Challenges to utilization of dental services for the person with special needs

• Finances
• Limited number of providers who accept Medicaid participants
• Adult Medicaid coverage provided by the state may be limited
• Physical accessibility due to limited space in offices built prior to the Americans with Disabilities Act (ADA) in 1990
• Dentist’s lack of training in the care of persons with disabilities
• Special transport services required
• Dependency on the availability of caregivers and guardians

Challenges to utilization of dental services for the provider

Consent/Guardianship

Depending on the state in which they live minors may become emancipated at 18 or 21 years of age. This ruling applies even to those with special needs such as intellectual disabilities. Therefore, a parent or interested party must petition the courts for guardianship to make health care decisions on behalf of that person which can be costly and long. No oral health care can be provided without consent. In the case of a medical emergency a spouse, parent, sibling, relative, caregiver or friend in that order, may legally sign the consent.

Comprehensive Medical History

Many persons with special needs know their complete medical history and can provide an accurate accounting, however many others cannot. The oral health care professional may have to rely on the caregiver or medical records from a group home or long term care facility (LCF). Often it is necessary to consult with the primary care physician to obtain critical health care information such as illnesses, medications, surgeries and allergies etc.

Specialized Equipment

Specialized equipment may be necessary to enable oral care to be delivered in a safe and non-threatening environment including:

• chemical restraint and physical positioning devices when appropriately consented
• transfer belts, slide boards or mechanical transfer devices
• multi size and shape pillows to support contracted limbs or the head and neck.
• specialized mouth props
• monitoring equipment for vital signs and oxygen saturation when indicated
• portable radiographic equipment

Supportive Equipment

Patients who present with supportive equipment such as wheelchairs, stretchers, walkers, protective head gear, braces for extremities, tracheostomies, respirators, percutaneous endoscopic gastrostomy tubes (PEG), urinary drainage bags etc. will require additional attention. Understanding the management of these devices will help to make a successful dental visit.

Cooperation with Dental Treatment

Many patients with special needs present with behavioral issues and are non-compliant for dental care. This may be related to decreased cognition, fearful prior experiences, inability to control physical movements such as involuntary reflexes or simply willfulness on the part of the patient. The approach to a successful dental visit is attempted through a continuum of treatment modalities.

• Behavior modification
• Positive reinforcement
• Strengthening positive behaviors
• Negative reinforcement
• Extinction
• Modeling
• Desensitization
• Tell-Show-Do
• One voice
• Oral sedation
• Intravenous sedation
• General anesthesia in operating room setting

Group home setting

After the deinstitutionalization of facilities for persons with special needs many disabled persons moved into community based group homes. While many homes provide a loving and nurturing environment with a stable staff who knows their clients well, others do not. Continuity of care, medical history, home care instructions, prevention plans, etc. may not be followed as there may be no single point of contact available for follow through.