Читать книгу A Practical Approach to Special Care in Dentistry - Группа авторов - Страница 111

 The treatment plan will be determined by the patient's oral manifestations, degree of co‐operation and the presence of comorbidities (Table 2.3.1; Figure 2.3.5)

 Orthodontic therapy can be performed in selected casesTable 2.3.1 Considerations for dental management.Risk assessmentPostoperative infections (immunological deficiencies)Risk of bacterial endocarditis (congenital heart disease)Variable co‐operationSpeech disorders and intelligibilityHearing lossAtlantoaxial instabilityCriteria for referralMost patients can be treated in a conventional dental clinicReferral to a specialised clinic or hospital centre is determined mainly by the patient's co‐operation and extent of comorbidities (e.g. severe heart disease)Access/positionPrevent neck hyperextension (atlantoaxial instability)Access to the teeth may be impeded by lingual protrusionMinimise waiting timeConsider shorter sessionsCommunicationAdapt in relation to cognitionIf hearing aids are worn, ensure these are present and switched on at the dental appointmentsConsent/capacityCapacity assessment is required (should be decision specific)Discussion of risks should include those related to comorbidities (e.g. predisposition to infections) and the level of oral hygieneDementia may occur at an early age and have an additional impact on reducing capacityAnaesthesia/sedationLocal anaesthesiaThis may be challenging to administer in relation to patient co‐operation, altered anatomy and lingual protrusionSedationThe nasal hood used for inhalational sedation may not fit well due to hypoplasia of the mid‐third of the faceAssociated comorbidities should be assessed, including the degree of hypotonia, associated cardiac disease and respiratory dysfunctionGeneral anaesthesiaDifficulties in endotracheal intubation (hypoplasia of the middle third of the face, short neck, adenoid hypertrophy, atlantoaxial subluxation)Increased risk due to cardiac complications (due to underlying heart disease and/or anaemia), respiratory dysfunction and infections (increased susceptibility)Dental treatmentBeforeEarly periodontal treatment and the use of adjuvant antimicrobial mouthwashes are effective in improving periodontal healthPulpal treatments in primary dentition are not recommendedThe prognosis for orthodontic therapy is determined by the patient's degree of collaboration, the level of oral hygiene, the presence of parafunctions and the state of the periodontiumRehabilitation with fixed prosthesis can be performed if the oral hygiene is optimal, the dental morphology is appropriate and the periodontal state is acceptable; otherwise, opt for a removable prosthesis (not always well accepted by patients)Stimulating palatal plaques combined with orofacial physical therapy and speech therapy exercises improves muscle tone and orofacial abnormalitiesDuringConsider the use of tongue guards, supplemented by high‐volume suction to improve vision/access to the dentitionAfterOrthodontic treatments, with both removable and fixed multibracket appliances, usually take longer than in the general population (slow activation rhythm), and complications are more frequent (particularly traumatic ulcers)The prognosis for dental implants in these patients is poorer than in the general population, with an estimated failure rate of 20% (generally, the losses occur before completing the prosthetic rehabilitation)Drug prescriptionConsider drug interactions with medications used to treat comorbidities (e.g. avoid macrolide antibiotics for patients taking antihypertensives such as verapamil/diltiazem)Education/preventionOral hygiene educationInvolve the relatives and care‐giversIncreased frequency of reviews (every 3 months) to closely monitor periodontal diseasePeriodic calculus removalDietary counselling