Oral health care for patients with special needs

British Medical Journal, August 19, 2000 by Roger Davies, Raman Bedi, Crispian Scully

People with special needs are those whose dental care is complicated by a physical, mental, or social disability. They have tended to receive less oral health care, or of lower quality, than the general population, yet they may have oral problems that can affect systemic health. Improving oral health for people with special needs is possible mainly through community based dental care systems. Education of patients and parents or carers with regard to prevention and treatment of oral disease must be planned from an early stage. This will minimise disease and operative intervention since extractions and surgical procedures in particular often produce major problems. Dental healthcare workers also often need to be educated about this subject.

In this context various conditions can lead to people needing special care, not least patients with dental phobias. Many of these patients can be treated with behavioural modification techniques, though a minority will require sedation or general anaesthesia.

This article concentrates on those who are medically compromised, mentally challenged, mentally ill, or socially excluded.

Medically compromised patients

The commonest problems are in patients with a bleeding tendency or cardiovascular disease, or who are immunocompromised.

Bleeding disorders

Dental extractions and surgical procedures, including local analgesic injections, can cause problems in patients treated with anticoagulant drugs and those with coagulation defects or severe thrombocytopenic states.

With patients treated with anticoagulant drugs, local analgesia and minor surgery (simple extractions of two or three teeth) may generally be carried out safely in general practice with no change in treatment if test results are within the normal therapeutic range (international normalised ratio [is less than] 3). The same is true for patients with thrombocytopenia if the platelet count exceeds 50 x [10.sup.9]/1. Postoperatively, a 4.8% tranexamic acid mouthwash, 10 ml used four times daily for a week, may help.

In all but severe cases of haemophilia, non-surgical dental treatment can be carried out on haemophilic patients under antifibrinolytic cover (tranexamic acid), though care must be taken to maintain urinary flow to avoid urinary blood clot problems. Haematological advice must be sought before other procedures are undertaken. With mild haemophilia, minor oral surgery may be possible under desmopressin (DDAVP) cover. In other cases factor replacement is necessary.

Cardiovascular disease

Ischaemic heart disease

It is generally accepted that routine dentistry for most patients with ischaemic heart disease should be undertaken using short appointments and under local analgesia. More complex surgical procedures should be carried out in hospital with full cardiac monitoring. Elective dental care for patients who have recently had a myocardial infarct should be deferred for at least three months, and some recommend a delay of 12 months.

Cardiac pacemakers

The chief hazards from dental equipment to pacemakers are from electrosurgery and diathermy, but these are infrequently used and the risk from other equipment such as ultrasonic scalers or pulp testers is very small.

Cardiac valvular defects

Tooth extractions and dental procedures involving the periodontium can produce a bacteraemia of oral microorganisms, especially Streptococcus mutans and S sanguis, which can lead to infective endocarditis in patients at risk. However, dental treatment precedes only 10-15% of diagnosed cases, and in real terms the risks are thought to be fairly remote.

Oral health care (including maintaining high levels of oral hygiene) should be completed before valvular surgery. It is considered prudent to provide antibiotic cover for patients at risk who are about to have extractions, periodontal surgery, mucogingival flaps raised (oral surgery), scaling, tooth reimplantation, or other procedures where there is gingival laceration. However, there is no convincing evidence for the need for antibiotic prophylaxis for most local analgesic injections or for non-surgical, prosthetic, restorative, or orthodontic procedures other than banding or debanding.

The current basic recommendations are to use a chlorhexidine mouthwash and, one hour before the dental procedure, a single oral dose of 3 g of amoxicillin (or 600 mg clindamycin for patients allergic to penicillin). Patients with a history of infective endocarditis require intravenous antibiotic prophylaxis.

Immunocompromised patients

Oral diseases in immunocompromised people tend to be more common with poor oral hygiene, malnutrition, and tobacco use. The commonest lesions are candidiasis and herpes viral infections, but others include ulcers, periodontal disease, and malignant neoplasms. Purpura and spontaneous gingival bleeding also are seen in patients with leukaemia. Drugs such as ciclosporin can cause gingival swelling.

Oral lesions in patients with HIV infection or AIDS are most likely to appear when the CD4 cell count is low and are often controlled, at least temporarily, by antiretroviral treatment. Anti-HIV drugs can cause oral problems such as ulcers, xerostomia, and salivary gland swelling. Oral features are now classified as strongly, less commonly, or possibly associated with HIV infection.