Читать книгу A Practical Approach to Special Care in Dentistry - Группа авторов - Страница 93

 Poor communication and interpersonal skills may be misinterpreted as disruptive behaviour

 Pharmacological adjuncts may be required, with some patients requiring general anaesthesia to deliver dental treatment safely

 An individualised approach is required to enable delivery of dental care (Table 2.2.1; Figures 2.2.3 and 2.2.4)Table 2.2.1 Considerations for dental management.Risk assessmentVariable behaviour/presentation (requires an individualised approach)Stereotypy/uncontrolled movementsRepetitive routines/activitiesSelf‐aggression, particularly when distressedIntolerance for physical contact, noise, vibration, bright lights, strong taste/smellsHigh sensitivity to pain (may not respond when testing for pain/pulp vitality)Criteria for referralMany patients can be treated in a conventional dental clinic, although they generally need several prior desensitisation sessionsReferral to a specialised clinic or hospital centre is indicated mainly by the degree of co‐operation and hence pharmacological adjuncts required, and/or the extent of the treatment needsAccess/positionThe presence of a family member/carer is desirable to give the patient reassurance and to also give guidance to the dentistArrange acclimatisation visits, ensuring that a predictable routine is followed with the same dental clinic and dentistMinimise waiting timeShort sessionsCommunicationIn many cases, both verbal and non‐verbal communication is impairedKeep language and sentences simple – avoid metaphors, humour may be misunderstoodAllow extra time to process informationDesensitisation in school or at home with visual and manual support may be helpfulUse of pictogramsSimulation of proceduresRepetition of ordersTell–show–do and immediate positive/negative reinforcement techniques can be useful Consent/capacityCapacity assessment is required as some patients can make informed decisions (e.g. Asperger syndrome)If capacity is confirmed as being impaired, a best interest decision is required, involving the patient's parents or guardiansThe consent process/best interest discussion should include the possibility of unexpected reactions to certain stimuli (e.g. pain and noise)Anaesthesia/sedationLocal anaesthesiaPain tolerance may be present and local anaesthesia may be avoided in some procedures (e.g. some filings)Acclimatisation with the same process being repeated may be effectiveIf local anaesthesia cannot be given safely, alternative approaches should be consideredSedationThe effectiveness of conscious sedation is unpredictable (paradoxical effect may occur)Inhalational sedation with nitrous oxide and oxygen may not be accepted due to use of the nasal hood/contact with the faceGeneral anaesthesiaMay be required for patients needing complex dental treatment and those where sedation is not effectiveA single side room rather than a bed on an open ward is preferableA day‐stay modality is desirableDental treatmentBeforeIndividualised risk assessment required to identify potential triggers that can cause distressConsider the possibility of pain insensitivityDuringIn the event of intolerance to the noise of the rotary instrumentation, chemical–mechanical caries removal techniques may be employed – headphones may also helpThe dental chair light may also not be tolerated – dark patient glasses may help; alternatively, consider fibreoptic handpieces and/or smaller light sourcesTerminate the appointment if the patient demonstrates signs of anxiety/stress as this can quickly escalate to challenging behaviourAfterArrange another appointment, ideally at the same time, with the same dentist and in the same dental officeDrug prescriptionPatients taking selective serotonin reuptake inhibitors (SSRIs) may not experience adequate pain relief from codeine or its derivatives (SSRIs inhibit several families of hepatic enzymes, which may delay the biotransformation to the active metabolite of codeine)Education/preventionInvolve the relatives and caregivers where requiredUse pictogramsConsider that some patients cannot tolerate electric toothbrushes due to the noise and vibrationConsider the use of flavour‐free/mild‐flavoured toothpastes and mouthwashes; non‐foaming toothpastes may also be better acceptedDietary counsellingFigure 2.2.3 Desensitisation with visual support may be helpful.Figure 2.2.4 A visual timer may improve co‐operation.