic induction


3.2. Decision-Making About Treatment Modality – Behavior Scales

The indications described below were based on our clinical experience, the amended Frankl scale (Table 1) [9] and the scale developed by Houpt and co-workers (Table 2) [10]. This should not be used systematically for the convenience of the dental team, but rather should be seen as the last resource for protocol treatment. The proposed protocols were classified in three main groups:

- Conditions Techniques and / or Physical

Support: Patients in categories 3 and 4 (Tables 1 and 2) [9,10] who are cooperative with dental treatment but, eventually, do not show clear signs of interacting verbally with the dentist. Many patients are collaborative even though they are not able to carry out interactive communication with the dentist because their special conditions;

- Sedation Technic: For patients in category 2 (Tables 1 and 2) [9,10], and in cases of failure in the use physical support techniques, the dentist may use ambulatory care with sedation [26]. Selecting the most appropriate drug for sedation should take into consideration the dental need, the underlying disease of the

patient, and the advantages and disadvantages of using each of them (Table 3) [12,14]. The outpatient sedation technique should only be performed by qualified professionals. All support for any complications must be available and ready for use at the dental appointment. Regarding the assessment of the underlying disease, it is suggested this technique for patients ASA I and ASA II.

- General Anesthesia: We advocated that general anesthesia must be considered for patients classified in categories 1 and 2 (Tables 1 and 2) [9,10]. The use of the technique requires the participation of a multidisciplinary team in a hospital setting. The hospital routine must be respected. The cooperation of the patient is not required in this modality. Regarding the assessment of the underlying disease, it is suggested this technique for patients ASA I to ASA IV.

3.3. Guidelines of Service

3.3.1. Mild / Moderate Sedation

The sequence of service proposed by this work builds on the guidelines of the American Dental Asso- ciation [13], the Australian and New Zealand College of Anesthetists [15]. Figure 4 presents a sequence for use of sedation by the oral route in SNP.

Figure 4: Sedation sequence. Materials used: Midazolam, distilled water, disposable syringe, 2 ml of gooseberry juice. Mixture of the macerated sedative with the distilled water, and addition of 2 ml of the gooseberry juice. Sedative administration.


Step 1 - Initial Assessment of the Patient: Comple- tion of a health questionnaire, including medical history, physician reports, hospital treatments, medications in use, health problems, alimentary habits and behavior. Patients included in category 2 (Tables 1 and 2) are potential for intervention.

Step 2 - Preoperative Evaluation: Medical assessment by the team which manage the patient; request of laboratory exams about the clinical state; verbal and written instructions to the patient and / or guardian about the pre, intra and postoperative procedures; informed consent form of the patient and / or guardian; dietary restrictions of 4 hours without ingesting solids and liquids; evaluation of the patient's vital signs (blood pressure and respiratory rate).

Step 3 - Professionals and Equipment: At least one person, besides the dentist, with training in BLS must be present, and monitoring equipment of vital signs and resuscitation equipment must be easily accessible. This professional will be responsible for monitoring the patient's vital signs. For the accomplishment of the dental procedure, it is required the presence of an auxiliary on oral health and / or another dentist.

The room should be wide and equipped in order to deal with cardiopulmonary emergencies [15] and must contain at least: 1) stethoscope to auscutate the breathing (check every five minutes); 2) oximeter to monitor- ate peripheral perfusion; 3) non-invasive monitor to check the blood pressure (sphygmomanometer or auto- matic cuff device); 4) supply and administering of 100% oxygen source; 5) supply for intravenous medication (must be performed by a qualified professional) [12].

Step 4 - Patient Monitoring: Oxygenation: Colora- tion of mucosal, skin or blood should be evaluated continuously; oxygen saturation by peripheral oximetry may be considered clinically useful.

Ventilation: The dentist and / or the qualified professional should observe elevations of the chest and check breathing continuously. Maintain airway perme- ability.

Circulation: Blood pressure and heart rate should be evaluated preoperatively and monitored intra and postoperatively [12].

Step 5 – Dental Treatment: The most favorable cases are those in which the dental needs are small and easily resolved with short appointments. Prevent-

ive, restorative and surgical treatment can be performed and concluded in different approaches.

Step 6 - Documentation: All the procedures should be documented, reporting the sedative drugs and the local anesthetics administered, as well as the doses and the pre / postoperative medications. The description of the dental procedure performed is also part of this description.

Step 7 - Patient Discharge: It is necessary that the patient is capable to walk with minimal assistance. Postoperative pain and bleeding should be minimal or absent. The patient should be accompanied by a responsible person who will receive verbally and written postoperative orientations [12].

3.3.2. General Anesthesia

The assistance sequence proposed by the present study takes as reference the guidelines of the Ameri- can Dental Association [13] and the Australian and New Zealand College of Anesthetists [15].

Step 1 - Initial Assessment of the Patient: Com- pletion of a health questionnaire, including medical history, physician reports, hospital treatments, medications in use, health problems, alimentary habits and level of cooperation. Patients included in categories 1 and 2 (Tables 1 and 2) are potential for intervention.

Step 2 - Preoperative Evaluation: Medical assessment by the team which manage the patient; request of laboratory exams (urea, creatinine, complete blood count, complete coagulation exams, X-ray of the chest, electrocardiogram for patients older than 50 years or for patients who have pre-existing cardiac abnormalities) [18]; verbal and written instructions to the patient and / or the responsible person about the procedures before, during and after surgery; informed consent form of the patient / guardian; dietary orientations (absolute fasting of 10 hours).

Step 3 - Professionals and Equipment: Among professionals, it is necessary an anesthesiologist, the nursing team and the dental team. Among the equipment, a complete surgical center is requested. Figure 5 presents the dental materials for the treatment of SNP under general anesthesia and Figure 6 presents dental procedures performed with the patient under general anesthesia.

Step 4 - Patient Monitoring: Responsibility of the anesthesiologist team.


Step 5 – Dental Treatment: The use of general anesthesia is indicated for cases of more complex dental problems, which involve extensive dental treat-

ment. Preventive, restorative and surgical treatment can be performed and concluded in a single appointment.

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

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

A B C

D E F

G H I

A B C

D E F

G H I


Step 6 - Documentation: The whole procedure must be documented, reporting the name of the administered inducing drugs and anesthetics (local and general), the doses and the pre and postoperative medications.

Step 7 - Recovery Room: Postoperative care related to the type of the dental procedure performed. Drug prescription must be maintained as used in the operat- ing room. The patient care is responsability of the hospital nursing team.

Step 8 - Hospital Liberation: For dental procedures without complications, patient will be released between 1-2 days. Anesthetic liberation is liability of the responsible anesthesiologist.

3.3.3. Home Care

The sequence of assistance for home care is based on the guideline proposed by the British Society for Disability and Oral Health [24]. Figure 7 illustrates a home care sequence.

Step 1 - Initial Assessment of the Patient: Com- pletion of a health questionnaire, including medical his-

tory, physician reports, hospital treatments, medications in use, health problems, alimentary habits and level of cooperation. Patients included in categories 3 and 4 (Tables 1 and 2) are potential for intervention.

Step 2 - Preoperative Evaluation: Medical assessment by the team which manage the patient; request of laboratory exams linked to the clinical state; verbal and written instructions to the patient and / or guardian about the pre, intra and postoperative procedures; informed consent form of the patient and / or guardian; dietary restrictions according to the underlying disease.

Step 3 - Professionals and Equipment: It is requested two dentists. The necessary equipments are presented in Table 5.

Step 4 - Patient Monitoring: Constant cardiac and respiratory monitoringalong the dental appointment is only necessary in cases of bedridden patients pre- viously monitored by the medical team. Blood pressure, oxygen and random blood glucose monitoring will be performed routinely according to the underlying disease of the patient. In these situations, the behavior will be the same done in the dental office.

Figure 7: Illustrative sequence of home care. A) House layout to receive the dental team. B) Portable equipment before installing. C) Dental assistance. D) Portable equipment installed and ready for use (equipment consists of portable compressor, outputs for micro motor, multifunction syringe and aspirator).

A B

C D


Step 5 – Dental Treatment: The most favorable cases are those in which the dental needs are small and easily resolved with short appointments. Prevent- ive, restorative and surgical treatment can be performed and concluded in different approaches.

Step 6 - Documentation: Every procedure should be documented, reporting each drug used (ie. admin-istered local anesthetics and pre / postoperative medications).

4. DISCUSSION

In the scientific literature there are no studies that address the use of different techniques directed to the management of special needs patients, from outpatient clinic approach - with the help of conditioning and physical support techniques – to general anesthesia, placing them at an increasing scale choice.

This scarcity exists by the magnitude of the subject involved. The area of special needs patients has as object of study heterogeneous subgroups of patients, whose classification ranges from oncological, infectious, psychiatric, chronic, systemic diseases to genetic disorders in adults and children. Thus, in order to focus this subject, it is necessary initially to define the study subgroup to which it is addressed.

Behavioral management, physical constraint and sedation techniques are more described in pediatric dentistry specialty [19]. However, they do not take into consideration many of the anatomical and neurological changes that occur in patients with neuro-psychomotor disturbances that might difficult the use of such techniques. It is based on this prerogative that professionals end up basing their behavior on the clinical experience acquired throughout their lives. In this

matter, we consider that the use of proposed on the amended Frankl scale [9] and scale developed by Houpt and co-workers [10], can be useful tool to analyze behavior as a basis for dental treatment [11].

The main aim of this study was to perform a literature review targeted at dentists who are unfamiliar with this area, in order to learn about different management techniques considered for dental care of patients with special needs. As to facilitate the access and the understanding of the subject addressed, the goal was to elaborate guidelines of dental care for different techniques based on the available literature. The theoretical basis necessary to develop this literature review was a challenge for the small amount of published works on the subject.

As a starting point, we tried to facilitate the identification of primary signals to be recognized on each patient, so that the dentist might choose the best therapeutic approach. For the preparation of the protocols presented in this work, we based our review on manu- als of the American Dental Association [13], Australian and New Zealand College of Anaesthetists [15] and on our clinical experience, which were reinforced with images of cases performed by the authors. The sedation and general anesthesia guidelines proposed by this study differ from the above protocols once they present a more dynamic and practical profile, with simplified topics.

Furthermore, the guideline presented here comprises additional information, such as references to the medication used for sedation, in addition to risks and directions on their use. Maybe this could be the differ- ential of this study since, when compared to other protocols, it was observed that not all authors cite this particular content or gather the information of the three

Table 5: List of Necessary Equipments for Home Care Approach

General Equipments Administratives Materials Consumables / Instrumentals

Portable light Medical records Vary according to the dental procedure

Portable equipment with dental aspirator, X-ray and ultrasound equipment

General recommendations (surgical and oral hygiene)

Rigid plastic box for transporting the contaminated material (instruments and

consumables)

IPE (Individuale Protective Equipment): gloves, mask and protective eyewears.

Biosecurity materials Forms laboratories Rigid plastic box for transporting and proper

disposal of needlesticks, sharps in the office.

Desinfectant solution Consent forms --

Liquid soap Photographic camera in order to record cases --

Dental instruments Illustrative material on health --


afore mentioned assistance options [5,8,13,15,17,19, 20,26,27].

Glassman et al. (2009) reviewed several guidelines about sedation and general anesthesia, concluding that despite the large amount of available protocols in the literature, few are specific to patients with special needs [8]. Thus, this guideline becomes a specific working tool. Differently from the elaborated assistance protocols for the modalities of sedation and general anesthesia, we found difficulty in developing a dental care protocol for home care technique. The major rea- son was the lack of scientific articles published on this subject to the date [5,27]. Among the selected articles, only one scientific paper has proposed the development of a practical protocol that based the formulation of the guideline of this work [5].

The ideal would be to elaborate an evolutionary scale to choose the best therapeutic approach, based solely on the underlying disease of the patient. In this matter, patients with Down syndrome, for example, might be potential targets for an outpatient approach under conditioning and / or physical stabilization, as well as autistic patients might be directly indicated for general anesthesia and so on. Facing such imposs- ibility, we believe that the development of the proposed guideline could assist in the decision-making.

In homecare subject, the studies are more related to oral health in patients living in institutions, paliative care units or nursing homes [5,24,27].

Searching the professional dental performance in the home care area is of considerable importance to improve the technique and to enrich the access to health services. According to the American Academy of Pediatric Dentistry [28], the home care reduces the risk of illness from preventable diseases, once only in this way the dental care can be performed on bedridden patients, not just to eliminate foci of pain, but also for prevention of diseases [27].

5. FINAL CONSIDERATIONS

The conducted literature review coupled with our clinical experience, has allowed us to develop an evolutionary guideline destined to a better therapy – sedation, general anesthesia or home care - for dental treatment of special needs patients with neuro psychomotor disorders. This was the first time in the literature that a scientific work discussed and compared the different therapeutic modalities involved in the dental treatment of special needs patients. We hope this guide could be

used by dentists that are not familiar with this area on the professional clinical routine.

ACKNOWLEDGMENTS

The authors thank Doctor Claudia Barbosa Pereira who kindly donated the home care images.

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Received on 19-03-2016 Accepted on 05-04-2016 Published on 19-04-2016 © 2016 Polli et al.; Licensee Revotech Press. This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.

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