Читать книгу A Practical Approach to Special Care in Dentistry - Группа авторов - Страница 130

A patient is considered to have a visual deficit if they have considerable difficulty differentiating objects at a distance of 40 cm even when using the best correction possible. Blindness is defined as the complete absence of vision or slight light perception but not in the form of objects (visual acuity less than 3/60). It is estimated that 124 million individuals worldwide have a severe visual deficit (2% of the population) and that 37 million have blindness (0.6% of the population).

Table 3.1.1 Considerations for dental management.

Risk assessment	Consider risks associated with a related underlying disease (e.g. polymalformative syndromes and diabetes)Unexpected contact, noise, vibration and light can startle the patient and cause unexpected movementsChildren with blindness may have a significantly lower pain threshold
Criteria for referral	Referral to a specialised clinic or hospital centre is rarely required and will be determined by the degree of patient co‐operation or the presence of significant comorbidities (e.g. poorly controlled diabetes)
Access/position	Avoid overprotectivenessAsk before offering assistance (do not attempt to touch the patient without permission)When guiding a patient with blindness, walk half a step in front of them to allow them to hold onto your arm if required (optionally, they can hold onto your shoulder or wrist), on the side opposite to the one holding the caneA patient who uses a guide dog should be asked whether they want to hold on to you or would prefer to follow you (the dog may enter the dental room)While walking to the dental office, information can be provided on the surroundingsUnder no circumstance should the patient's cane or clothing be held, nor should the patient be pushed from behind
Communication	Talk to the patient while looking them in the faceDirectly address the individual with visual deficit and not their companionUse the patient's name so that they are clear you are talking to themIntroduce yourself so that they know who is talking to themLet them know if there are other individuals present in the roomTalk in a normal tone, slowly and clearly; do not shout or raise your voiceBe precise in the messagesDo not use gestures as a substitute for spoken wordsConsent should be written in large font (ideally in Braille for those patients who have complete blindness)
Consent/capacity	Patients of legal age can generally sign the informed consent personallyIt is essential that this form be printed in sufficiently large type or even have a Braille versionIf the patient cannot read, a close family member/friend acting as a witness can read it for them (in some countries, the presence of this witness is mandatory)
Anaesthesia/sedation	Local anaesthesiaSome patients have poor pain tolerance (increased tactile sensitivity)SedationIn the event of glaucoma, benzodiazepines should not be employed to induce conscious sedationGeneral anaesthesiaFor patients with glaucoma who require general anaesthesia, avoid using atropine
Dental treatment	BeforeConsider the use of audio aids which the patient can access at home to remind them of the planned treatmentAllow the patient to touch the chair and equipmentExplain all the dental procedures that will be performedThe ‘tell–feel (physical contact)–do’ technique can be usefulBefore planning rehabilitation with a removable prosthesis, ensure that the patient is sufficiently able to recognise, insert and remove the prosthesisWhen planning for prostheses, consider that some patients with visual deficit do not tolerate muco‐supported prostheses wellFor selected patients, orthodontic treatments can be performed (including multibracket appliances) to improve function and aesthetics if this is a concernDuringWarn the patient if you need to leave the dental office and when you will returnThroughout the procedure, warn the patient of each manoeuvre that will be performed, explaining in advance anticipated contact, noise, vibration and lightExercise particular caution with rotary instrumentation and injectionsReinforce positive behavioursAfterThe success of fixed prostheses can be affected by poor oral hygieneReinforce positive behavioursPostoperative instructions should be written in large font (ideally in Braille for complete blindness) or provided in an audio format
Drug prescription	For patients with glaucoma, anticholinergic agents (such as atropine, scopolamine and glycopyrrolate, which are prescribed to control drooling), carbamazepine, diazepam, corticosteroids and tricyclic antidepressants are contraindicated
Education/prevention	Audio, tactile and supervised training techniques and instructions in Braille are useful for improving the oral hygiene of those with visual deficits (whose motivation is usually magnified)These modified approaches to educational programmes on oral health promotion have demonstrable efficacyElectric toothbrushes can be more effective than manual toothbrushes as long as the vibration is tolerated

Figure 3.1.3 Orthodontic treatment for a patient with visual impairment.