Effect of audio distraction with thermomechanical stimulation on pain perception for inferior alveolar nerve block in children: a randomized clinical trial.

Background: Pain control is a crucial aspect of pediatric dentistry for patient management. Thermo-mechanical devices (Buzzy™ Pain Care Labs, USA) work on the concept of vibration and cooling and have shown promising results in pain control during local anesthesia in pediatric dentistry. On the other hand, audio distraction has also been used for pain management. The amount of pain endured is determined by the patient's perception and attentiveness. Thus, if audio function is added to the thermomechanical device it might increase its efficiency. Hence, the present study aimed to compare pain on injection using a thermo-mechanical device with and without audio during inferior alveolar nerve block (IANB) injection in children aged 5-10 years old. Methods: Twenty-eight children aged between 5 and 10 indicated for IANB were included in this randomized study. Children who were undergoing the dental procedure were divided into 2 groups, with 14 children in each group. The study group was the thermo-mechanical device with audio distraction; the control group was the thermo-mechanical device without audio distraction. IANB was administered. Subjective pain evaluation was performed using the Wong-Baker Faces Pain Rating Scale (WBFPR) and objective pain evaluation was done using the Faces, Leg, Activity, Consolability, Cry (FLACC) scale. Results: The outcome depicted a significant reduction in pain on injection for both objective and subjective evaluations in the thermo-mechanical device with an audio distraction group. Conclusions: Less pain on injection was observed, when a thermo-mechanical device was used with audio distraction for IANB procedures.

Effect of Acupressure on Pain during Inferior Alveolar Nerve Block Injection in Children Aged 5-10 Years Old - An Experimental Study.

Background: Acupressure, which is related to acupuncture, is a noninvasive therapy suitable for use in children. However, data examining acupressure's effects on the pain of local anesthetic injection in children are sparse. Objectives: The purpose of this study was to evaluate acupressure's effects on the pain of local anesthetic injection in children. Methods: This randomized, double-blind, parallel-group clinical study included 37 5- to 10-year-olds who had an inferior alveolar nerve block (IANB) for a mandibular extraction and were randomized to one of two groups: acupressure (study group) or non-acupressure (control group). The Wong-Baker FACES Pain Rating Scale (WBFPS) and the Sound, Eye, Motor (SEM) scale were utilized for subjective and objective pain assessment during injection. Results: The objective and subjective assessment of pain during injection significantly differed between the groups, with the acupressure group displaying lower scores. Conclusion: Acupressure at the extra one point (EX-HN1) reduced pain during IANB injection in 5- to 10-year-olds and can be used as an adjunct to conventional measures like topical anesthesia to reduce pain.

Buffered articaine infiltration for primary maxillary molar extractions: a randomized controlled study.

Background: Dental pain management is an important aspect of patient management in pediatric dentistry. Articaine is considered the most successful anesthetic agent for infiltration anesthesia. Buffered articaine has been observed to have faster onset and longer duration of action with less pain on injection. The aim of this study was to evaluate and compare pain on injection, onset of action, and pain during extraction using buffered (using Sodium bicarbonate (NaHCO3)) and non-buffered 4% articaine (with 1:100000 adrenaline) infiltrations for primary maxillary molar extractions in 4-10-year-old children. Methods: Seventy children who required extraction of maxillary primary molars were enrolled in this triple-blind randomized study. Children undergoing extraction were randomly divided into two groups, with 35 in each group. The study group was the buffered articaine group; the control group was the non-buffered articaine group. Buccal and palatal infiltrations were administered with either buffered or non-buffered articaine. Subjective evaluation was done for pain on injection, pain during extraction using Wong-Baker Faces Pain Rating Scale (WBFPR) and onset of anesthesia in seconds. Pain on injection, pain during extraction were objectively evaluated using Sound Eye Motor (SEM) scale and onset of anesthesia was also evaluated objectively by pricking with sharp dental probe. Results: The outcome was, significantly less pain on injection and significantly faster onset of anesthesia with significantly less pain during extraction for both subjective and objective evaluations in the buffered articaine group. Subgroup analysis was also performed and it showed variable results, with only significant difference for WBFPR scores in age subgroup 4-7 years for palatal infiltration. Conclusion: Less pain on injection, faster onset of anesthesia, and less pain during extraction were observed when buffered articaine was used for maxillary primary molar extraction.

Non-syndromic Association of Natal Teeth in a Case of Septic Arthritis: Does Correlation Imply Causality?

Disturbances of dental development may result in anomalies, which may be apparent as soon as the child is born. This report aims to describe the occurrence of natal teeth in a non-syndromic case of neonatal septic arthritis of the knee joint. Various systemic conditions have been associated with the occurrence of natal teeth in the past. The present report highlights the importance of a proper referral system between the pediatrician and the pediatric dentist to provide a multidisciplinary approach in the first few months of life.

Oral Healthcare Management of Children after COVID-19 Outbreak.

The emergence of the novel 2019 coronavirus disease (COVID-19) pandemic has led to a significant challenge to healthcare professionals. Among all the healthcare providers, dental clinical setup is exposed to the generation of potentially hazardous aerosols which could be a point of cross-contamination. Dentists catering to pediatric patients need to take special precautions, as they have milder symptoms or could be asymptomatic and hence potential vectors for the transfer of infection. One needs to change the perspective to manage the oral health of children as a child's oral health presents specific problems that could be time-bound and hence need to be treated accordingly. These problems can be managed on one hand by preventive methods, and on the other by implementing specific protocols relating to the conditions that represent an emergency, or those situations that fall into the category of elective dental procedures. This article highlights the routes of transmission in a dental practice and focuses on the categorization of treatment for children based on treatment needs. It proposes a restructuring of the treatment protocol and hence shifting to minimal invasive or non-aerosol-generating procedures (AGP). These techniques are also proposed to be used even after the end of the current emergency period to minimize the aerosol splatter. CLINICAL SIGNIFICANCE: The article highlights the protocol that needs to be followed after treatment categorization during and after COVID-19 pandemic. HOW TO CITE THIS ARTICLE: Lamba G, Nagpal DI, Chowdhari P, et al. Oral Healthcare Management of Children after COVID-19 Outbreak. Int J Clin Pediatr Dent 2021;14(2):293-297.

Effectiveness of magnetized water and 0.2% chlorhexidine as a mouth rinse in children aged 12-15 years for plaque and gingivitis inhibition during 3 weeks of supervised use: A randomized control study.

BACKGROUND: Chlorhexidine mouth rinse, a 'Gold Standard'effective in reducing plaque and gingivitis, has some drawbacks like bitter taste, light brown staining of teeth etc. limiting its long-term use. Magnetized water is alkaline and inhibits the bonding process between plaque and teeth by "magnetohydrodynamic". Aim: To compare and evaluate effectiveness of magnetized water and 0.2% chlorhexidine as a mouth rinse in children aged 12-15 years for plaque and gingivitis inhibition during 3 weeks of supervised use. Settings and Design: This was a double blinded randomized control clinical study, carried out at a non-government high school. Methods:A total of 20 children aged 12-15 years were randomized into two groups, magnetized water and 0.2% chlorhexidine, each comprising of 10 children who were asked to rinse with the respective mouthwash. Plaque index (PI) scoresand gingival (GI) scoreswere evaluated at baseline, 2 weeks and at 3 weeksfor each child. Statistical analysis: Independent sample t test and paired sample t test were used to check the mean differences. Result: A statistically significant difference was found in reduction of mean PI and GI scores of magnetized water (p=0.0001) and Chlorhexidine groups(p=0.0001) both at 14 days (2 weeks) and at 21 days (3 weeks) with no adverse effects. Conclusion: Daily use of magnetized water as a mouth rinse was safe andeffective alternative to chlorhexidinein plaque and gingivitis reduction, which supplemented the benefits of daily toothbrushing in children.

Evaluation of tongue/mandible volume ratio in children with obstructive sleep apnea.

OBJECTIVE: The present study was an attempt to investigate tongue/mandible volume ratio in children, using volumetric magnetic resonance imaging (MRI) for early screening and to aid in treatment planning. METHODS: Volumetric evaluation of tongue volume/mandible volume ratio (TV/MV ratio) in children with obstructive sleep apnea (OSA) using MRI was carried out retrospectively on available DICOM MR images of children in the age group of 10-14 years. MRI image records of patients diagnosed with OSA were obtained from interventional radiology department records, at Sharad Pawar Dental College and Hospital (Datta Meghe Institute of Medical Sciences, Nagpur/India). The age, gender, height and weight of the subjects were retrieved from patient database and registered. For the control group, available MRI images of healthy subjects without OSA were retrieved. Body mass index (BMI) was also calculated using the height and the weight present in the records. Measurements from MR images were made using DICOM image processing software. Soft tissue and bony structure segmentation was performed by manual tracing. The tongue volume and mandible volume were directly computed using the software. The tongue volume/mandible volume ratio (TV/MV) was generated using the above values and expressed as a percentage for both groups. RESULTS: The difference between OSA group and control group with respect to TV/MV ratio was found to be highly significant at 0.05 level of significance. There was no significant correlation between BMI and TV/MV ratio in OSA group (p= 0.451) as well as in control group (p= 0.094). CONCLUSION: TV/MV ratio may be an appropriate variable to evaluate the risk of OSA, representing the balance between skeletal morphology and soft tissue morphology in craniofacial complex.

Evaluation of tongue/mandible volume ratio in children with obstructive sleep apnea

ABSTRACT Objective: The present study was an attempt to investigate tongue/mandible volume ratio in children, using volumetric magnetic resonance imaging (MRI) for early screening and to aid in treatment planning. Methods: Volumetric evaluation of tongue volume/mandible volume ratio (TV/MV ratio) in children with obstructive sleep apnea (OSA) using MRI was carried out retrospectively on available DICOM MR images of children in the age group of 10-14 years. MRI image records of patients diagnosed with OSA were obtained from interventional radiology department records, at Sharad Pawar Dental College and Hospital (Datta Meghe Institute of Medical Sciences, Nagpur/India). The age, gender, height and weight of the subjects were retrieved from patient database and registered. For the control group, available MRI images of healthy subjects without OSA were retrieved. Body mass index (BMI) was also calculated using the height and the weight present in the records. Measurements from MR images were made using DICOM image processing software. Soft tissue and bony structure segmentation was performed by manual tracing. The tongue volume and mandible volume were directly computed using the software. The tongue volume/mandible volume ratio (TV/MV) was generated using the above values and expressed as a percentage for both groups. Results: The difference between OSA group and control group with respect to TV/MV ratio was found to be highly significant at 0.05 level of significance. There was no significant correlation between BMI and TV/MV ratio in OSA group (p= 0.451) as well as in control group (p= 0.094). Conclusion: TV/MV ratio may be an appropriate variable to evaluate the risk of OSA, representing the balance between skeletal morphology and soft tissue morphology in craniofacial complex.

Resumo Objetivo: o presente estudo foi uma tentativa de investigar a relação volumétrica língua/mandíbula em crianças, usando imagens de ressonância magnética (IRM), para triagem inicial e como meio auxiliar no plano de tratamento. Métodos: a avaliação da relação volume da língua/volume da mandíbula (relação VL/VM) em crianças com apneia obstrutiva do sono (AOS) utilizando IRM foi realizada retrospectivamente em imagens de RM em formato DICOM disponíveis de crianças na faixa etária de 10 a 14 anos. As documentações com IRM de pacientes com diagnóstico de AOS foram obtidas nos arquivos do departamento de radiologia da Sharad Pawar Dental College and Hospital (Datta Meghe Institute of Medical Sciences, Nagpur/Índia). A idade, o sexo, altura e peso dos indivíduos foram obtidos a partir dos registros dos pacientes. Para o grupo controle, foram selecionadas imagens de RM disponíveis de indivíduos saudáveis sem AOS. O índice de massa corporal (IMC) também foi calculado a partir da altura e do peso constantes nos registros. As medições nas imagens de RM foram feitas usando um software de processamento de imagens DICOM. A segmentação entre tecidos moles e estrutura óssea foi realizada por delineamento manual. O volume da língua e o volume da mandíbula foram calculados diretamente com o software. A relação volume da língua/volume da mandíbula (VL/VM) foi calculada usando os valores acima e expressa em porcentagens, para ambos os grupos. Resultados: a diferença entre o grupo com AOS e o grupo controle, quanto à relação VL/VM, foi altamente significativa ao nível de significância de 0,05. Não houve, porém, correlação significativa entre o IMC e a relação VL/VM, nem no grupo AOS (p= 0,451), nem no grupo controle (p= 0,094). Conclusão: a relação VL/VM pode ser uma variável apropriada para se avaliar o risco de AOS, representando o equilíbrio entre a morfologia esquelética e a morfologia dos tecidos moles no complexo craniofacial.

Modified Angle's Classification for Primary Dentition.

AIM: This study aims to propose a modification of Angle's classification for primary dentition and to assess its applicability in children from Central India, Nagpur. METHODS: Modification in Angle's classification has been proposed for application in primary dentition. Small roman numbers i/ii/iii are used for primary dentition notation to represent Angle's Class I/II/III molar relationships as in permanent dentition, respectively. To assess applicability of modified Angle's classification a cross-sectional preschool 2000 children population from central India; 3-6 years of age residing in Nagpur metropolitan city of Maharashtra state were selected randomly as per the inclusion and exclusion criteria. RESULTS: Majority 93.35% children were found to have bilateral Class i followed by 2.5% bilateral Class ii and 0.2% bilateral half cusp Class iii molar relationships as per the modified Angle's classification for primary dentition. About 3.75% children had various combinations of Class ii relationships and 0.2% children were having Class iii subdivision relationship. CONCLUSIONS: Modification of Angle's classification for application in primary dentition has been proposed. A cross-sectional investigation using new classification revealed various 6.25% Class ii and 0.4% Class iii molar relationships cases in preschool children population in a metropolitan city of Nagpur. Application of the modified Angle's classification to other population groups is warranted to validate its routine application in clinical pediatric dentistry.

Volumetric MRI Evaluation of Airway, Tongue, and Mandible in Different Skeletal Patterns: Does a Link to Obstructive Sleep Apnea Exist (OSA)?

Backgroun/Objectives: Craniofacial disharmony has been long debated as an important predisposing factor in the development and progression ofsleep-disordered breathing and OSA. The present study was aimed to determine and compare whether a direct correlation occurs between the airway volume, mandibular dimension, and tongue volume in different craniofacial growth patterns. The objectives were the 3D MR[ assessment and comparison ofairway volume, mandibular dimensions, and tongue volume in Class I normodivergent, Class II hyperdivergent, and OSA group. MATERIALS/METHODS: Study population included 45 patients (12-18 years). Soft tissue volume estimation for airway [oropharyngeal (OP), nasopharyngeal (NP)] and tongue was carried out using MRI and DICOM image processing software(Osirix@ v5.6).Mandibular dimensions were characterized on MR, and derivations were made using the Pythagoras theorem. Subsequently, 3D reconstructions were carried out. The mean and standard deviation were obtained. Kruskal-Wallis and Wilcoxon rank sum test were used. Multiple regression analysis was performed for OP and NP volumes using BMI, mandibular area, and tongue volume as predictors for the complete sample. RESULTS: It was found that in overall sample, mandibular length showed a positive correlation with OR NP and tongue volumes. For both OP and NP glossomandibular area, and tongue volume were found to be statistically significant predictors. CONCLUSIONS/IMPLICATIONS: A direct correlation was confirmed between the airway volume, mandibular dimensions, and tongue volume in different craniofacial growth patterns. The present knowledge can be utilized on patients for treatment of reduced airway space using the derived formula for mandibular dimensions, and the regression equations can be used as a diagnostic aid in determining the OP and NP volume for any individual using 2D radiofraphs in orthodontics.

Oral Rehabilitation for Amniotic Band Syndrome: An Unusual Presentation.

Amniotic band syndrome (ABS) is a congenital disorder caused by entrapment of fetal parts in fibrous amniotic bands while in utero. The syndrome is underdiagnosed and its presentation is variable. The syndrome has been well described in the pediatric, orthopedic and obstetric literature; however, despite the discernable craniomaxillofacial involvement, ABS has not been reported in the dental literature very often. The present report describes a case of a patient with ABS and concomitant dental findings. How to cite this article: Hotwani K, Sharma K. Oral Rehabilitation for Amniotic Band Syndrome: An Unusual Presentation. Int J Clin Pediatr Dent 2015;8(1):55-57.

A pediatric viewpoint on peripheral ossifying fibroma: a case report.

A peripheral ossifying fibroma (POF) is a type of reactive hyperplasia that is found exclusively on the gingiva. It is identified through histologic evidence of calcifications and ossifications that are seen in the context of a hypercellular fibroblastic stroma. This article presents the case of a POF in a 7-year-old girl, and examines the pediatric considerations for diagnosing and managing this lesion.

Phytodentistry: use of medicinal plants.

Finding healing powers in plants is an ancient idea. Herbs have been used as a traditional form of medicine since time immemorial. The natural products derived from medicinal plants have proven to be an abundant source of biologically active compounds, many of which have been the basis for the development of new chemicals for pharmaceuticals. Phytodentistry implies the use of plants and their products in the process of treating disease directly or indirectly. A crucial role is played by phytotherapy in the treatment of stomatological problems. It started with the use of miswak (chewing stick), and it is still relevant today as herbal toothpaste in many parts of the country. India is the largest producer of medicinal herbs and is appropriately called the botanical garden of the world. The use of this readily available, natural and safe resource as a part of dental practice has great potential for a more "Natural and Green Dental Practice". Plant products have long been used in dentistry as part of various dental materials right from impression materials to eugenol, which forms an integral part of the dental clinic. The use of herbs in dental practice is not limited to only material sciences. A single herb shows a variety of effects like anti-inflammatory, antibacterial, antifungal activity and many more. Hence the incorporation of these herbs in dental practice will prove to be a valuable adjunct in dental treatment. This review is aimed at exploring the perspectives of this holistic treatment approach in dentistry and its benefits as an adjunctive therapy.

Orthodontic airway imaging: the cutting edge in treatment planning.

The upper airway has long been an area of interest in orthodontics. A normal airway is an important factor in the physiologic growth of craniofacial structures. The imaging of the upper airway is an indispensable tool in the field of orthodontics. Differing methods of measurement of nasal airway dimensions and function have been proposed and utilized; each technique has its strengths and limitations. Upper airway imaging has allowed us to begin to understand the biomechanical bases for obstructive sleep apnea syndrome and mouth breathing. Modern developments in imaging have produced many options and methodologies. This article reviews the contemporary status of approaches in airway imaging and discusses potential future needs and directions.

Effects of first premolar extraction on airway dimensions in young adolescents: A retrospective cephalometric appraisal.

OBJECTIVE: To evaluate the upper airway dimensions in adolescents treated for bimaxillary proclination with first premolar extraction. MATERIALS AND METHODS: A retrospective cephalometric evaluation was carried out on the available pre and post orthodontic treatment records of 150 patients (12-18 years of age) who had bimaxillary proclination and were treated with fixed orthodontic therapy. Cephalometric landmarks for sagittal airway measurements and hyoid bone were identified; linear and angular measurements were obtained. Descriptive statistics using paired t-test was used to assess changes in pre and post treatment values and Pearson's correlation coefficient was calculated to evaluate the reliability of observations. The method error calculations were performed using the Dahlberg formula. RESULTS: It was observed that the mean values of nasopharyngeal dimension and Total Airway Length (TAL) showed no statistically significant difference in pre and post treatment groups. All other airway and hyoid parameters showed statistically significant difference. Pearson's correlation coefficient showed statistically significant correlations in all the airway and hyoid parameters. CONCLUSIONS: In the present study, the nasopharyngeal dimension and TAL were not found to be directly affected by the retraction of anterior teeth, This can be attributed to the fact that nasopharyngeal dimension and TAL are not under direct influence of tongue position. The other findings also indicated direct correlation of tongue position to oropharynx and hypopharynx. Consequently, we emphasize clinically relevant anatomic risk factors that should be given prime importance and serious consideration on the decision whether to extract or not in growing patients.

Platelet rich fibrin - a novel acumen into regenerative endodontic therapy.

Research into regenerative dentistry has added impetus onto the field of molecular biology. It can be documented as a prototype shift in the therapeutic armamentarium for dental disease. Regenerative endodontic procedures are widely being added to the current armamentarium of pulp therapy procedures. The regenerative potential of platelets has been deliberated. A new family of platelet concentrates called the platelet rich fibrin (PRF) has been recently used by several investigators and has shown application in diverse disciplines of dentistry. This paper is intended to add light on the various prospects of PRF and clinical insights to regenerative endodontic therapy.

Comparative in vitro assessment of color stability of hybrid esthetic restorative materials against various children's beverages.

PURPOSE: The present study was aimed to evaluate and compare the color stability of two hybrid tooth-colored restorative materials, namely, resin-modified glass ionomer cement (GC Fuji II LC Capsules - GC Corporation, Tokyo, Japan) and giomer (Beautifil II - Shofu Inc, Kyoto, Japan) when subjected to immersion in various children's beverages. MATERIALS AND METHODS: Standardized disc specimens were prepared using the test restorative materials. After preparation and rehydration of the specimens, baseline color evaluations were performed using spectrophotometer. The readings were recorded according to CIELAB color space. The experimental groups were further subdivided for immersion in orange juice, bournvita milk, and coke. Subsequent to immersion and pH cycling, new color evaluations were carried out after 1 week and 4 weeks for all the experimental groups. The mean color change values were calculated. RESULTS: The obtained data was subjected to statistical analysis. The results indicated that giomer specimens exhibited less color change as compared to RMGIC specimens indicating better color stability. The maximum color changes were found with the use of coke for a period of 4 weeks. CONCLUSION: Amongst the two materials, giomer showed less color changes as compared to RMGIC indicating a better color stability.

Assessment of safe zone in maxillary molar region for miniscrew placement in the mixed dentition period--a digital volumetric tomographic (DVT) study.

Assessment of bone thickness in maxillary frst molar region for miniscrew placement during the mixed dentition period with reference to the following variables a) mesio-distal bone width b) buccal cortical plate thickness c) palatal cortical plate thickness d) bucco-palatal bone depth. DVT images of fifteen healthy patients aged 8-10 years with early exfoliated maxillary second deciduous molar were obtained using the Kodak 9000 extra-oral imaging system. The scanned images were analyzed using Kodak dental imaging software [3DmoduleV2.2] and the bone thickness measurements were obtained at six mm and eight mm apical to the cemento-enamel junction. The mean and standard deviation for the measurements was calculated and data was statistically analysed using paired 't' test. The Method error calculations were performed using the Dahlberg formula. The mean values for the mesiodistal width, buccopalatal depth, buccal and palatal cortical bone thickness were found to be sufficient for miniscrew placement up to 1.2mm diameter and 10mm length. The bone thickness measurement and assessment of safe zone in maxillary posterior region from the present study showed potential for miniscrew placement in pediatric age group. Miniscrews can be considered as a promising aid in pediatric space management; so also, they can be used for molar distalization and space regaining in early mixed dentition period.

Antibacterial effects of hybrid tooth colored restorative materials against Streptococcus mutans: An in vitro analysis.

OBJECTIVE: The objective of this study was to evaluate the antibacterial effect of two hybrid restoratives, namely resin modified glass ionomer cement (GC Fuji II™ LC, GC Corporation, Tokyo, Japan) and giomer (Beautifil-II, Shofu Inc., Kyoto, Japan) against Streptococcus mutans [Microbial Type Culture Collection (MTCC), 890]. MATERIALS AND METHODS: The antibacterial effect was evaluated using an agar diffusion test. The prepared wells in petri dishes were completely filled with chlorhexidine (positive control group), resin modified glass ionomer cement and giomer respectively. Prepared bacterial suspension was poured over the petri dish and was spread evenly using the plate spreader. The culture plates were placed in the incubator for 24 h at 37°C. The antibacterial activity was evaluated after 24 h, 48 h, and 7 days for each group in triplicates. RESULTS AND CONCLUSION: The results of the antibacterial effect of the tested materials were collected, statistically analyzed using the ANOVA test to determine the difference between the mean diameters of the inhibition zone produced. The mean zone of bacterial inhibition was found to be more with the giomer specimens at all time periods. However, this inhibitory activity showed a gradual decrease over a period of 7 days and the maximum inhibition was evident after 24 h with both the test materials.

Dental management of early childhood caries in spastic quadriparesis: a case report and clinical guidelines.

Cerebral palsy (CP) describes a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain. The motor disorders of CP are often accompanied by epilepsy, secondary musculoskeletal problems, and disturbances of sensation, perception, cognition, communication, and behavior. Spastic quadriparesis is the most severe form of spastic cerebral palsy. The present report describes the management of a 5-year-old patient with early childhood caries and spastic quadriparesis. The oral manifestations and clinical guidelines are discussed considering the special health care needs in these patients so as to provide comprehensive dental care.