Treating children, not teeth
When you obtain your professional dental/hygiene licence, it means that society gives you the right and obligation to practice your profession for the good of society. You are obligated to treat the general public, everyone that requires your services. The main exception is when their dental requirements are beyond your level of expertise.
The need to service everyone includes people with special needs. Special needs is a category that needs refinement as it breaks down to several categories:
- Medically compromised patients
- Physical disability, restricted or lack of mobility
- Psychological disability
- Communication disabilities
- A combination of all four
For those with complete disability, you will have to visit these patients as they are likely housed in a facility or hospital that usually have some dental space or tools. For those with restricted mobility, they need to have access to your facility. People with special needs have a reduced access to dental care due to some professionals unwilling or unable to treat these people. The other reason is a paucity of facilities, both public and private, to care for the dental needs of these individuals. Treatment is difficult for various reasons, from access to finances, which may result in a poorer standard of care, where extraction is carried out in lieu of a more preferred restorative care. Extractions may also be planned due to lack of follow up and regular preventive services being available.
Thus, for special needs, prevention is imperative, both from a treatment and cost perspective. Preventive services can be carried out at most private dental clinics. Only the most unmanageable patients need to be treated in an institution. Even aggressive patients can be handled fairly well with parental or care giver assistance. Prevention must be modified to the patients’ needs and abilities, and the help of the care givers. Patience is required, and several appointments may be necessary to achieve the desired results. This may be necessary either for compliance or giving the patient a chance to familiarize themselves to you. Remember, they have extensive experience with medical professionals and not all good.
Rewards to treating special needs patients will be a long and fruitful relationship. The patient and parents will appreciate your work and build up a trust in your services and abilities. Success in preventive services can prevent more extensive treatment that would be difficult to carry out or prevent a treatment that would be detrimental to eating, speaking, and overall health. When I first started practice, a 20-year-old man with Down Syndrome presented at my office for treatment. He was referred to have all his teeth extracted. He did not have any caries but a severe periodontal condition with all his teeth having a mobility of 2-3, with 60-75% bone loss. I spoke to the parents and went over the treatment options. We could extract all his teeth (he was not in any pain), but I doubted that he would cope with full or partial dentures. The second option was to set up a preventive program with the hope of delaying the extractions as much as possible. That would require regular 3-month visits and dental care by the parents, which we would provide and supervise. They opted for the second option, and we treated him for 15 years. During this time, we extracted only 1 tooth that was bothering him. Unfortunately, when his elderly parents passed away, the new care givers did not continue treatment.
A good preventive program can delay more extensive treatment indefinitely. For example, you can use Silver Diamide Fluoride to slow caries development in certain situations. As wait times for dental treatment may be from 6-12 months in medical facilities, any prevention that reduces the amount and severity of treatment is a true gift. Small measures go a long way. As a pediatric dentist, I not only treat special needs kids, but keep them as patients when they transition to adults, as they have few places and dentists who would take them on as patients. Special needs patients have many medical needs and issues, thus helping to prevent dental treatment can help them in eating and comfort. Be cognisant of any dental pain. Is the patient being difficult or are they in pain? Any change in eating or sleeping habits may be an indication of pain. When the patient refuses to eat normal foods and is reluctant to have you touch a particular area, it may be due to pain. Changes in chewing habits or biting on only one side may be a signal of discomfort.
Prevention is a process, and it may take several appointments. As trust builds, you will be more effective in implementing your program. You may need to modify your goals to what is possible and not what is ideal. You may need to book several appointments weeks apart to gauge progress. Get feedback from the parents on how things are progressing, what is working, and what is not. Once you have reached a baseline, book a 3-month follow-up appointment, and, if all is well, followed by regular 6-months recalls. Expect to see ups and downs and see if there are any changes in behaviour or medications. It is best to make these appointments first thing in the morning or first thing in the afternoon. Once you accept the challenge you will learn how gratifying it is.
About the author
Originally from Montreal, having taken his dental education at University of Montreal (in French), Dr. Maltz moved to Toronto in 1973. He practiced for 5 years and obtained his diploma in Paediatric Dentistry from U of T in 1979. He lectured for hygiene at Niagara College for two years and also served as head of the dental department at Peel Memorial hospital, and started the paediatric division at Etobicoke General Hospital. As a two-term president of Ontario Society of Paediatric dentistry, he did a presentation at Queens Park on dental care. In addition to being a clinical instructor and lecturer at U of T, Dr. Maltz wrote numerous articles for the professional and lay press, including a book for the public, “We Treat Children Not Teeth”. He is happily married for 35 years with three kids and three grandkids. Hobbies and pastimes include traveling, swimming, hiking, fishing, reading good books, and enjoying fine food and fine wines.
