A Patient with a History of Right-Sided Stroke and Hemiplegia, in a Wheelchair, Presents with a Complaint of Upper Left Tooth Pain.

Patients with a history of stroke often present with numerous neurologic deficits and varying degrees of disability. Ambulation problems requiring the use of a wheelchair can make accessing and receiving dental care difficult for these patients. Side effects from medications can compromise their oral health and complicate care. Possible dexterity limitations decrease their ability to maintain their oral health. Innovative care plans and adaptations may be needed to accommodate the needs of these patients but care generally can be provided safely and effectively in the outpatient dental setting.

A Patient with Dementia Presents from a Nursing Home with a History of Decreased Oral Intake, Malodor, and Weight Loss.

Individuals with dementia can present with varying challenges depending on their state of disease. The individuals caring for them may be faced with resistant behaviors when trying to provide adequate oral care. A poor oral condition can lead to decreased caloric and fluid intake causing multiple comorbidities to be exasperated due to the declining oral condition. Creating a management plan and an oral disease prevention plan are key to improving the overall health outcomes of these patients.

Patient with a History of Down Syndrome Presents for Periodic Examination and Cleaning.

Genetic disorders such as Trisomy 21, Down Syndrome, can have numerous signs and symptoms leading to treatment complications of varying degrees. Obtaining the details regarding the patient's presentation of such disorders in addition to a thorough medical history before first seeing the patient is imperative. Treating the individual is less intimidating when you evaluate how each element affects the treatment you plan to provide and allows you to be adequately prepared to provide dental care and develop an oral health plan.

Nonverbal Patient with Autistic Spectrum Disorder Presents for an Initial Dental Visit.

Autistic spectrum disorder (ASD) can be characterized by communication and social interaction difficulties, focused or repetitive behaviors, and an apathetic demeanor. The understanding level of an individual who cannot communicate cannot be assessed; therefore, we cannot assume the level of understanding of some individuals with ASD. Unfortunately, general anesthesia (GA) is oftentimes used for individuals with ASD due to their inability to cooperate, possible aggressive behaviors, and inadvertent movements, without first trying less-restrictive techniques. Teaching dentists how to develop and execute management plans without GA can increase access to dental care for this population and improve their overall health.

A Patient with Cerebral Palsy Presents for Evaluation of Third Molar Pain.

Cerebral palsy (CP) is a developmental disorder caused by brain trauma in utero or within the first few days of life, although symptoms may not develop until early infancy. Each of the 4 types of CP has its own signs and symptoms and can present unique challenges to accessing and providing dental care. Providers may be reluctant to treat these individuals due to uncontrolled body movements, primitive reflexes, varying mental capabilities, seizures, visual and hearing impairments, dysphagia, and dysarthria.

An educational model for special patient care in dentistry.

Dental school graduates often have a basic knowledge in the management of patients with specialized healthcare needs. As of August 2019, CODA amended their accreditation standard 2-25: dental school graduates must be competent in the assessment and management of treatment of patients with specialized healthcare needs and disabilities. While the majority of these patients require modified dental care, many dental schools lack the facilities to provide both the proper care and education. This paper identifies improvements to dental education brought on by the innovations at Penn Dental Medicines' Personalized Care Suite for Persons with Disabilities (PCARE). Patient centered care is the emphasis of the PCARE curriculum. Although the clinic has special rooms and equipment to assist in accommodating the special needs of the patients, the program focuses on teaching dental students how to provide comfortable, safe, and effective care in a typical office setting. Detailed patient assessment, non-pharmacological management techniques, and treatment plans designed to meet the needs and abilities of the patients and caregivers are taught through lecture and direct patient care. Teaching assessment and management of this population is of great importance. Including treatment in Standard 2-25 creates another challenge to dental education. Penn Dental's facility allows multidisciplinary care in a cohesive and timely manner. The experience in PCARE offers unique opportunities to educate dental professionals in developing a patient centered approach in the treatment and maintenance of oral health in those patients who require accommodation.

Scaling and Root Planing in a Patient with Atherosclerosis, Arrhythmia, and Anticoagulation.

Patients with cooccurring coronary artery disease and arrhythmias are frequently encountered by dental providers. Individuals with comorbid cardiovascular disease who require dual anticoagulant and antiplatelet therapy are a clinical challenge with regard to the need to balance the risks and benefits of intensive antithrombotic therapy. Modifications to dental care will need to be individualized considering the current disease state and medical management. Oral health promotion and good oral hygiene measures are recommended among this population.

Restorative Treatment in a Patient with Symptomatic Valvular and Structural Heart Disease.

Heart failure (HF) and valve replacements are common conditions encountered by dental professionals. Identification and differentiation between acute versus chronic HF symptoms will be key to providing safe and effective dental care. Vasoactive agents should be used cautiously in individuals with advanced HF. People with underlying cardiac conditions that put them at an increased risk of developing infectious endocarditis require antibiotic prophylaxis before all dental procedures. Establishing and maintaining optimal oral health is necessary to minimize the risks of bacterial seeding from the oral cavity to the heart.

Crown Preparation in a Patient with Hypertension and Type 2 Diabetes Mellitus.

Management of the diabetic dental patient should focus on the delivery of comprehensive dental care with an emphasis on maintaining periodontal health. Gingivitis, periodontitis, and associated bone loss independent of plaque accumulation are associated with poorly controlled diabetes. Periodontal status should be monitored carefully in patients with diabetes and underlying disease managed aggressively. Likewise, the dental team plays an important role in the identification of hypertension and managing dental-related side effects of anti-hypertensives.

Treatment of a Mandibular Abscess in a Patient with Coronary Artery Disease and Intermittent Angina.

An in-depth understanding of coronary artery disease will be critical to providing safe and effective dental care. Individuals with ischemic heart disease are at increased risk for anginal symptoms during dental care. Consultation with a cardiologist is advisable to ascertain cardiac stability for dental care if a patient has undergone recent coronary artery bypass graft surgery (less than 6 months ago). Judicious use of vasoactive agents during dental treatment is recommended. Antiplatelet and anticoagulant medications should be continued and local hemostatic measures used to control bleeding.

A Patient with Permanent Cardiac Pacemaker, History of Stroke Presents for an Extraction of Mandibular Molar Tooth.

Poor oral health and/or dental disease are highly prevalent among stroke survivors. Muscle weakness and loss of dexterity can decrease the patient's ability to provide effective oral hygiene post-stroke. Modifications to dental treatment should be based on the degree of neurologic sequelae, including scheduling needs. Special considerations must be taken with individuals who have permanent cardiac pacemakers.

Complete Denture Fabrication in a Patient with Chronic Obstructive Pulmonary Disease and Active Tobacco Use.

Patients with chronic obstructive pulmonary disease (COPD) have varying degrees of compromised airway function that can affect their ability to tolerate dental treatment. Thus, the delivery of dental care to individuals with COPD may need to be modified based on an understanding of the severity and control of the patient's disease, exacerbating factors, frequency of signs/symptoms, and disease management protocols. There is a strong association between aspiration of plaque organisms and pneumonia in individuals with COPD. Good oral hygiene and tobacco cessation education can help mitigate COPD exacerbations.

A Patient with a History of Extrinsic Asthma Presents for Endodontic Therapy for the Upper Molar.

With increasing rates of asthma in the general population, dental professionals need to be able to recognize the signs and symptoms of poorly controlled asthma and modify dental treatment accordingly. Prevention of an acute asthma exacerbation is key. Patients should be reminded to bring their rescue inhaler with them to every dental appointment. Patients who are using inhaled corticosteroids to manage their asthma are at greater risk of oral candidiasis, xerostomia, and caries. Regular dental visits and good oral hygiene are important among this population.

Restorative Treatment in a Patient with Chronic Obstructive Pulmonary Disease, Ischemic Heart Disease, and Arrhythmia.

Cardiovascular diseases are among the most common medical problems in the general population. Individuals with underlying cardiac conditions require special considerations with regard to appropriateness of dental treatment and precautions needed to deliver safe and effective care. Patients with unstable cardiac disease are at higher risk of developing complications during dental treatment. Similarly, comorbid conditions among patients with ischemic heart disease, such as chronic obstructive pulmonary disease, can further affect dental health and treatment, and they often require more individualized dental approaches.

An Initial Visit in a Patient with a History of Tuberculosis.

As public health stewards, dental providers must be mindful of actual of potential infectious disease risks. Tuberculosis (TB) is a leading cause of death in adults worldwide and is spread via aerosolized droplets. Individuals at the greatest risk of contracting TB are those with impaired immunity or those who have a higher risk of being exposed to an infection due to environmental factors. Dental providers must be aware of the clinical and public health implications of treating people with active versus latent TB infections.

Periodontal Maintenance in a Patient with a Lung Transplantation Post-COVID-19 Infection.

Early dental screening and treatment before and after solid organ transplantation are recommended infection prophylaxis measures. Dental treatment after transplantation should only be rendered after a discussion with the patient's health-care provider and/or transplant surgeon to determine the patient's stability for dental care. Potential sources of acute or chronic oral infections should be evaluated at every visit. Periodontal evaluation and through dental prophylaxis should be performed. Oral hygiene instruction including the importance of maintaining excellent oral health after transplant should be reviewed.

Recent Recommendations for Management of Human Immunodeficiency Virus-Positive Patients.

Human immunodeficiency virus (HIV) infection has become a chronic condition. HIV is not a valid reason to deny, delay, or withhold dental treatment. There are no absolute contraindications and few complications associated with comprehensive oral health care treatment delivered in an outpatient setting for asymptomatic HIV-infected patients and clinically stable patients with AIDS. Consultation with the patient's medical provider and modifications in the delivery of dental treatment may be necessary when treating patients with advanced HIV disease or other comorbid conditions. Oral health care is an integral and important part of comprehensive health care for all patients with HIV/AIDS.

Neurologic Diseases in Special Care Patients.

Neurologic diseases can have a major impact on functional capacity. Patients with neurologic disease require individualized management considerations depending on the extent of impairment and impact on functional capacity. This article reviews 4 of the more common and significant neurologic diseases (Alzheimer disease, cerebrovascular accident/stroke, multiple sclerosis, and Parkinson disease) that are likely to present to a dental office and provides suggestions on the dental management of patients with these conditions.

Incorporating Experiential Learning Techniques to Improve Self-Efficacy in Clinical Special Care Dentistry Education.

The New York University College of Dentistry has introduced a clinical rotation for fourth-year dental students that focuses on treating people with special health care needs (PSN). The aim of this study was to investigate the hypothesis that clinical experience in treating patients with special health care needs during predoctoral education is associated with increased self-assessed student ability and comfort and therefore self-efficacy. The study also investigated whether other characteristics, such as prior personal or volunteer experience with this population, service-mindedness, and/or the inclination to treat underserved populations, were associated with comfort in treating PSN. A survey was used to assess changes in students' perceived knowledge, beliefs, and attitudes regarding treating PSN before and after the clinical experience for July 2012-June 2013. The survey included questions about students' service-mindedness, comfort, perceptions of abilities of PSN and educational importance of learning to treat PSN, desire for clinical experience, and future intent or interest in treating PSN. Out of 364 students invited to participate, 127 surveys were returned, for a response rate of 34.9%. The results showed statistically significant increases on six items following training: impressions about the importance of oral health among PSN, comfort in treating people with cognitive disabilities and with medical complexities, intent to treat PSN in future practice, interest in including PSN in postgraduate training, and belief that PSN could be treated in the private practice setting. These students reported preferring to learn in the clinical setting over didactic instruction. This clinical experience was associated with improved self-efficacy in treating PSN and increased intentions to treat this population in future practice. Improvements were particularly evident among those with the least prior experience with PSN and were independent of other aspects of the students' past experience, future goals, or personality characteristics.

Dental management of special needs patients who have epilepsy.

Patients who have developmental disabilities and epilepsy can be safely treated in a general dental practice. A thorough medical history should be taken and updated at every visit. A good oral examination to uncover any dental problems and possible side effects from antiepileptic drugs is necessary. Stability of the seizure disorder must be taken into account when planning dental treatment. Specific considerations for epileptic patients include the treatment of oral soft tissue side effects of medications and damage to the hard and soft tissue of the orofacial region secondary to seizure trauma. Most patients who have epilepsy can and should receive functionally and esthetically adequate dental care.