During our Let’s talk Oral Health webinar series for oral care professionals, we have monthly conversations about home-based oral care, each time from the viewpoint of a different dental specialty. After episodes dedicated to periodontology, orthodontics, and cancer therapy, we focused on special needs dentistry in July. Curious about what our two experts, Ms. Anna Louise Tolan and Dr. Mohit Kothari, had to say on this topic? Continue reading below!
Special needs: definition and patient segmentation
In modern medicine, we often try to tailor our treatment to the individual needs of the patient, and to facilitate this, we try to categorize them. In the case of patients with special needs, this is a particularly complicated matter due to the heterogeneity of this population. Nevertheless, Dr. Kothari roughly categorizes his patients in two groups: “One category is elderly patients who are otherwise healthy, but the aging process is letting them down physically and socially, hindering their normal everyday activity.; the other one is elderly who have co-morbidities, such as cardiovascular disorders brain injury, diabetes or impaired motor activities and cognition and who. require more attention, either by a professional in a hospital setting or at home by their spouse or guardian,.” Ms. Tolan recognises this from her own experience, working with special needs patients for 17 years both in her own clinic as well as in a hospital or nursing home setting. “In my practice it’s a mix between community-dwelling clients and patients living at home.” . Some require so-called oral health care plans (OHCP),. An OHCP – like a prescription – describes services that must be accomplished with or for the client, from supervising and coaching to physically providing the care, recommending products and tools that need to be purchased. The person-centered care approach reveals the client’s needs, beliefs, and preferences and is adjusted at each appointment. Dr. Kothari agrees: there are no validated oral health care plans in Europe, but the approach is to tailor-make an OHCP according to the special need. As an example, he uses Parkinson’s patients who suffer from dexterity issues, and are therefore recommended to use a toothbrush with a large-handled grip, soft bristles, and a small brush head to reach the corners better. Moreover, Dr. Kothari again emphasizes the importance of educating the spouse or guardian, giving out small, practical tips, such as recommending the 2-square formula during instructions (brushing twice a day for two minutes) or making the toothbrush easier to grasp by placing the handle inside a bike handlebar grip or a tennis ball.
Functional & psychosocial special needs
While we discussed above how we can categorize patients with special needs on a population level (e.g., community dwelling vs. living at home), the broad range of actual special needs allows categorisation on patient level as well. For example, Ms. Tolan distinguishes functional and psychosocial issues. For the functional aspects, we’re talking for example about clients and/or their caregiver who aren’t able to brush their teeth properly: “For those, we try to think outside the box, building in reward systems with stars, getting someone to use a munchie in order to stimulate tissues and saliva production, introduce accessory devices in order to hold oral care tools, etc.” A psychosocial issue can also occur on top of a functional issue, making it very limiting for the patient: “It can exist because of previous experiences, any type of fear regarding any type of caregiving, patients feeling shameful about the fact they cannot look after themselves. So, make sure they understand that we are not here to judge, we are here to help them. Be emphatic and try to get an understanding of the origin of their previous experience.” Ms. Tolan continues: “I love to use the show-tell-do type of the concept, because we need to remove that fear and build trust. For example, showing how the saliva ejector works, demonstrating the different sounds your devices make, and what those sounds set off, before actually do it with them.”
Fear and anxiety
Already introduced above, fear or anxiety occurs quite often in patients with special needs, and it can be extremely limiting. Dr. Kothari explains that dental anxiety is incredibly common and can affect anyone. The term is generally used to describe feelings of unease, fear, or stress before or during a dental appointment. It can be attributed to a variety of factors:
- The dental setting that triggers stress, such as a fear of needles.
- The perceived lack of control during a dental appointment can also make them feel uneasy.
- Self-judgement: Delayed dental visits sometimes due to financial constraints, making individuals apprehensive. Individuals may feel self-conscious about their oral health.
Symptoms of dental anxiety are for example increased heart rate and sweating, and it can lead to postponements or entirely skipping appointments. Dental phobia is more severe than dental anxiety, and it is also less common. This condition leaves individuals completely overwhelmed and terrified by the thought of visiting the dentist. Individuals avoid scheduling an appointment until they experience a painful issue or may never visit the dentist at all. The same things that cause dental anxiety can also cause dental phobia, such as bad experiences. In many cases, people with dental phobia know that their fear is irrational. However, they still have a tough time confronting and overcoming their panicked feelings without help. So how to help these patients? Besides continuing education and conversation, Dr. Kothari has a special approach for his patients: “We never directly enter the patient’s mouth, but always start with a hand gesture, because sensory stimulation always starts from the hand. The patient feels that a hand touch is something soothing, and you can easily see the reaction in the patient’s eyes, as it helps them to get comfortable. And then you move on to the oral cavity, starting with the lips.”
Senses and emotions
The example of the hand gesture emphasizes the importance of responding to and making use of the senses and emotions of patients, especially in those with special needs, as Ms. Tolan explains:
- What do we see? Make sure things look tidy and simplified and follow the same processes each time to avoid overwhelming situations. If they are light-sensitive or have a headache or are prone to migraines, dim the light in your practice and only use the illumination on your loupes. Also, to avoid building up anxiety in the waiting room, make sure everyone, including the caregiver, knows very well how and when to arrive.
- What do we smell? Does your office smell like a dental office or cookies? At her dental office, they practically bake cookies every day, not just for the smell, but also to offer as reward afterwards.
- How does it taste? What flavour do they like, what is normal to them, considering issues like oral dryness for example.
- What do we hear? For example, the sound of a high-speed handpiece can bring up traumas from previous experience. In such cases, putting on headphones can be helpful; watching their favourite TV show or listening to their favourite music helps them be more relaxed.
- What do we feel? Use a blanket or even the lead apron for comfort and the prevention of anxiety.
Patients also may be claustrophobic, in that case, it can help unlatch or leave open the door to the operatory room, so that the patient at least has the feeling he or she can still “escape”.
Ms. Tolan emphasizes that under such challenging circumstances, it is important to start building a relationship by thinking out of the box: “I have seen people in their car, on a picnic table, outside in front of the office. Just to be able to start building a relationship. It is important to realize that we have to develop these types of relationships slowly and carefully, so that then we can really help them with their oral health.”
Oral health status of patients with special needs
Leading an interdisciplinary team, Dr. Kothari set out to explore the extent and root causes of oral health problems in two hundred patients with brain injury: “Out of these two hundred patients, almost fifty percent of them had very acute problems like having high visible plaque and bleeding on probing, so there’s inflammation present. Interestingly however, we also found a lot of chronic issues, with one of the major issues being severe periodontitis.” When retrospectively looking at some behavioural and social characteristics of the population, they found interesting data: “All these patients came from a relatively low socioeconomic background, and 64% of them were smokers or passive smokers.” Similarities between brain injury patients and periodontitis patients regarding socioeconomic status and biological factors led Dr. Kothari to the interesting hypothesis that periodontal health could act as a prognostic marker for future brain injury: “If you have a yearly check-up at the age of 20-25, and there is a periodontal problem, you should relate that maybe this person could have a stroke or traumatic injury in the future. And this emphasizes the importance of keeping the oral cavity clean.”
But that was not the only oral-systemic link Dr. Kothari observed in this population of patients with brain injury: “fifty percent of the patients also have a swallowing disorder, and as a result, food does not reach the stomach but can be aspirated instead and reach the lungs, causing pneumonia which can be a fatal issue. A lot of microbiological studies has also shown that there are microbiota in our lungs which are very similar to the oral microbiota.” Most likely, in this population, the reason is a combination of poor oral health, poor masticatory function and swallowing disorders. Dr. Kothari further explains: “Periodontitis, the biofilm, bleeding on probing, all were connected with long term hospitalization. Also, all those patients who had pneumonia had poor oral health, combined with very serious cognitive and motor issues. And patients with better oral health had better cognitive abilities. And that means they can understand you and clean their teeth better and improve their oral hygiene. And that is how everything is kind of correlated like a vicious cycle”.
How to deal with disappointments and setbacks?
Working with patients with special needs can be very rewarding, but the inevitable setbacks can also be extremely frustrating. How do the speakers deal with such setbacks and disappointments? Ms. Tolan keeps it simple in such cases: “We have to keep in mind that it is just today, and the next day will be better. I just try to remember that we have at least one excellent visit a year with the specialty clients who I see every three or four months. And this is also where good documentation is important.” You also have to learn from previous experience, as this example from Ms. Tolan highlights: “Once we took an autistic non-verbal client into a different operatory, and that was a no-go, that didn’t go well. So, we will never do that again, we have to learn from that.” One of the challenges Dr. Kothari faces with his brain injury patients, is the risk of being bitten: “Sometimes you just want to give up. No, this patient is too difficult. But then comes the next day, and you move forward. As preventive measures, we now have bite blocks, or spatulas that we use a lot in our practice. For sure, there will be many setbacks, but we just have to face it and move forward.”