Professional Documents
Culture Documents
PRACTICE
primary dental care.
Higher levels of oral disease can occur
This article about special care dentistry in the middle years considers people who have Downs syndrome and cerebral
palsy and those who have cardiac and respiratory disease. The increased life expectancy of people with Downs syndrome,
currently 50-60 years, is reected in the changing population prole and needs of these individuals. The preventive and
dental treatment of most people with Downs syndrome and cerebral palsy can be met in general dental practice. However,
those people with profound disability, anxiety or learning disability may require either a shared approach to care or referral
for specialist care. Cardiac and respiratory disease occur commonly in the general population both in middle and older age
groups and the dental team will meet increasing numbers of people with these conditions. The procedures and drugs used
in dentistry can aggravate heart disease and it is important that the dental team are aware of the common cardiac condi
tions and their management, as well as how to best manage the oral care of this group. Also, they have a role to play in
the provision of oral health advice, smoking cessation and dietary advice. This is particularly important as poor oral hygiene
has been linked to respiratory pathogen colonisation and dental plaque may act as a reservoir for aspiration pneumonia in
susceptible individuals.
ACCESS TO SPECIAL This second article on seamless care for biochemical factors have also been sug
CARE DENTISTRY people in their middle years considers two gested.1 Pre-natal risk factors include pre
conditions which have traditionally been eclampsia, irradiation, a maternal age of
1. Access
considered with childhood and young less than 20 or over 35, and infections such
2. Communication
adult conditions, and two conditions that as cytomegalovirus, rubella and syphilis.
3. Consent
have traditionally been associated with Peri-natal risk factors include trauma,
4. Education
older people. The rst two cerebral palsy breach birth or prolonged delivery.1,2
5. Safety
and Downs syndrome are included in Damage may also be caused post-natally
6. Special care dentistry services for
adolescents and young adults this article to reect the increasing life following infections such as encephali
7. Special care dentistry services for expectancy of people with these condi tis and meningitis during infancy. Other
middle-aged people. Part 1 tions and the subsequent change in their risk factors include cerebral ischaemia,
8. Special care dentistry services for population prole and needs. The latter haemorrhage and hypoxia secondary to
middle-aged people. Part 2
two conditions cardiac and respiratory trauma, respiratory distress, hypothermia
9. Special care dentistry services for
older people disease now occur commonly in middle or hypoglycaemia.1,2
age as well as in older age and the den Cerebral palsy is the most common
tal team will see increasing numbers of congenital cause of physical impair
people with these conditions. ment,1 with an incidence of approxi
1
Senior Dental Ofcer in Special Care Dentistry, Dorset mately 2-2.5 per 1,000 live births in
Healthcare NHS Foundation Trsut, Dental Department, 1. CEREBRAL PALSY developed countries.2 Primarily it is a
Canford Health Centre, Poole, Dorset, BH17 9DW;
2*
Chairperson of the Specialist Advisory Group in Special Cerebral palsy (CP) is an umbrella term disorder of voluntary moment, which
Care Dentistry/Senior Lecturer and Consultant in Special
Care Dentistry, Department of Sedation and Special
encompassing a group of non-progres results in a wide spectrum of disabil
Care Dentistry, Kings College London Dental Institute, sive neurological and physical disabilities ity ranging from virtually unnoticeable
Floor 26, Guys Tower, London, SE1 9RT; 3Lecturer and
Consultant for Medically Compromised Patients, Division
caused by damage or a lesion to a childs physical impairment. It may affect only
One/Special Care Dentistry, Dublin Dental School and brain early in the course of development, one limb (monoplegia), both lower limbs
Hospital, Lincoln Place, Dublin 2, Ireland
*Correspondence to: Dr Janice Fiske
either in utero, during birth or in the rst (paraplegia), one upper and one lower
Email: Janice.Fiske@gstt.nhs.uk few months of infancy.1 The damage to limb on the same side (hemiplegia) or all
DOI: 10.1038/sj.bdj.2008.850
the brain is caused mainly by hypoxia, four limbs equally (quadriplegia).1 There
British
Dental Journal 2008; 205: 359-371 trauma and infection but genetic and are four main types of CP (Table 1), the
increased signicantly in the last dec- affects their upper limbs and manual
ades, however respiratory infections are dexterity. Pre-disposing factors to peri-
common and aspiration pneumonia is a odontal disease in this group include
major cause of death.1 Wheelchair design mouth breathing, gingival hyperplasia
and assistive devices can help to provide secondary to the use of phenytoin for
a degree of independence (Figs 1 and 2). the treatment of epilepsy7 and increased
food retention which is exacerbated by
Oral and dental features difculties in oral self-care and plaque
People with CP will encounter the same removal.3,4 The increasing use of peg
oral and dental disease as the rest of the (percutaneous endoscopic gastronomy)
population, however there are additional feeding has helped improve the nutri
factors such as access to dental care tional status of patients with swallowing
and support in carrying out daily liv difculties, but the need for regular and
ing activities, which can result in higher meticulous oral hygiene has not been
levels of untreated disease and tooth addressed4 even though Dicks et al.8 have
loss.4 Scope, the national voluntary and shown that calculus formation is signi
political body for CP, works actively cantly more rapid in tube-fed patients.8
on campaigns to get equal and make This is important as poor oral health in
rights a reality. At the time of writing it patients with dysphagia has frequently
was running an online campaign seek been associated with the development Fig. 3 A woman with cerebral palsy using a
mouth-held device to aid independence
ing out disablism, which it describes as of aspiration pneumonia.9 There is good
discriminatory, oppressive or abusive evidence that improved oral hygiene and
behaviour arising from the belief that frequent professional oral healthcare palsy12,13 and although the incidence is
disabled persons are inferior to others.2 reduces the occurrence or progression of lower in adults, for many individuals it
It will only be a matter of time before respiratory diseases.10 is severe enough to interfere with daily
their active and ongoing research high Caries the risk of caries is increased social and practical functions.13,14 It is
lights the inequality in oral health and by a number of factors related to CP not caused by hyper-salivation, but is
acts accordingly. and its treatment, for example reduced due to impaired swallow and poor con
There are many potential causes of chewing and swallowing ability, the trol of the orofacial musculature15,16 and
increased risk of dental disease in CP. tendency for food to be retained in the can be exacerbated by malocclusion,
They include: mouth,4 malocclusion and mechanical postural problems, dental caries and an
Developmental abnormalities the and physical difculties in removing inability to recognise salivary spill.17
maxillary arch is frequently tapered plaque. In the absence of effective oral Lip trauma is a condition associated
or ovoid and the upper incisors may be hygiene procedures, individuals with with individuals who have a profound
labially inclined, making oral hygiene feeding difculties who use dietary sup neurodisability18,19 and has been reported
difcult.1 The incidence of malocclu plements and laxatives with a high sugar in people with cerebral palsy.20,21 The
sion is high and delayed eruption, poor content can develop extensive levels of bite reex occurs pathologically in this
oromuscular co-ordination, lack of ade caries rapidly.4 group and is often a result of facial
quate lip seal and oral habits of tongue Fractured teeth the increased like hypersensitivity, anxiety and poor
thrust contribute to this.1,3,4 lihood of falls3 and seizures1 amongst head position.19,22
Uncontrolled movement characteris people with CP means that fractured
tic symptoms of the movement disorder teeth are more likely than in the general Seamless care
may be observed in the orofacial and population. The management of oral health needs
cervical muscles,6 including spasticity Xerostomia dry mouth secondary to be embedded into the general care
of the temporomandibular joint (TMJ) to the use of medication to control sei plan of every individual with CP. While
musculature.3 Facial grimacing, dys zures is undoubtedly a causative factor at times the dental team may be on the
phagia and swallowing difculties are of oral disease.7 However, studies have periphery of the multidisciplinary team,
common 3 and jaw dislocation due to shown that even when not taking such at others they are integral and can play
spontaneous subluxation may occur.1,4 medication, people with CP have a lower a signicant role in improving the qual
Bruxism and tooth wear these are than normal salivary ow rate, lower pH ity of life for people with CP. Some of the
common in CP, especially in those indi and reduced buffering capacity, further ways they contribute to this include:
viduals with athetoid CP.3 Loss of tooth increasing their risk of oral disease.11 The maintenance of independence.
tissue may be exacerbated by erosion Exacerbated by mouth breathing, crust If an individual relies on mouth-held
due to gastro-oesophageal reux, which ing mucous deposits are commonly seen devices to carry out certain activities or
is also common.1,4 on the palate and soft tissues.4 to assist communication, maintaining
Periodontal disease is reported in a Drooling problem drooling affects good oral health is critical to retaining
high proportion of people with CP which up to 58% of children with cerebral independence (Fig. 3).
2. DOWNS SYNDROME
Downs syndrome (DS) is a genetic con
dition caused by a chromosomal abnor
Fig. 9 The characteristic dental features associated with Downs syndrome
mality (usually trisomy of chromosome
21) that results in a characteristic The former explanation is generally Table 2 Differential diagnosis of
appearance, learning disability (which favoured, and it is thought that the age behavioural and functional change in
ranges from mild to severe) and a vari ing process starts sooner or is speeded up. later life in people with Downs syndrome
ety of physical and medical features.39 Subtle memory losses, physical tiredness Depression
The characteristic appearance in DS and general frailty, as well as specic
Hypothyroidism
is that of short stature, relatively short illnesses, may be present when a person
arms and legs, broad hands and short with DS is in his/her thirties rather than Sensory impairments, visual and/or hearing
ngers, attened face and occiput, his/her sixties. However, Alzheimers Dementia, usually Alzheimers disease
slanting eyes with prominent epican disease (AD) is the only condition associ
thic folds and underdevelopment of the ated with decreased life expectancy that Impact of major life events, eg bereavement
middle third of face resulting in relative occurs earlier in DS.51 It increases from Other rare illnesses
prognathism (Fig. 8). about the age of 30, and by their fties
Source: reference 48
Oral and dental characteristics include around 50% of people with DS show
delayed development and eruption of signs of AD. It increases with age at a
both dentitions, hypodontia, microdon similar rate as in the general population, found a lower caries rate in the DS group
tia, short roots, hypocalcication and but 30 or 40 years sooner. Its onset can than the matched control group. The
hypoplastic defects, occlusal problems, be difcult to detect as in people with adults with DS had signicantly fewer
and a high incidence of severe early DS it may affect personality or behav lled teeth, fewer decayed teeth, more
onset periodontal disease (Fig. 9).40 Phys iour before the classical early features of peg-shaped maxillary lateral incisors,
ical and medical features include cardiac memory loss become apparent.48 Demen and more retained deciduous teeth.58
anomalies (40%),41 visual impairment tia will be explained in more detail in The low caries prevalence in children
(50%),42 hearing impairment (mild to the next article in this series. Diagnosis with DS has been linked to immune pro
moderate in 50%),43 atlantoaxial insta is based on the exclusion of other con tection from elevated salivary Strep
bility or subluxation (20%),44 compro ditions that might present with similar tococcus mutans IgA concentrations.59
mised immune system,41 hypothyroidism symptoms (Table 2). However, a study among 39 people with
(15%),45 increased risk of epilepsy (2-10% People with DS experience the same DS aged from 11 to 69 years demon
depending on age),46 increased risk of conditions as the general population as strated a lower rate of salivary secretion
diabetes Type 1 (2%) 47and earlier onset they age but experience them at an ear in people with DS than in a non-DS con
of Alzheimers disease.48 All of these lier age. However, they may be misinter trol group. It was attributed to decreased
conditions need to be considered when preted and where, for example, hearing stimulated parotid salivary ow and,
providing dental treatment.49 or visual impairments lead to a decline although not statistically signicant,
in communication or living skills, they decreased with increasing age. Thus it
Living longer can be misdiagnosed as depression.48 is possible that caries may become more
There are currently more than 26,000 Depression itself is one of the most fre of a problem as people with DS age,
people with DS in the UK and an inci quently diagnosed psychiatric disorders although as yet there is no evidence to
dence of 1 in 1,000 births, both male and in the DS population, but is probably support this hypothesis.
female.46 The life expectancy of people under-reported as people with DS may The severity, prevalence and extent of
with DS has improved dramatically from nd it difcult to express how they are periodontal disease are all signicantly
an average of nine years in 1900 to an feeling, complicating its diagnosis. greater in the DS population than in the
average of 50-60 years currently. As the general population.60 Prevalence has
prevalence of DS is set to rise, ageing in Oral health been reported from 58-96% for people
DS is only beginning to be researched Despite an ageing DS population, most with DS under the age of 35 years,60 with
and addressed.50 Although many people of the literature about oral health and lower incisors and upper rst molars
with DS are able to live healthy adult DS relates to children and adolescents.52 most commonly affected.61 This situa
55
lives without concerns related to seri These studies generally indicate a tion is not attributed solely to poor oral
ous illness or additional disability, it is lower caries rate than in the child popu hygiene and there has been a focus on
reported that the health needs of older lation as a whole. However, Davila et al. an altered immune response due to the
people with DS are not yet being met found 53% of their study population had underlying genetic disorder of DS.60
and some people with DS are dying from caries56 and a study of 20-40 year old Findings regarding the management of
manageable and treatable conditions.51 adults with learning disability living periodontal disease in people with DS
Although life expectancy has in an institution found a signicantly are mixed. Zigmond et al.61 reported that
increased, it is still lower than for the lower DMFT in people with DS compared a preventive programme had no effect
general population. Possible explana with those with cerebral palsy or idi on reducing the progression of either
tions are that people with DS age pre opathic developmental delay.57 A Hong generalised or localised periodontal
maturely and thus life expectancy is Kong survey looking at the oral health disease, indicating that impaired oral
reduced; and that DS is associated with status of 65 community dwelling adults hygiene plays a relatively minor role in
an increased risk of illness and mortality. with DS aged between 17 and 42 years its pathogenesis. This is at odds with
the ndings of Zaldivar-Chiapa et al., once co-operation is established, local The dental team are important mem
who reported that while there is partial analgesia is the rst line of treatment bers of the DS multidisciplinary care
impairment of immunological functions for most dental procedures for most team, as a healthy mouth can reduce the
in people with DS, this did not seem to people.69 The choice of technique must problems associated with DS and help to
affect the clinical response to surgical always take account of any systemic dis maintain the individuals self-esteem,
or non-surgical periodontal therapy in a ease, such as congenital heart and neu quality of life and social acceptability.
group of 14 people with DS aged 14 to rological conditions. Shared care with
30 years.62 This is supported by the work specialist support can be put in place if 3. CARDIOVASCULAR DISEASE
of Yoshihara et al., whose results sug conscious sedation or general anaesthe Cardiovascular disease (CVD) is the
gest that periodic preventive care (at one sia is required. most common cause of adult death in the
to three month intervals) is effective in Access to dental care is essential for developed world. Dental procedures and
suppressing the progression of periodon adults with DS in order that a rigorous drugs used in dentistry can aggravate
tal disease in young adults with DS aged preventive regime that will hopefully heart disease and it is important that the
15 to 26 years.63 Positive ndings are control periodontal disease and reduce dental team are aware of the common
also reported by Cheng, Leung and Cor the risk of tooth loss can be provided. cardiac conditions and their manage
bett,58 who achieved satisfactory healing The literature suggests that this should ment, as well as how to best manage the
responses following non-surgical peri include daily adjunctive chlorhexidine oral care of this group. The risk factors
odontal therapy with the adjunctive use and professional input on a monthly for CVD are shown in Table 3. Although
of chlorhexidine and monthly recalls in basis. Tooth replacement is not straight precise mechanisms of interaction
21 adults with DS aged 20 to 30 years.58 forward for this group of people. Den remain unclear, sufcient evidence
While the balance seems to be in favour tures are difcult, although not always exists to conclude that periodontitis
of preventive programmes improving impossible, for people with learning places certain patients at increased risk
the periodontal situation for people with disability to manage. Attention needs of developing CVD.72-74 Dentists need to
DS, the programmes require a degree of to be given to denture design mak take a careful medical history to ascer
intensity and/or monthly review.58,63,64 ing it as simple as possible, avoiding tain the patient at risk of CVD.
The short roots of teeth in DS com gingival margin coverage and provid
bined with increased periodontal dis ing as good retention as is possible. a) Hypertension
ease make it probable that tooth loss Patience is required on the part of the Hypertension is a persistently raised
from periodontal disease is more likely. dentist and the individual with DS. The blood pressure >140/90 mm Hg. Ninety
There would seem to be no evidence in use of adhesive bridges can be compro percent of cases are essential, with no
the literature to support or refute this mised by small crown size and/or spac obvious cause, although smoking, diet
supposition. The limited information ing between teeth. While the literature and lifestyle are recognised causes.
relating to tooth wear is in the child related to the use of dental implants for Pharmacological intervention should
population only and the ndings are people with DS is sparse, the two papers be offered to patients with persistently
mixed. Bell et al. report it as signi available suggest that implant dentistry high blood pressure of over 160/100
cantly more common than in the general is a viable treatment option70,71 provided mm Hg, with the aim of maintaining
population (59% and 8% respectively),65 there is support from carers for the pro it at or below 140/90 mm Hg to reduce
with an aetiology of attrition and ero vision of good oral hygiene.71 the risk of cardiovascular disease and
sion, while more recently, bruxism has In dealing with adults with DS in their death.75 Antihypertensive drug manage
been reported as no more common in forties and fties, it must be remembered ment includes the use of diuretics, beta
children with DS than in those without that some of them will have elderly par blockers, calcium channel blockers, ACE
it.66,67 There appears to be no literature ents who may nd it increasingly dif inhibitors, sympatholytics and vasodi
indicating whether tooth wear is a prob cult to support them in their oral hygiene lators.76 A signicant number of people
lem in adults with DS. needs. They will need information, advice are in receipt of anti-hypertensive ther
and support to maintain their motiva apy, with up to 5% and 13% of patients
Seamless care tion. Many of the issues associated with attending general dental practice and
The majority of dental treatment for seamless care for middle-aged people dental hospitals, respectively, reported
most people with DS should be possi with DS have been explored in greater to take anti-hypertensive drugs.77 Stress,
ble in the primary dental care service. depth earlier in this series of articles, for including that associated with den
Achieving patient co-operation is based example issues related to physical access tal treatment, may further increase an
on building trust and rapport through to the surgery in article 1,32 communi already raised blood pressure, leading to
the use of behavioural management cation in article 2,35 capacity and con a risk of stroke or cardiac arrest.78
techniques such as acclimatisation and sent (including physical intervention) in The National Institute for Health and
tell-show-do. The degree to which this article 333 and provision of information Clinical Excellence (NICE) recommends
is successful in people with a learning and materials related to oral hygiene in patient-centred care for management of
disability may depend on the sever article 4.24 The reader is referred to them hypertension, taking account of individ
ity of the learning disability. However, for further information. ual needs and preferences and providing
Smoking
Excess alcohol
Diabetes mellitus
Hypercholesterolaemia
Sedentary lifestyle
Obesity
Source: reference 78
b) Angina at diagnosis to avoid the need for dental angina during treatment.81 GTN should
Angina is severe, crushing chest pain. care later on. If feasible, dental treat also be easily to hand throughout dental
Stable angina is typically precipitated ment is best carried out using local treatment and should relieve chest pain
by effort and relieved by rest within ten analgesia, with or without conscious in angina within ve minutes. Prolonged
minutes. The usual cause is coronary sedation. Anxiolytic agents and use of use of GTN tablets has been found to
atherosclerosis resulting in insufcient sedation are valuable tools for reducing cause caries localised to the area where
blood ow to and oxygenation of the the effects of stress while maintaining the tablet is retained (Fig. 10).82 This can
heart muscle.78 The pain typically occurs oxygenation and obviating the need be avoided by using a GTN spray.
behind the sternum, radiating to the left for general anaesthesia. Side-effects of It is commonly recommended that
upper arm and occasionally to the left beta blockers can include xerostomia patients do not receive dental care for
mandible, and rarely to the teeth, tongue and appropriate management of dry at least six months after experiencing
or palate. Unstable angina is that occur mouth needs to be instigated.24 Also, an MI.83,84 However, Meechan suggests
ring at rest, on minimal exertion or with calcium channel blockers, particularly that ideally, elective treatment should be
rapidly increasing severity. Both forms nifedipine, have been associated with postponed for a year as there is a high
are relieved by sublingual glyceryl trin gingival overgrowth which is best man chance of a further infarct during this
itrate (GTN) spray or tablets. Unstable aged through good oral hygiene but may period.78 Until this time, acute dental
angina carries a signicant risk of myo require surgery.76,79 needs should be managed in consulta
cardial infarct and elective dental treat Both beta blockers and non-potas tion with the patients physician. All
ment should not be carried out. Surgical sium sparing diuretics can exacerbate patients with CVD should be managed
treatment using either stents or coro the effects of epinephrine in dental using a stress-reduction protocol that
nary artery bypass grafts has a good local anaesthetic agents and it is recom includes short appointments, preferably
survival rate. mended that patients with mild to mod in the morning when patients are well
erate CVD receive the smallest amount rested; use of effective local anaesthetic
c) Myocardial infarction of local anaesthetic needed to provide to minimise discomfort; use of conscious
Signs and symptoms of myocardial inf effective analgesia, using an aspiration sedation to reduce stress; and provision
arction (MI) are similar to angina but technique to prevent intravascular injec of excellent post-operative analgesia.
are more severe, of longer duration and tion.80 Many patients with CVD may be
are not relieved by GTN. The dental team taking anticoagulants such as aspirin or d) Congenital cardiac conditions
should be aware that some myocardial warfarin and the management of these
and acquired cardiac disease
infarctions are silent and occur with individuals is described in article 5 of Infective endocarditis (IE), although
out any recognised symptoms or signs this series.38 uncommon, may affect damaged heart
at the time. Effective analgesia, short appointments valves, prosthetic heart valves, a coar
and availability of both oxygen and GTN tated aorta, patent ductus arteiosus or
Seamless care are all important in treatment regimens. ventricular septal defect. As Strepto
For patients with hypertension, preven Prophylactic GTN prior to dental treat coccus viridans is the most commonly
tive advice and information on access ment has been shown to be effective in isolated bacteria in IE,78 until recently
to oral healthcare should be instituted the prevention of both hypertension and prophylactic use of antibiotics was
dietician may also be involved, as about UK deaths were attributable to asthma. Additionally, efforts should be made to
one third of people with COPD have sig- It is described as a generalised airway allay anxiety as far as is possible. Pref
nicant malnutrition related to dimin obstruction which, in the early stages, is erably, treatment should be carried out
ished appetite and the increased energy paroxysmal and reversible. The obstruc with local analgesia.95 If conscious seda
expenditure required for breathing. tion is due to bronchial muscle contrac tion is required, relative analgesia is the
The dental professional can be a valu tion, mucosal swelling and increased technique of choice as in the event of an
able member of the MDT as there are a mucous production and leads to cough asthma attack, it can be more rapidly
number of oral health risk factors. The ing, wheezing, and/or shortness of controlled than intravenous sedation.95
frequency and severity of periodon breath.96 Common triggers include house Aspirin is not recommended for anal
tal disease is increased in people with dust mites, animal fur, pollen, tobacco gesia as many people with asthma are
COPD.93 The oral health risk can be exac smoke, cold air, chest infections and allergic to it.95 Also, use of non-steroi
erbated if the individual is a smoker, or stress, and adult asthma can develop dal anti-inammatory drugs (NSAIDs)
if they are on oxygen therapy, which after a viral infection. There is no cure may precipitate an asthma attack
is associated with xerostomia. Addi for asthma and treatment and manage and it is safer to recommend the use
tionally, patients may be advised to eat ment include the use of preventer and of paracetamol.
small, nutrient and calorie-rich meals reliever inhalers. If this proves insuf If an asthma attack occurs on the
frequently. The dental team have a role cient, inhaled steroids are used and dental premises, the individual should
to play in the provision of oral health in severe cases systemic steroids may use their reliever inhaler immediately,
advice, smoking cessation and dietary be prescribed. sit but not lie down, and loosen any
advice. This is particularly important, tight clothing. If there is no immediate
as poor oral hygiene has been linked to Seamless care improvement, they should continue to
respiratory pathogen colonisation and Anti-asthmatic medication, such as use their reliever inhaler at the rate of
dental plaque may act as a reservoir salbutamol inhaler or tablets and bec one puff every minute for ve minutes
for acquired pneumonia in older peo lamethasone inhaler, can lead to both or until symptoms improve. If symp
ple, particularly residents of long-term increased dental caries and periodontal toms do not improve in ve minutes the
care facilities.94 disease. In order to control any possi emergency services should be called and
Most people with COPD can receive ble exacerbation of dental disease, peo the reliever inhaler use continued every
dental treatment safely, with only minor ple with asthma should be advised by minute until help arrives.96
adjustments to procedures, in general their doctor, pharmacist or dentist that Although a large proportion of peo
dental practice. For comfort of breath they need to adopt more precautionary ple with respiratory disease are able
ing, they may need to have their dental oral hygiene practices and have regu to receive routine dental treatment in
treatment in an upright or semi-reclined lar dental reviews.97 Salbutamol is a 2 general dental practice, those with sig
position. People on oxygen therapy will adrenergic agonist and can produce nicant respiratory problems are best
need ambulance transport for dental dry mouth, taste alteration and discol treated in a hospital setting.
appointments and an adequate supply ouration of teeth. People using corti The illustrative material used in Figures 1, 2, 3
of oxygen during the visit, or provision costeroid inhalers are also predisposed and 5 is credited to www.JohnBirdsall.co.uk. The
authors would like to thank the Downs Syndrome
of domiciliary oral healthcare. Patients to developing candidosis.98,99 To help Association for providing them with the illustra
with severe COPD are at particular risk prevent these side-effects, people are tive material used in Figure 8.
when given intravenous sedatives, opi advised to rinse and gargle with water 1. Scully C, Dios P D, Kumar N. Special care in
ates or general anaesthetics due to res and brush their teeth after using their dentistry: handbook of oral healthcare. pp 92-97.
Edinburgh: Churchill Livingstone, 2007.
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should be treated with local analgesia.88 Before dental treatment, an asthma 3. Wilkins E M. Patients with special needs. In Clinical
practice of the dental hygienist. 9th ed. pp 936
The respiratory centre of a blue bloater history that includes efcacy of medica 938. Boston: Lippincott Williams & Wilkins, 2004.
is relatively insensitive to carbon diox tion, use of steroids and any episodes of 4. Grifths J, Boyle S. Holistic oral care - a guide for
health professionals. Chapter 11. London: Stephen
ide and the individual relies on hypoxic hospitalisation should be ascertained.95 Hancocks Ltd, 2005.
drive to maintain respiratory effort. Pro If steroids have been taken long-term, 5. Bobath Wales website. 2008.
www.bobathwales.org.
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