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 <3). The same is true for patients with thrombocytopenia if the platelet count exceeds 50×109/l. 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.
In patients with bleeding disorders• Surgery can be hazardous in bleeding states• Haemophilic patients need factor replacement before most surgery• Patients treated with anticoagulant drugs can usually safely undergo minor procedures if the international normalised ratio < 3• Thrombocytopenic patients can usually safely undergo minor procedures if platelet count is over 50 × 109/l • Tranexamic mouthwashes used postoperatively may help haemostasis• Good oral care and hygiene are essential
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.
In patients with cardiac valvular defects• Good oral care and hygiene are essential• Oral healthcare screening and treatment should be completed before valvular surgery• Antimicrobial prophylaxis is indicated before invasive dental procedures
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.
WHO classification of oral lesions in HIV infection and AIDS
Group I. Lesions strongly associated with HIV infection
| • Candidiasis | • HIV-gingivitis |
| Erythematous | • Necrotising ulcerative gingivitis |
| Hyperplastic | • HIV-periodontitis. |
| Thrush (pseudomembranous) | • Kaposi's sarcoma |
| • Hairy leucoplakia (Epstein-Barr virus) | • Non-Hodgkin's lymphoma |
Group II. Lesions less commonly associated with HIV infection
| • Atypical ulceration (oropharyngeal) | • Viral infections (except Epstein-Barr virus) |
| • Idiopathic thrombocytopenic purpura | Cytomegalovirus |
| • Salivary gland diseases | Herpes simplex virus |
| • Dry mouth | Human papillomavirus (wart-like lesions)—condyloma acuminatum, focal epithelial hyperplasia, verruca vulgaris |
| Unilateral or bilateral swelling of major salivary glands | • Varicella-zoster virus—herpes zoster and varicella |
Group III. Lesions possibly associated with HIV infection.
Miscellany of rare diseases
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.
Candidiasis
Thrush and erythematous candidiasis are common in patients with immune defects and are often an early manifestation of the immunodeficiency. There is an increase, especially in those with HIV infection or AIDS, in antifungal resistance of Candida albicans and in non-albicans species such as C krusei and new species such as C dubliniensis and C inconspicua. Fluconazole in high doses, however, is often still effective.
Viral infections
Herpesviruses, especially herpes simplex virus, may cause herpes labialis, or oral or perioral ulcers. Hairy leucoplakia, a common corrugated (or “hairy”) white lesion, is usually seen in HIV infection or AIDS but may be seen in any immunocompromising state.
Mouth ulcers
Ulcers in immunocompromised persons may be related to aphthous type ulcers, infections (herpesviruses, mycoses (especially histoplasmosis or cryptococcosis), mycobacteria or syphilis, or protozoa such as leishmaniasis), malignant neoplasms (see below), or drugs (such as cytotoxic or antiretroviral agents).
Diagnosis can be difficult, and biopsy with microbial studies may be needed to exclude infections such as cytomegalovirus or deep mycoses. Specific treatments are often indicated. Chlorhexidine and topical analgesics can be helpful local treatments. Granulocyte colony stimulating factor or thalidomide can be helpful in HIV related aphthous-like ulceration.
In immunocompromised patients• Oral candidiasis is common, and antifungal drugs are indicated• Oral hairy leucoplakia is common in patients with AIDS; Epstein-Barr virus is implicated, but treatment is rarely indicated• Mouth ulcers are common, and a wide range of aetiologies is possible• Kaposi's sarcoma, lymphomas, and carcinomas may be seen
Gingival and periodontal disease
Necrotising ulcerative gingivitis and periodontitis occur disproportionately often in immunocompromised patients for the level of oral hygiene. They can be painful and cause rapid loss of alveolar bone. Improved oral hygiene, debridement, chlorhexidine, and sometimes metronidazole are needed.
Malignant neoplasms
Immunocompromising conditions predispose patients to oral leucoplakia and carcinoma (see earlier articles), Kaposi's sarcoma, and lymphomas.
Kaposi's sarcoma typically occurs on the palate or maxillary gingivae and presents as red, blue, or purple macules that progress to papules, nodules, or ulcers. It is associated with human herpesvirus 8. It can respond badly to irradiation but responds transiently to chemotherapy. Oral lesions are often managed with intralesional vinblastine or systemic chemotherapy if there are extraoral lesions.
Lymphomas are typically non-Hodgkin's lymphomas in the maxillary gingivae or fauces. They are part of widespread disease and are usually associated with Epstein-Barr virus. They are resistant to treatment, and chemotherapy is required.
Immunosuppressed patients and those with indwelling peritoneal catheters
Dental procedures are rarely followed by infection of such patients, and any infections rarely involve oral microorganisms. Thus, patients do not require antimicrobial prophylaxis before routine dental procedures unless they have a severe immune defect, there is some other indication, or surgery is to be performed.
Patients with artificial joints
Joint prostheses are only rarely infected because of dental procedures or oral microorganisms. Thus, patients with artificial joints do not require antimicrobial prophylaxis before most dental procedures unless there is some other indication, although antimicrobial use may be prudent for the first two years after arthroplasty and in patients with inflammatory arthropathies or who are immunocompromised.
In immunocompromised patients or those with prosthetic joints• Good oral care and hygiene are essential• Antimicrobial prophylaxis is not usually necessary before dental procedures
Mentally challenged patients
Mentally challenged people often have poor oral health (missing or discoloured teeth, periodontal disease, and oral malodour), which worsens their struggle for social acceptance. Barriers to dental treatment include fear (aggravated by inability to comprehend the need for treatment), the need to be accompanied, difficult access to healthcare facilities, and often a negative attitude or lack of training of the professional.
Patients with a mild to moderate disability can often be treated in general dental practice with help and encouragement from relatives and carers. Recent guidelines issued by the General Dental Council on minimum standards for general anaesthesia will probably lead to a decline in the availability of this in general practice. Those who require additional resources are often treated in the community dental service. For the most severely affected patients, dental care may have to be performed under general anaesthesia or intravenous sedation, often only available in the community dental service or hospital.
In mentally challenged patients• Good oral care and hygiene are essental• Access to care is often limited• Preoperative sedation may be needed
Patients with mental illness
People with mental illness often avoid dental care, and their oral hygiene may be impaired, with consequential periodontal disease and caries. Their medication may produce adverse oral effects, especially xerostomia (with increased risk of caries) and dyskinesias. Dental management commonly involves ensuring good oral health care (which may involve the support of a carer), delaying treatment until there is relative psychiatric equilibrium, keeping appointments short, and oral or intravenous sedation as required.
Socially excluded patients
Overall, oral health in UK children has been improving, and these benefits should soon be reflected among adults. However, the inequalities in oral health and in the use of services have increased between affluent and deprived groups, especially socially excluded groups (institutionalised elderly people, homeless people, refugees and asylum seekers, those engaged in substance misuse, etc).
In socially excluded people• Oral health is often poor• Access to oral health care is impeded• Good oral care and hygiene are essential
Institutionalised elderly people are more likely to have fewer teeth but more gross caries and root caries than other elderly groups.
Further reading
Aartman IH, de Jongh A, Makkes PC, Hoogstraten J. Treatment modalities in a dental fear clinic and the relation with general psychopathology and oral health variables. Br Dent J 1999;186: 467-71
Academy of Dentistry for Persons with Disabilities. A position paper from the Academy of Dentistry for Persons with Disabilities: preservation of quality oral health care services for people with developmental disabilities. Spec Care Dentist 1998;18:180-2
Bedi R, Uppal RDK. The oral health of minority ethnic communities in the United Kingdom. Br Dent J 1995;179:421-5
Carter EF. Dental implications of narcotic addiction. Aust Dent J 1978;23:308-10
Hakeberg M, Dernevik L, Gatzinsky P, Eklof C, Kennergren C, Jontell M. The significance of oral health and dental treatment for the postoperative outcome of heart valve surgery. Scand Cardiovasc J 1999;33:5-8
Porter SR, Scully C, eds. Oral healthcare for those with HIV and other special needs. Northwood: Science Reviews, 1995.
Scully C, Flint S, Porter SR. Oral diseases. London: Martin Dunitz, 1996
Yilmaz S, Ozlu Y, Ekuklu G. The effect of dental training on the reactions of mentally handicapped children's behavior in the dental office. ASDC J Dent Child 1999;66:154-5, 188-9
Homeless people often are not registered for dental care, make little use of dental services, miss dental appointments, have poor oral health, and are at increased risk of oral cancer.
Refugees and asylum seekers often find access to dental services difficult.
People who engage in substance misuse often have poor oral hygiene; tend to prefer sweet foods and sugar (especially methadone users), leading to caries; have damaged or lost teeth because of convulsions; and make little use of dental services, about which they have high anxiety.
Figure.
Appalling oral hygiene and periodontitis in a patient awaiting cardiac valvular surgery. Dental procedures involving gingival laceration or periodontal disruption (such as extraction) can produce bacteraemia of oral microorganisms, which could lead to infective endocarditis
Figure.
Erythematous candidiasis, presenting as a median rhomboid glossitis, is common in patients with immune defects
Figure.
Angular cheilitis caused by candidiasis
Figure.
Hairy leucoplakia may be seen in immunocompromised patients
Figure.
Kaposi's sarcomas in typical sites in the palate
Figure.
Poor oral condition in a mentally challenged person
Figure.
Uncleaned denture in a person with psychiatric illness
Acknowledgments
Crispian Scully is grateful for the advice of Dr Rosemary Toy, general practitioner, Rickmansworth, Hertfordshire.
Footnotes
Roger Davies is consultant in special needs dentistry, Raman Bedi is professor of transcultural oral health, and Crispian Scully is professor of special needs dentistry at the Eastman Dental Institute for Oral Health Care Sciences, University College London, University of London (www.eastman.ucl.ac.uk).
The ABC of oral health is edited by Crispian Scully and will be published as a book in autumn 2000.