Handicapped Children

Willyanti Soewondo Sjarif, drg., Sp.Ped

 Handicapped Children

Handicapped Children (People)

If they can not play, learn, work or do
things other of their age can do or if they
are hindered in achieving their full play
social, mental and social potentialities

Handicapped Children In DENTISTRY :

If they can not play, learn, work and
receive routine dental treatment as
normal children.
 HC
Physically
Medically
Mentally
Compromised
Combined
 Dental Disabled

Patients who have a physical and/or mental, or

emotional condition that may prevent them from
being treated routinely
Mental Retardation :
American Psychiatry Association: Mental
retardation that there is significant deviation
below the mean intelligence quotient (IQ)

Mental Handicaped
Mental sub normality/mental
deficiency.
Characterized by :
Low intelligence
Failure of adaptation.
 Mental Age
IQ = 100%
Chronological Age
Classification Of MR is related to IQ as follow
Degree of MR IQ
Border line 68 - 83
Mild 52 - 67
Moderate 36 - 51
Severe 20 - 35
Profound Below 20
Level IQ
Educable* 50 - 79
Trainable** 25 - 49
Non Trainable Below 25
*Educable : Special Education
**Trainable : Doing only a simplest tasks
 Medically Compromised Children

Children with complex medical problems :

1. Disabled Patient
Mentally retardation: -Down Syndrome
- Many syndrome
Physical impairment

2. Cardiovascular disorders

3. Bleeding disorders

4. Respiratory/ Chest problem

Medically Compromised Children
Children with complex medical problems :
5. Hepatitis
6. Epilepsy
7. Diabetes
8. Hospitalization
9. Allergies
10. Medication
Medical History for HC
Medical Problem
Medication : Past and present
Systemic Disease
Antibiotics
Clinical Features : DS
Extra Oral
Slanting of the eye
Hypotonia
Low set ear
Dry skin, soft hair and
straight
Flat face and broad nose
bridge
Mild microcephali
Short metacarpal
Simian crease
Wide gap between first and
second toes
Small penis and scrotum
 Macroglossia
Fissured and geographic tongue
narrow, high palate
Prevalence periodontal disease
Dental caries usually low
Delayed eruption in both primary and
permanent teeth
Congenitally missing teeth
Teeth often small and/or hypoplastic
Diagnosis

Clinical
features
Chromosomal analysis
Dermatoglyphic evaluation
Chromosome in Down Syndrome
 Physical Impairments
Cerebral Palsy :
It is a group of non progressive
neuromuscular disorders

Caused : Brain damage which can be

Pre
Peri Natal
Post
 Classification children with
impairments
Intellectually impaired
- Mentally retarded ADHD
- Learning Difficulties Autism
Physically impaired Hyperactive

Combination of impairments
Sensory impairments
Medically compromised
Intellectual Impairment may occur in

Cerebral palsy
Some syndromes: Down syndrome
Autism
Birth Anoxia
Microcephali
Mayor Trauma
Metabolic Disorders
Severe Infection
 CP
Classification according to the type
of molar defect :
1. Spasticity :
- Impaired ability to control voluntary movements.
There is the appearance of severe muscle
stiffness
- 50 % of CP
2. Athetosis :
- un controlled, slow twisting and writhing and
movements which are frequent and
involuntary
- 16 % of cases
 CP
Classification according to the type
of molar defect :

3. Rigidity :
Resistance to passive movements which may
be over come by sudden action
4. Ataxia
Difficulty in grasping
5. Hypotonia
6. Mixed : A combination of the
obove
Oral Health / Dental features in CP
Patients
Increased periodontitis
Dental erosion
Drug induced gingival over growth
Enamel hipoplasia
Bruxism
Tongue thrusting and mouth breathing in crease
in caries prevalence
 Cardiovascular Disorders :
Congenital heart Disease :
Acyanotic ASD
Cyanotic
oral sign: - nail and oral mucous
- delayed growth & development teeth?
VSD
Pulmonary Stenosis
Patent Ductus Arteriosis
Tetralogy of fallet : severe
Aortic stenosis

Acquired :
Rheumatic heart disease
Follows a groups streptococcus infection of upper
respiratory tract developing country
2 3 weeks after sore throat
Atherosclerosis.
 Oral Status of CVD :
Cyanosis of Gingival tissue

Dental care for CVD :

Prevention of dental disease as soon as a
child is diagnosed having CHD
Dental evaluation, fluoride application. OHI,
fissure sealant.

Treatment planning:
An invasive operative procedure required
antibiotic prophylaxis
Epilepsy : 0,5 1 % of the population
recurrent seizures

Caused :
a. Idiopathic epilepsy
b. Secondary epilepsy :
Degenerative cerebral disease
CNS infections
Cerebral neoplasm
Cerebral malformation (Down
syndrome , Hydrocephalus)
Drug intoxication
Metabolic disorders.
Seizures :

Grand mal seizures

Petit mal seizures.
Treatment :

Medical management usually long term

anticonvulsant drug therapy (phenytoin
dilantin)
Oral status, gingival hyperplasia (gingival
overgrowth due dilantin side effect.
Dental Care :
Routine Dental Treatment
Oral Hygiene Instruction
Fissure sealant
Fluoride application

Specifically for convulsan patient

Pedi-wrap could be use during
treatment.
An instrument can minimize tongue
biting during a seizures use mouth prop
 Bleeding disorders
Abnormal Bleeding
Disorder of Homeostasis vary depending
On the phase affected

Classification
Platelet disorders
Thrombocytopenia
Thrombocytosis
Platelet function disorders
Von willebrands disease
Vitamin C deficiency
Connective tissue diseases
Platelet disorders
Thrombocytopenic this may occur as an isolated entity
ot unknown cause (idiopathic thrombocytopenic
purpura), as a result of morrow suppression by drugs or
from other hematological diseases such as aplastic
anaemia.

Thrombocytosis
An increased number of platelets (> 500 x 109 per L)
may be associated with bleeding caused by abnormal
platelet function
Platelet function disorders
These may be congenital or acquired

Connective tissue diseases

Diseases of connective tissue such as scurvy
(vitamin C deficiency) and Ehlers Danlos
syndrome result in bruising and purpura caused
by vascular abnormalities and capillary fragility
Von Willebrands disease
As well as being a disorder of coagulation,
platelet function is also decreased (see below)

Dental implications
A decrease in the number of platelets or
platelet function will result in failure of initial
clot formation.
Dental Management
It'spreferable to have platelet levels
> 500 x 109 per L before extraction
Endodontic procedures may be
preferable to extractions in order to
avoid the need for platelet
transfusion
Good surgical technique and local
measures to control bleeding
Dental Management
Avoid block injections as these may
be complicated by dissecting
hematoma and airway obstruction
Antifibrinolytics
Tranexamic acid (Cyklokapron) 25
mg/kg loading dose and 15 20
mg/kg three times a day for 5 7
days OR
Dental Management
-aminocaproic acid (Amicar) 100 mg/kg
loading dose and then 30 mg/kg four
times a day for 7 days
During the time that antifibrinolytics are
given, the patient should be instructed not
to use straws, mental utensils, pacifiers or
bottles
Avoid platelet transfusions, if possible,
because of the development of antiplatelet
antibodies and the risk of transmission of
viral diseases such as hepatitis C and
human immunodeficiency virus (HIV)
Coagulation Disorders
Coagulation disorders result from a decrease in
the amount of particular factors in the
coagulation cascade.

Haemophilia A
X linked recessive disorders with
deficiency of factor VIII
1 : 10 000 live male births, 30 %
spontaneous mutation
Moderate
2 5 % factor VIII
Less severe bleeding, which usually follows
minor trauma.

Severe
< 1 % factor VIII
Spontaneous bleeding into joints and
muscles, including intracerebral
hemorrhage.
Mild
5 - 25% factor VIII
May not manifest until middle or old age
after significant trauma or surgery

Normal
50 200% factor VIII from factor VIII
assay.
Von Willebrands disease

Autosomal dominant (gene locus 12p 13)

Abnormality of factor VII molecule
complex
Platelet and factor VIII activity
decreased, therefore both bleeding time
and activated partial thromboplastin time
(APTT) are elevated
Von Willebrands disease

The Von willebrands factor is found in the

plasma, platelets, megakarjocytes and
complex. This disease is divided into
subtypes, based on the platelet and
plasma multimeric structure of the von
willebrands factor. Treatment is
dependent on the subtype
Christmas disease (haemophilia B)
FactorIX deficiency
Elevated APTT

Other disorders of coagulation

VitaminK deficiency
Liver disease
Disseminated intravascular coagulation
usually from overwhelming (Gram
negative) infection
Tests
Bleeding
Full-blood count (FBC) for platelet count: 150 400 x
103/mL
Skin bleeding time : 9 minutes
Platelet function tests in selected cases

Coagulation
Prothrombin time test of extrinsic pathway :150 400 x
103/mL
APTT test of intrinsic pathway 9 minutes
Dental impications
Consultation with physician (hematologist)
Local measures to control hemorrhage
Good local technique (i.e. minimal trauma
during restorative and surgical work)
Dental impications
No block anesthesia without factor cover,
due to risk of hematoma
Maxillary infiltration anaesthesia can
generally be administered slowly without
pretreatment with -aminocaproic acid and
/or factor replacement. However, if the
infiltration injection is into loose
connective tissue or a highly vascular
Dental procedures

Extraction must never be performed

without first consulting the
hematologist
Endodontics can be safely carried out
without factor cover
Periodontal therapy with scaling and
sub gingival curettage requires factor
replacement
Dental procedures

Multiple extractions require

hospital admission in conjunction
with the hematology team
Use rubber dam to protect soft
tissues.
Haemophilia A
Minor trauma may be life
threatening, especially with intra
cerebral bleeds; 15% of patients will
form antibodies (inhibitors) to factor
VIII, severely complicating
management
Hemophiliacs are treatment with
replacement therapy
Haemophilia A
Severe hemorrhage is treated to
100% replacement, although minor
bleeds can be controlled with
replacement between 30 and 50%
One unit of factor VIIIc per kilogram
will raise levels by 2 %
Von Willebrands disease
Type I may be treated with 1-deamino (8 D
arginine) vasopressin (DDAVP)
Types II and III require cryoprecipitate

Christmast disease
Prothrombine, or fresh frozen plasma for mild
cases
Available factor replacements
Factor VIIIc
Recombinant factor VIII
Cryoprecipitate
Prothrombinex (II, IX, X), used for other clotting deficiencies

Antifibrinolytics
Tranexamic acid (Cyklokapron)
-aminocaproic acid (Amicar)
 Learning Difficulties
Autism
(Childhood Shizofrenia, Childhood psyhosis)
Complicated development disorders
Communication
Socialization
Behavior and learning disorders
ADHD
Behavior Disorder
Diagnosis :

3 Components : - Inattention
- Impulsivity
- Hyperactivity
 Dental Management of ADHD
Need Prepare & understanding Pediatric Dentist
1. Psychological Approach
Communication : Verbal & Non verbal
Behavior Shaping Tell, Show, Do
2. Physical Approach
- Pedi wrap
- Mouth prop
3. Pharmacological Approach
- Premedication : Stimulant & Anti Depressant
- Sedation : Inhales, Oral, Rectal
 Important Thing Of Management ADHD

1. Dental Appointments done in the morning

and not in holiday School
2. Emphasis should be on brushing the teeth
than tooth brushing techniques
3. Assistance by neuro pediatric and
psychology/psychiatrist
4. Short Sentences, Soft voice and Humor
Factor VIII assay
These assays are usually performed after the
initial diagnosis of a coagulopathy

Factor VIII von W Von Willebrands cofactor,

the main portion of the molecule, binds to
platelets, carrier protein for factor VIII
concentrate (factor VIIIc)
Factor VIIIc Procoagulation portion
participates in the clotting cascade,
deficient in haemophilia A

Factor VIIIag Antigenic cofactor, antigenic

component of FVIII von W

Factor VIIIrcof Ristocetin cofactor, supports

platelet aggregation