Oral Health Considerations for Children with Special Health Care Needs (CSHCN)

The term Children with Special Health Care Needs (CSHCN) is used by most governmental agencies to serve children who have or are at increased risk of having a variety of physical, developmental, behavioral or emotional conditions. The California First Smiles Project is committed to assuring that its training and educational materials emphasize assurance of oral health for all infants and young children, including those with special health care needs, and to promoting use of people first language among health care providers.

What Are the Issues?

Oral diseases can exacerbate certain health conditions, especially in children with systemic diseases. Likewise, certain diseases and conditions can create or exacerbate oral health problems. More than 80 craniofacial syndromes have been identified that can affect oral development. Certain oral motor abnormalities or exaggerated reflexes; special diets or poor dietary practices; frequent use of medications that contain sugar, reduce salivary flow or create gingival overgrowth--all can place a child at high risk for dental caries or periodontal disease. Parents may encounter problems trying to care for their childs oral health if there are behavioral problems, reflexes that interfere with toothbrushing, or medical conditions that require frequent hospitalizations or special precautions.

Many general dentists lack the educational preparation to confidently manage children with special health care needs. This situation can create delays and added expenses for families, especially those in rural areas, if they need to seek specialty dental services that may have long waiting lists or may be located far away. Increased training efforts in California through various childrens hospitals, residency programs, dental schools and professional societies are attempting to address this problem.

Roles for Health Professionals

The following list covers general recommendations. More detailed information for specific conditions, oral health problems, and coordination of care is included in the resource links on the next page.

• Perform a comprehensive oral health risk assessment as part of a general risk assessment/health interview with the parents. Ask important questions about 1) fluoride sources, 2) bottle and/or breastfeeding practices and any special diets, and 3) oral hygiene care. Review any medications youve recommended for sugar content or oral side effects.
• Examine the childs mouth for developmental problems (especially if there are other developmental problems or delays), oral hygiene status, chalky white spots on the teeth that indicate the beginning stages of dental decay, cavitated areas of dental decay, soft tissue lesions and oral injuries. This can be done with the child on an exam table or in a wheelchair, or in a parents lap with the head reclined in your lap as you are seated facing the parent in a knee-to-knee position. Order infant and child-size toothbrushes for your practice, especially ones with slightly larger handles. Removal of plaque is essential for oral health. Ask the parents to demonstrate how they brush their childs teeth, noting any problems they have and suggesting some solutions. Fluoride varnish can be applied at this time as well. Brushes are also useful for the oral inspection.
• Provide anticipatory guidance (counseling), discuss any areas of concern and answer questions, refer the child for regular dental care if that has not been started, and discuss the importance of a dental home. The parents may need supportive services for finding and paying for dental care. The dental office may want a consultation about the childs health history or medications.
• During subsequent visits, remember to check the childs oral health status, update risk factor information, reapply fluoride varnish if indicated, make sure the child has a dental home, ask how home oral care is progressing, and provide additional anticipatory guidance. Help these children achieve optimal oral health so they have one less special need to manage.

Resources

First Smiles Project website: http://www.first5oralhealth.org. Includes handouts used in First Smiles training courses and other resources. There is a section for the Medical Team.

National Institute for Dental and Craniofacial Research: Oral Conditions in Children with Special Needs: A Guide for Health Care Providers (2006): fact sheet with full color photographs of oral conditions, each accompanied by a paragraph of descriptive text and a recommendation for health professionals who encounter the condition. http://www.nidcr.nih.gov/HealthInformation/DiseasesAndConditions/ChildrensOralHealth/OralConditionsinChildrenwithSpecialNeeds.htm.

National Maternal and Child Oral Health Resource Center, Georgetown University:

• A Health Professionals Guide to Pediatric Oral Health Management (2005): 7 self-contained online modules with a focus on infants and young children, including prevention of oral disease, oral conditions and abnormalities, and an entire module on children with special health care needs. http://www.mchoralhealth.org/PediatricOH/index.htm.
• Special Care: An Oral Health Professionals Guide to Serving Young Children with Special Health Care Needs (2006): 5 self-contained online modules that address unique oral health needs in a comprehensive, family-centered, and community-based manner; health professionals will benefit from reviewing the material and are encouraged to refer dental colleagues to the online course. http://www.mchoralhealth.org/SpecialCare/.
• Bright Futures in Practice Oral Health Pocket Guide (2005): designed to help health professionals implement specific oral health guidelines during pregnancy and postpartum, infancy, early childhood, middle childhood, and adolescence; includes considerations for children with special health care needs. http://www.mchoralhealth.org/pocket.html for downloading or ordering copies.
• Oral health for children and adolescents with special health care needs: Challenges and opportunities (2005): 2-page fact sheet. http://www.mchoralhealth.org/PDFs/SHCNfactsheet.pdf
• Strategies for improving the oral health system of care for children and adolescents with special health care needs (2005): 4-page fact sheet. http://www.mchoralhealth.org/PDFs/SHCNtipsheet.pdf.
• Oral health services for children and adolescents with special health care needs: Resource guide (2005): Guide is divided into three sections, including 1) journal articles; 2) books, reports, curricula, manuals, modules, guidelines, papers, fact and tip sheets, CD-ROMs; and 3) agencies and organizations that may serve as resources. http://www.mchoralhealth.org/PDFs/SHCNResGuide.pdf

University of the Pacific School of Dentistry, Pacific Center for Special Care: http://www.pacificspecialcare.org/. The Center promotes a community-based approach to oral care; although most resources are for dental professionals and caregivers, there are a number of resources and task forces that will interest other health professionals.

First Smiles Project, Dental Health Foundation, 2006