Physical Disorders

Sensory Limitations

Visual Impairment

Visual impairments vary from total blindness to limitations in color perception, distance perception, recognition of shapes, and size of visual field.  To assist these individuals, medical history and consent forms should have large type.

The dental staff should use a verbally oriented approach.  Explain procedures before performing them, e.g., “I am going to put a small mirror in your mouth, it is the size of a quarter.  Do you have any questions?”.  Comment on textures, odors, vibrations and taste that the patient is likely to experience.  the dentist and staff should attempt to paint a picture for the patient using words.

People with visual impairments may have an increased sense of touch.  Verbally advise them of your presence.  an unexpected touch on the face or arm can be extremely startling to the patient and increase anxiety.  Do not leave the room without advising the patient.

When guiding the blind patient offer your arm and let them hold your arm, do not push them.  Describe obstacles as you guide the patient.  If a guide dog is being used, do not pet or interfere with the dog; ask the patient how to handle the dog.

The treatment plan must consider the patient’s ability to perform with oral hygiene, insertion and removal of removable prostheses, and anxiety about dental procedures.

Hearing impairment

The patient with a hearing impairment may exhibit fear or hostitlity if they feel they are not going to understand directions and may pretend to hear to aviod embarrassment.

Facilitate communication by reducing extraneous noise as much as possible, i.e.; high-volume evacuator, saliva ejector, radio or piped-in music. Remove your mask when speaking to expose your lips. Use mirrors, models, drawings and written information to augment communication. A sign language interpreter can be very valuable.

Hearing devices can be adversely affected by the high pitched tone of the handpiece or ultrasonic scaler which may make the device useless and cause the patient to be less cooperative. All discussions must be concluded and patient’s hearing device turned off before treatment is begun.

Conduction of vibrations from burs via teeth and bone can be very disturbing to the hearing impaired; the dental staff should be sensitive and understanding.

Degenerative Neuromuscular Disorders

Multiple sclerosis

Multiple sclerosis (MS) is a progressive disorder that eventually causes paralysis. It causes multifocal plaques of demyelination in the CNS (myelin is a fat-like substance that forms a sheath around nerve fibers). MS is the most common human demyelinating disease. The etiology unknown and there is no known cure.

The demyelination leads to four important CNS disturbances:

  • decreased nerve conduction velocity
  • differential rate of impulse transmission
  • partial conduction blocking
  • complete failure of impulse transmission

The cardinal clinical manifestations are caused by injury to:

  • visual fiber systems (60% of patients)
  • motor systems (100% of patients; excessive fatigue, dragging of an extremity, stumbling, loss of fine motor skill, clumsiness, Babinski sign present)
  • sensory fiber systems (common; paresthesia of the limbs, inability of limbs to detect the degree of hot or cold, bladder problems, impotence)

After 25 years more than 75% of patients are still alive. Remissions, complete and partial, are common.

Appropriate patient treatment goals include:

  • keep patient free of acute disease
  • maintain oral function
  • retain esthetics to maximize patient self image
  • enable patient to care for their own oral health

Treatment plans must consider limitations of motor skills. The preventive dental program may require involvement of family member or nurse.

Clinical considerations:

  • patients with severe MS require short appointments
  • patient may have to be transferred from wheel chair to dental chair
  • patients may have difficulty localizing intraoral pain and discomfort; all diagnostic tools must be used before performing extractions or endodontic therapy
  • some patients develop trigeminal neuralgia (tic douloureaux), usually bilaterally
  • these individuals develop severe respiratory problems, due to the disease’s effect on the muscles that control breathing, and deficits in protective airway reflexes; rubber dam may be useful if the patient can breath through the nose
  • patients should not be placed in a supine position (to protect airway); can be placed at 45 degrees
  • sedation, general anesthesia, or hospitalization may be required prior to providing treatment

Patients with MS may be receiving one or more of the following medications:

  • corticosteroids
  • muscle relaxants
  • antidepressants
  • immunosuppressants

Amyotrophic Lateral Sclerosis

Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s Disease, is a degenerative nervous system disease causing a loss of motor neurons in the cerebral cortex, brain stem and spinal cord with resultant muscular atrophy, weakness, and spasticity. Significant sensory symptoms are absent. The disease is unremittingly progressive; patients survive 3 to 5 years or less. The etiology is unknown and there is no known cure.

This disease affects 2 to 7 individuals per 100,000 and the mean age of onset is 50 to 60 years.

Weakness begins in the upper extremities often unilaterally.

Patients may have difficulty placing and removing a removable prosthesis. Complete dentures should be avoided since oral muscle function will diminish.There are severe effects on respiration and deglutition.

Appropriate treatment goals include:

  • keep patient free of acute disease
  • maintain oral function
  • retain esthetic to maximize patient self image
  • enable patient to care for their own oral health

Treatment plans must consider limitations of motor skills. The preventive dental program may require involvement of family member or nurse.

Clinical considerations:

  • patients with severe ALS require short appointments
  • patient may have to be transferred from wheel chair to dental chair
  • these individuals develop severe respiratory problems due to the disease’s effect on the muscles that control breathing; and deficits in protective airway reflexes develop – rubber dam may be useful if the patient can breath through the nose
  • should not place patient in a supine position (to protect airway); can be placed at 45 degrees

Patients with ALS may be receiving one or more of the following medications:

  • muscle relaxants
  • anti-epileptics

Muscular dystrophy

Muscular dystrophy (MD) is a group of muscle diseases which present as progressive atrophy and weakness of skeletal muscles. The muscle fibers degenerate and are replaced by fatty and fibrous tissue. This disease is eventually fatal due to the onset of infectious and respiratory diseases, and pulmonary disfunction. A respirator is necessary in later stages.

Weakness of facial and neck muscles causes secondary malocclusion, decreased protective reflexes, and a decrease in the ability to swallow secretions. Poor oral hygiene may be present due to an inability to provide self care.

Treatment plans must consider the patient’s limitations of motor skills. The preventive dental program may require involvement of family member or caregiver. Use frequent recall appointments, topical fluoride, and antiplaque agents.

Appropriate treatment goals include:

  • keep patient free of acute disease
  • maintain oral function
  • retain esthetic to maximize patient self image
  • enable patient to care for their own oral health

Clinical considerations:

  • patients with severe MD require short appointments
  • patient may have to be transferred from wheel chair to dental chair
    • these individuals develop severe respiratory problems due to the disease’s effect on the muscles that control breathing; and deficits in protective airway reflexes develop – rubber dam may be usefull if the patient can breath through the nose
    • should not place patient in a supine position (to protect airway); can be placed at 45 degrees.

Parkinson’s Disease

Partkinson’s Disease is characterized by muscular rigidity, tremor, bradykinesia (iatrogenic parkinsonism closely resembling Parkinson’s disease may be induced by various drugs, principally major tranquilizers; always reversible). It is thought to be a pathophysiological condition caused by a dysfunction of brain dopamine neuronal systems, specifically, degeneration of neurons in the substantia nigra. The cause of degeneration is unknown.This disease affects 130 individuals in 100,000.

There is a slow gradual progression over many years and it is not generally fatal. One third of patients also have a gradual dementia in the later course which may manifest as paranoia, confusion, visual hallucinations. The patient may have swallowing difficulties and poor control of oral secretions.

Medications are routinely used to control the effects of the disease which may cause xerostomia and disorientation.

Treatment plans must consider limitations of motor skills and tremor. The preventive dental program may require involvement of family member or caregiver. Use frequent recall appointments, topical fluoride, and antiplaque agents.

Appropriate treatment goals include:

  • keep patient free of acute disease
  • maintain oral function
  • retain esthetic to maximize patient self image
  • enable patient to care for their own oral health

Clinical considerations:

  • patients with Parkinson’s Disease may require short appointments
  • patient may have to be transferred from wheel chair to dental chair
  • rubber dam may be usefull if the patient can breath through the nose
  • should not place patient in a supine position (to protect airway); can be placed at 45 degress

Patients who have Parkinson’s Disease may be receiving one or more of the following medications:

  • anticholenergics
  • dopamine agonists
  • beta blockers
  • monoamine oxidase inhibitors – type B

Developmental Neuromuscular Disorders

Cerebral Palsy

Cerebral Palsy (CP) is a group of non-progressive neuromuscular disorders caused by brain damage (usually due to anoxia) sustained during the prenatal or perinatal period or during infancy.

This condition affects 1 to 4 individuals in 1000 live births. One in 7 die during their first year.

Neuromuscular effects include:

  • spasticity (increased muscle contraction when stretched) is present in 55 % of individuals
  • athetosis (uncontrollable slow twisting or writhing movements) is present in 25 % of individuals
  • ataxia (loss of balance) is present in 10 % of individuals
  • rigidity is present in 11 % of individuals
  • hypotonia (all muscles are flaccid with decreased function) is rare
  • a mix of these symptoms is present in 15 – 40 % of individuals

Disorders commonly associated with CP are:

  • seizure disorders (35 – 60 percent)
  • mental retardation
  • sensory disorders
  • learning and emotional disorders
  • speech and communication defects
  • decreased swallowing and cough reflex

Dental conditions associated with CP include:

  • increased periodontitis and phenytoin induced gingival hyperplasia
  • malocclusions
  • tongue thrust and mouth breathing
  • possible increase in caries
  • enamel hypoplasia
  • dental trauma, fractured teeth
  • TMJ disorders and bruxism
  • poor oral hygiene
  • drooling
  • decreased parotid flow rate

Treatment plans must consider the decreased control and function of the upper extremities and limitations of motor skills. The preventive dental program may require involvement of family member or nurse. A seizure disorder and ataxia would be contraindications for removable prostheses and fixed anterior prostheses. Patient may or may not be able to provide consent for dental treatment.

Clinical considerations:

  • patients with severe CP require short appointments
  • patient may have to be transferred from wheel chair to dental chair
  • patients should not be placed in a supine position (to protect airway); can be placed at 45 degrees
  • padding or restraints may be necessary to provide the patient with assistance in cooperating for the procedure
  • dental chair should be moved slowly to prevent spastic muscle responses
  • muscle relaxants can be of benefit
  • sedation, general anesthesia, or hospitalization may be required to provide treatment

Patients with CP may be receiving one or more of the following medications:

  • anti-epileptics

Orthopedic Disorders

Amputation

The person who has had a amputation may have diabetes or vascular disease and should receive a medical evaluation prior to the delivery of dental care. Medications must be reviewed as well.

Patients with upper limb amputations may have difficulty with removable prostheses and oral hygiene

Proper wheelchair transfer technique is essential

Patients who have had an amputation may be receiving one or more of the following medications:

  • antidepressants

Scoliosis

Scoliosis is a lateral curvature of the spine often associated with kyphosis and lordosis. It can exist alone but is sometimes associated with systemic diseases as well as repiratory disease and cardiac abnormalities which should be identified.

Dental treatment is usually not affected by this disorder unless there are cardiac or respiratory problems. Generally the dentist should provide for the physical comfort of the patient in the dental chair.

Cerebrovacular Accident (CVA)

The person who has had a stroke may exhibit a wide variety of motor, cognitive, and sensory deficits as well as confusional states, memory loss, and emotional distress. Lesions of the brain stem may compromise the gag and swallowing reflexes.

The clinician must be aware of the likelyhood of significant coincident medical conditions associated with a stroke and adjust treatment accordingly. These conditions include:

  • cardiovascular disease
  • hypertension
  • diabetes

Medical consultation is often necessary to coordinate care with patient’s needs and limitations

Coumadin levels and prothrombin time may have to be adjusted prior to certain dental procedures.

The treatment plan must consider physical limitations; paralysis often results from CVA.

Patients may be unable to use dentures due to neuromuscular deficits and oral hygiene instructions must be tailored to the patient’s abilites. Patient may not be able to provide consent for dental treatment.

Speech impairments may include:

  • apraxia (coherent but inaprropriate responses)
  • dysarthria (slurred speech due to muscle weakness and poor coordination)
  • aphasia (inability to find words to express oneself)

Swallowing dysfunction (dysphagia) compromises protection of the airway, consider:

  • using the rubber dam
  • limiting handpiece water spray
  • maintain patient in an upright position
  • rapid evacuation of oral fluids

Patients who have had a cerebrovascular accident may be receiving one or more of the following medications;

  • anticoagulants
  • NSAIDs

Seizure Disorder

Epilepsy or seizure disorder is not a disease entity but a manifestation of brain damage that causes abnomal electrical brain activity which may manifest in several ways:

  • varying levels of consciousness
  • altered or lost muscle control
  • violent muscular contractions

A minor or “petit mal” seizure may be characterized by a very brief loss of consciousness or simply a localized twitching of a limb. These seizures last only a few seconds and rarely interfere with daily activites. Major or “grand mal” seizures may result in loss of consciousness (2-5 minutes), convulsive activity with extreme muscle involvement, incontinence, and self injury.

Seizure activity manifested by continued muscular jerking for 10 minutes or more iis known as “status epilepticus” and is an acute medical emergency requiring medical support. If this occurs:

  • maintain the patient’s airway
  • administer diazepam
  • do not attempt to insert any device between a patient’s teeth

Epilepsy is associated with other disabilities such as:

  • cerebral palsy
  • mental retardation
  • psychiatric illnesses

Clinical management includes:

  • identification of type of seizures the patient experiences
  • awareness of trigger factors
  • awareness of the presence of an aura
  • typical post seizure events
  • sedation may help to prevent a seizure during a stressful dental visit
  • staff should be prepared to handle an emergency
  • severe cases may require treatment under general anesthesia

The treatment plan must consider problems with drug-induced gingival overgrowth. Optimal oral hygiene is required to prevent gingival overgrowth. Removable prostheses may be contraindicated if the seizure disorder is not well contolled. If anterior teeth are repeatedly traumatized and repaired; consider acrylic veneers instead of porcelain in fixed prostheses.

Patients who have a seizure disorder may be receiving antiepileptic medications which may cause increased bleeding tendencies, drowsiness, lack of coordination, drug-induced gingival overgrowth, and xerostomia.

Arthritis

Patients with rheumatiod or osteoarthritis may have a disability secondary to changes in their boney joints and may have limited self-care abilities. TMJ involvement may require special attention such as; heat, exercise, antiinflammatory drugs, analgesics, surgery and prosthodontic rehabilitation. Interocclusal relationships can change periodically due to inflammation.

Patient’s with rheumatoid arthritis may also suffer from Sjögren’s Syndrome. The decreased saliva production requires aggressive preventive care.

Patients who have arthritis may be receiving one or more of the following medications:

  • NSAIDs
  • acetominophen
  • corticosteroids

Anti-inflammatory medications and steroids may effect blood clotting and impair healing.

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