1. Protecting All Children’s Teeth
Special Needs

2. Introduction
Paper Permission on file from Joe Martinez
Approximately 18% of US children and youth have a special health care need. Many of these conditions, including mental retardation, developmental disabilities, cerebral palsy, craniofacial abnormalities, and seizure disorders, can impact a child’s oral health. By understanding the potential barriers to oral health care and the consequences of poor oral health in children with special health care needs, health professionals can identify at-risk patients early, provide anticipatory guidance, refer to appropriate dental professionals, and assist patients and families in overcoming barriers to accessing and utilizing care.
Notes:
The federal Maternal and Child Health Bureau's Division of Services for Children With Special Health Care Needs established a work group that redefined children with special health care needs in the following terms: “Children with special health care needs are those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.”
This definition was adopted by the American Academy of Pediatrics in 1998.

3. Learner Objectives
Paper Permission on file from Joe Martinez
Upon completion of this presentation, participants will be able to:
Recall that dental care is the most common unmet need among the special needs population.
List barriers to accessing dental care
State reasons why children with special health care needs (SCHN) are at increased risk for caries.
Complete the oral health examination checklist at routine visits.
Assist families in addressing oral hygiene concerns and suggest techniques for optimizing oral care in children with special needs.
Discuss appropriate timing of referral to a pediatric dentist and list conditions that mandate early referral.

4. Access to Care
For children with special health care needs, access to care may be limited. In the United States, dental care is the most common unmet need in the special needs population. Children with special needs are twice as likely than their aged-matched peers to not have their dental needs met.*
Families encounter greater difficulty obtaining needed dental care for children with certain diagnoses, including Down syndrome, other forms of mental retardation, cerebral palsy, and autism.
Notes: *According to the National Health Interview Survey. Access the survey at
References:
Lewis CW. Dental Care and Children with Special Health Care Needs: A Population-Based Perspective. Academic pediatrics
Lewis CW, Robertson AS, Phelps S. Unmet dental care needs among children with special health care needs: implications for the medical home. Pediatrics, : e426–e431
van Dyck PC, Kogan MD, McPherson MG et al. Prevalence and Characteristics of Children with Special Health Care Needs. Arch Pediatric Adolesc Med. 2004; 158(9):

5. Access to Care
Children with special health care needs may face the following barriers to accessing oral health care:
• Transportation or physical access to the building 
• Financial strain, especially with multiple visits or costly restorative work
• Insurance coverage
• Difficulty finding a dentist who will see children with special health care needs
If a child has numerous medical concerns, families may consider oral health a lower priority.
Notes: Most insurance companies pay only a portion of restorative work, leaving families with private insurance responsible for a large fee. 
Reference: Casamassimo P, Seale S, Ruehs K. General dentists’ perceptions of educational and treatment issues affecting access to care for children with special health care needs. J Dent Educ. 2004; 68(1):23–28.

6. Caries Risk
Children with special health care needs are at increased risk for developing caries for the following reasons: 1. Diet
2. Xerostomia
3. Difficulties performing oral hygiene
4. Gastroesophageal Reflux Disease and vomiting
5. Gingival hyperplasia and crowding of the teeth
6. Medications containing sugar
Notes:
Many children require prolonged or frequent feedings or a special diet that is cariogenic.
Decreased saliva production increases the risk of caries and is usually secondary to a medication. Medications containing sugar that cannot be timed with meals are additional sugar exposure to the teeth.
Difficulties performing oral hygiene is more common in children with neuromuscular conditions or cognitive disability (children remain dependent on a caregiver to perform proper oral health hygiene); oral aversion and behavioral concerns (children who cannot cooperate with regular oral hygiene practices are at risk for dental decay and infection); or difficulty swallowing and oral motor hypotonicity (both interfere with the cleaning of oral surfaces).
Regular acid exposure to the teeth can cause enamel wear and increase the likelihood of dental decay.
To minimize iatrogenic effects, clinicians should carefully consider medication side effects and select sugar-free preparations and medications that do not inhibit saliva production whenever feasible.
Glossary: Hyperplasia: An abnormal or unusual increase in the elements composing a part (as cells composing a tissue) Xerostomia: Abnormal dryness of the mouth due to insufficient saliva production

7. Caries Risk, continued
In children with special health care needs, uncoordinated chewing may leave more food in the mouth.
A weak, uncoordinated tongue may not be able to adequately clean all oral surfaces.
Gagging on the toothbrush, paste, or saliva may inhibit complete brushing of all surfaces.
An inability to spit may result in the swallowing of toothpaste.

8. Neonatal Tooth Eruption with Riga Fede Ulceration of the Tongue
Tooth eruption may be delayed,
normal, or advanced in children
with special health care needs. Delayed eruption is more
common in children with Down
syndrome and hypothyroidism.
Neonatal Tooth Eruption with Riga Fede Ulceration of the Tongue
Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke Pediatric Dentistry, Duke Children's Hospital

9. Malocclusion and Crowded Teeth
Anterior Crossbite
Malocclusion and crowded teeth occur
more often in children with abnormal
muscle tone (cerebral palsy), mental
retardation, and craniofacial
abnormalities. Crowded teeth are more difficult to
clean, thereby increasing the risk of
dental caries and periodontal disease.
Glossary: Malocclusion: An abnormality in the coming together of teeth
Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke Pediatric Dentistry, Duke Children's Hospital

10. Dental Anomalies Teeth may vary in shape, size, or number.
Dental anomalies are a cosmetic concern and may increase the risk for caries.
Notes:
Many syndromes are accompanied by tooth anomalies including anodontia, hypodontia, or supernumary teeth.
Tooth defects, including enamel hypoplasia and discoloration, may be the result of genetic conditions or fetal medication exposure.
Glossary:
Anodontia: An especially congenital absence of teeth Hypodontia: A congenital condition marked by a less than normal number of teeth; partial anodontia Enamel: Intensely hard calcareous substance that forms a thin layer partly covering the teeth; the hardest substance of the animal body; consists of minute prisms arranged at right angles to the surface and bound together by a cement substance Hypoplasia: A condition of arrested development in which an organ or part of an organ remains below the normal size or in an immature state

11. Gingival Hyperplasia Gingival hyperplasia usually occurs
in children taking anti-epileptic
medications for seizures, especially
phenytoin.
Medications causing hyperplasia:
• Phenytoin
• Calcium channel blockers (nifedipine)
• Cyclosporin A
Chronic gingivitis from poor hygiene
can also trigger or exacerbate
medication induced gingival overgrowth.
Glossary:
Hyperplasia: An abnormal or unusual increase in the elements composing a part (as cells composing a tissue).
Gingivitis: Inflammation of the gums
Used with permission from Rocio B. Quinonez, DMD, MS, MPH; Associate Professor Department of Pediatric Dentistry, School of Dentistry University of North Carolina

12. Gingival Hyperplasia
In addition to the cosmetic concern, gingival hyperplasia puts children at risk for:
• Poor oral hygiene
• Impaired tooth eruption
• Difficulty chewing
• Severe gingivitis
Treatment includes: • Meticulous hygiene
• Discontinuing the offending medication
• Gingivectomy if severe
Glossary:
Hyperplasia: An abnormal or unusual increase in the elements composing a part (as cells composing a tissue).
Gingivitis: Inflammation of the gums 12

13. Trauma Trauma to the face and mouth occurs more frequently in
children with seizures,
developmental delays, poor
muscle coordination, and
abnormal protective reflexes. Some children with special
needs exhibit self-injurious
behavior, which may damage
oral structures.
Used with permission from Rocio B. Quinonez, DMD, MS, MPH; Associate Professor Department of Pediatric Dentistry, School of Dentistry University of North Carolina

14. Bruxism Bruxism is more common and often more severe in children
with cerebral palsy or severe mental retardation.
Bruxism may lead to enamel loss and difficulty with chewing or
tooth sensitivity. Children with suspected bruxism should be referred to a
pediatric dentist for evaluation.
Notes:
More information about bruxism is available online at
Glossary:
Bruxism: The habit of unconsciously gritting or grinding the teeth especially in situations of stress or during sleep

15. Problems With Oral Care
Children with special health care needs may not be able to
fully cooperate with oral hygiene practices due to gagging,
oral defensiveness, or behavioral issues They may also have difficulty tolerating fluoride liquid,
toothpaste, varnish, sealants, or other caries prevention
strategies

16. Daily Preventive Care
Daily home preventive dental care may have to be tailored to meet the specific needs of the child
This is often best addressed by the dental and other health professionals involved in caring for the child
Patients with SHCN who have a dental home are more likely to receive appropriate preventive and routine care
Notes:
Caregivers should be encouraged to discuss their concerns with the pediatric dentist and the occupational or speech therapists. They may be able to help
the family with techniques to optimize oral care.
References:
Guideline on Management of Dental Patients with Special Health Care Needs. American Academy of Pediatric Dentistry Clinical Guidelines, Council on Clinical Affairs; 2012, Pediatr Dent; 35(6): Available online at: Accessed Nov 11th, 2013.
American Academy of Pediatric Dentistry. Policy on dental home. Pediatr Dent. 2012;34(special issue):24-5.

17. Used with permission from Guisy Romano-CLarke
Toothbrushing
If there are concerns about swallowing toothpaste, families should minimize the amount of toothpaste used (a smear, less than a pea-sized amount) or use a non-fluoridated toothpaste.
Notes:
For additional suggestions on toothbrush adaptations, flossing tips, and brushing positions, review A Guide to Good Oral Health for Persons with Special Needs
at:
Used with permission from Guisy Romano-CLarke
If gagging is triggered by toothpaste, the teeth can be brushed with fluoride mouthrinse.

18. Toothpaste Amounts
“Smear”
“Pea-sized” 18

19. Toothbrushing
For older patients with limited dexterity, consider the following options:
An electric or battery-powered toothbrush
Extending the brush handle with a tongue depressor
Widening the brush handle (wrapping it with a sponge)
Using a mouth prop for brushing
Notes:
For additional suggestions on toothbrush adaptations, flossing tips, and brushing positions, review A Guide to Good Oral Health for Persons with Special Needs at

20. Dental Office
Children with special health care needs may require sedation even for routine cleanings, restorative procedures, and minimal oral surgery. If there is concern about a child’s cooperation or ability to tolerate oral manipulation, consider referral to a pediatric dentist or a specialist with training in sedation.
Notes:
Sedation options include local anesthesia, nitrous oxide, oral conscious sedation, and general anesthesia.
Paper Permission on file from Joanna Douglass, BDS, DDS

21. Pediatric Office Screening
Oral examination may be more difficult in a child with special health care needs. The primary care physician should make increased efforts to complete an examination checklist. Early referral to a dental professional comfortable treating children with SHCN (typically a pediatric dentist) will help ensure the oral examination is complete and all issues are addressed.
Paper Permission on file from Mayra Patino

22. Examination Checklist
The oral examination of a child with special needs is
similar to the routine child oral examination. Oral defensiveness, increased gag reflex, and oral
motor hypotonicity may make the examination more
difficult and should be documented.

23. Examination Checklist, continued
Practitioners should examine
the following areas and
document abnormalities:  
Oral-facial anomalies
Teeth  
Gingiva
Palate
Cleft Lip
Notes:
Oral-facial anomalies include cleft palate, micrognathia, and oral injuries. 
When examining teeth, practitioners should also examine for enamel hypoplasia or demineralization, malocclusion, or missing or abnormally shaped teeth and evaluate the pattern of tooth eruption. Dental caries and its severity should be documented.
Poor gingival health can be identified by examining for erythema, swelling, bleeding, and hyperplasia.
Glossary:
Cleft Palate: Congenital fissure of the roof of the mouth produced by failure of the two maxillae to unite during embryonic development and often associated with cleft lip
Enamel: Intensely hard calcareous substance that forms a thin layer partly covering the teeth; the hardest substance of the animal body; consists of minute prisms arranged at right angles to the surface and bound together by a cement substance Hypoplasia: A condition of arrested development in which an organ or part of an organ remains below the normal size or in an immature state Malocclusion: An abnormality in the coming together of teeth Hyperplasia: An abnormal or unusual increase in the elements composing a part (as cells composing a tissue).
Used with permission from David A. Clark, MD; Chairman and Professor of Pediatrics at Albany Medical Center

24. Referrals
All children with special health care needs fall into a high risk
category and should be referred to a dentist by 1 year of age.
Any child with evidence of caries or tooth, gingival, or eruption
anomalies should be immediately referred to a dentist who is
comfortable caring for children with special needs.
Notes:
For a complete review of the management of oral health in the special needs population, refer to Special Care: An Oral Health Professional’s Guide to Serving Young Children with Special Health Care Needs at
Reference: American Academy of Pediatrics Policy Statement. Oral health Risk Assessment Timing and Establishment of the Dental Home. Pediatrics. 2003; 111(5): Available online at: Accessed Nov 11th, 2013.

25. Dental Insurance Dental insurance coverage may be a problem for some
children who have special health care needs. Most of these children qualify for Medicaid, which automatically
qualifies them for comprehensive oral health services through
the Early and Periodic Screening and Diagnostic and Treatment
(EPSDT) program.
Notes:
Some states have age minimums that do not correspond to the American Academy of Pediatrics and the American Academy of Pediatric Dentistry guidelines for referral and examination.
Learn more about the Early and Periodic Screening and Diagnostic and Treatment (EPSDT) program at

26. Question #1 Which of the following is not a risk factor for caries in
children with special needs?
A. Bruxism
B. Gastroesophageal Reflux Disease.
C. Xerostomia from the use of certain medications.
D. A special diet that is often cariogenic.
E. Oral motor hypotonicity.

27. Answer Which of the following is not a risk factor for caries in
children with special needs?
A. Bruxism
B. Gastroesophageal Reflux Disease.
C. Xerostomia from the use of certain medications.
D. A special diet that is often cariogenic.
E. Oral motor hypotonicity.

28. Question #2 You inform the family of a child with special needs that
the presence of gingival hyperplasia may put the child
at risk for which of the following:
A. Premature tooth loss.
B. Severe gingivitis.
C. Increased likelihood of tooth-grinding.
D. Increased risk of tooth injury from oral trauma.
E. All of the above.

29. Answer You inform the family of a child with special needs that
the presence of gingival hyperplasia may put the child
at risk for which of the following:
A. Premature tooth loss.
B. Severe gingivitis.
C. Increased likelihood of tooth-grinding.
D. Increased risk of tooth injury from oral trauma.
E. All of the above.

30. Question #3 Which of the following methods will help to prevent
children with special needs from swallowing
toothpaste?
A. Using less than a pea-sized amount of toothpaste.
B. Brushing the teeth with plain water.
C. Using a non-fluoridated toothpaste.
D. Using an electric or battery-powered toothpaste for children with limited dexterity.
E. All of the above.

31. Answer Which of the following methods will help to prevent
children with special needs from swallowing
toothpaste?
A. Using less than a pea-sized amount of toothpaste.
B. Brushing the teeth with plain water.
C. Using a non-fluoridated toothpaste.
D. Using an electric or battery-powered toothpaste for children with limited dexterity.
E. All of the above.

32. Question #4 True or False? For a child with special health care
needs, early referral to a pediatric dentist will help to
ensure the oral examination is complete.
A. True
B. False

33. Answer True or False? For a child with special health care needs,
early referral to a pediatric dentist will help to ensure
the oral examination is complete.
A. True
B. False

34. Question #5 Based on the AAP risk group designations, by what age
should children with special health care needs be
referred to a dentist?
A. 6 months
B. 9 months
C. 12 months
D. 18 months
E. 24 months

35. Answer Based on the AAP risk group designations, by what age
should children with special health care needs be
referred to a dentist?
A. 6 months
B. 9 months
C. 12 months
D. 18 months
E. 24 months

36.
References
American Academy of Pediatric Dentistry. Policy on dental home. Pediatr Dent. 2012;34(special issue):24-5.
American Academy of Pediatrics Policy Statement. Oral health Risk Assessment Timing and Establishment of the Dental Home. Pediatrics. 2003; 111(5): Available online at: Accessed Nov 11th, 2013.
Barzel R, Holt K, Isman B et al. Special Care: An Oral Health Professional’s Guide to Serving Young Children with Special Health Care Needs. Available online at: Accessed Nov 11th, 2013.
Casamassimo P, Seale S, Ruehs K. General dentists’ perceptions of educational and treatment issues affecting access to care for children with special health care needs. J Dent Educ. 2004; 68(1):23–28.
Guideline on Management of Dental Patients with Special Health Care Needs. American Academy of Pediatric Dentistry Clinical Guidelines, Council on Clinical Affairs; 2012, Pediatr Dent; 35(6): Available online at: Accessed Nov 11th, 2013.
Lewis CW. Dental Care and Children with Special Health Care Needs: A Population-Based Perspective. Academic pediatrics
Lewis CW, Robertson AS, Phelps S. Unmet dental care needs among children with special health care needs: implications for the medical home. Pediatrics, : e426–e431

37. References, continued
McPherson M, Arango P, Fox H et al. Commentary: A New Definition of Children With Special Health Care Needs. Pediatrics. 1998; 102(1): 137 –139.
Newacheck PW, McManus M, Fox HB et al. Access to Health Care for Children With Special Health Care Needs. Pediatrics. 2000; 105(4):
Newacheck PW, Strickland B, Shonkoff JP, et al. An Epidemiologic Profile of Children With Special Health Care Needs. Pediatrics. 1998; 102(1):
Perlman SP, Friedman C, Kaufhold GH. Special Smiles: A Guide to Good Oral Health for Persons with Special Needs. Available online at: Accessed Nov 11th, 2013.
van Dyck PC, Kogan MD, McPherson MG et al. Prevalence and Characteristics of Children with Special Health Care Needs. Arch Pediatric Adolesc Med. 2004; 158(9):