patients with disabilities Treatment of Patients with Intellectual and Developmental Disabilities in a Family Dental Practice

By Catherine E. Bridges, DMD, State Dental Executive Director, Florida Department of Health

This article discusses the prevalence of shared intellectual and developmental disabilities, the need for early intervention, helpful tips in patient treatment and training opportunities.

In 2021, the Centers for Disease Control and Prevention (CDC) reported that one in 44 children in the U.S. is diagnosed with autism spectrum disorder (ASD). The prevalence is higher in boys than in girls.1 The estimated number of children ages three to 17 years who are diagnosed with attention deficit/ hyperactivity disorder (ADHD) is six million. The prevalence is higher in boys than girls.2 The CDC estimates that cerebral palsy affects approximately three live births out of every thousand in the U.S.3 The CDC also estimates that one out of every 700 babies are born with Down Syndrome in the U.S.4 According to HealthyPlace, the internet’s largest consumer mental health site, one in five children, or 20%, have learning and attention issues. Children in the U.S. who receive special education services for a learning disability number approximately 2.5 to 2.8 million. Seven out of 10 children with an individualized education plan for a learning disability or other health impairment spend 80% or more of their school day in their regular education classroom instead of a special education classroom or resource room.

How do these statistics relate to dental providers? The prevalence of patients diagnosed with intellectual or developmental disabilities (IDD) is increasing. Most children with IDD are now in mainstream education classrooms and grow up socially inclusive. We may interact with them in our families, friendships, places of worship, community functions, the grocery store and other places. It is imperative that dental providers make the extra effort to include patients with IDD in their regular patient care. Dental care should begin early, and visits should be frequent. America’s Academy of Pediatric Dentists, a not-for-profit professional membership association representing the specialty of pediatric dentistry, recommends that every child have a dental home no later than 12 months of age.6 Early visits allow the dentist and hygienist to provide early education, prevention and intervention in children’s dietary habits and oral home care so that the child can grow up disease-free.

In Florida, more dentists are needed to provide family dentistry, including seeing children and adults on Medicaid. Care of young children can certainly be challenging, but early intervention is critical to guiding them toward success. Another reason for early intervention is in December 2016, the Food and Drug Administration issued a Drug Safety Communication warning that “repeated or lengthy use of general anesthetic and sedation drugs during surgeries or procedures in children younger than three years or pregnant women during their third trimester may affect the development of children’s brains.” 7 While sedation is sometimes necessary, other options are available such as arresting caries with silver diamine fluoride, providing treatment while using nitrous oxide or medical immobilization/protective stabiliza- tion. In addition to early education, detection and treatment of caries, the dental provider can help the child become desensitized to dental visits. Since patients with ASD and ADHD often are hypersensitive to light, noises, vibration, touch and smells, early and regular desensitization will enable the child to become more acclimated to the dental world. Some additional challenges in patients with ASD and ADHD are that they often crave sweets, and many caregivers resort to using sweets as a reward for good behavior. In addition, patients with ASD often pouch their food, keeping it in their cheeks long after mealtime. Often children with ADHD chew on objects such as pens, cell phones, remotes, clothes and blankets. Since caregivers face multiple challenges caring for patients with IDD, many tend to provide reactive health care practices, such as taking the patient to the dentist when something hurts, or there is an infection. Early education could intervene in this negative process by urging the caregiver on the importance of regular brushing, flossing if able, using positive rewards that are not sweets and visiting a dental professional every three to six months.

Before the initial dental visit for children, especially children and adults with IDD, the office should initiate a pre-visit phone call or teledentistry visit. Many insurance companies, including Medicaid and Florida Healthy Kids, reimburse Teledentistry. This pre-visit helps the dental provider and caregiver be prepared for the dental visit. During the pre-visit, ask the caregiver about special health care needs and consult the patient’s medical provider if necessary. Ask about the best time of day to see the patient and avoid scheduling him/her when their medications are less effective. Children, particularly children and adults with IDD, are not the patients to treat before lunch or at the end of a long day. Ask what the patient likes and dislikes and what items or objects the patient enjoys. Ask the caregiver to bring some of those items to the visit. Ask how the patient communicates, verbal or non-verbal. Approximately 40% of patients with ASD are non-verbal.8 Consider communicating with a picture board for common words and phrases. Ask the caregiver what strategies they use to calm the patient and what reward system they use to achieve positive behavior. Incorporate these strategies as applicable. Finally, ask the patient or caregiver if there is a particular concern or chief complaint to be addressed in the visit, and be sure to address it promptly. Consider sending a short storybook with pictures to show the steps of a dental visit. Dental storybooks are available for purchase, or get creative and make one of your own.

Dental visits should be organized, thorough and flexible. Having the pre-visit appointment helps facilitate the initial in-person visit. Minimize noise in the waiting room or move the patient and caregiver to a safe space where he/she can play with their sensory items. Minimize the wait time before the patient is brought in for the treatment. In addition, consider taking training offered by the American Academy of Developmental Medicine and Dentistry (AADMD). Go to bit.ly/3WHirtA to view Optimizing Comfort — AADMD, 9 this is an excellent resource from an occupational or physical therapist’s vantage point to assist in treating patients with IDD.

During visits, greet and talk to the patient, not just the caregiver. Tell the patient what you will do before you do it, and ask permission before you touch them. Consider providing plastic sunglasses for the patient to help with light sensitivity and headphones with the patient’s favorite music to help with noise sensitivity. Ask the caregiver if he/she could bring headphones the patient uses at home. Vibration sensitivity can be tough to overcome but wrapping the child up in their favorite blanket (with or without the caregiver holding them)