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Treating Special Needs and Intellectually Disabled Patients

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Intellectually and developmentally disabled patients (commonly referred to as: “Special Needs”) are a very broad and diverse group of individuals. When I started practicing dentistry 10-and-a-half-years-ago, in 2008, I was still developing my skill set and clinical parameters (determining what could be accomplished in our office.)

Today, I am proud to tell you that our office has been serving intellectually-disabled (IDD) patients for the better part of the past 10-years. We now have extensive experience delivering a full range of services to these patients. There have been 3 things that have made this possible. 1. Training in Sedation 2. Strategic Partnerships, and 3. Staff Willingness.

Immediately after graduation (2008) from UT School of Dentistry in Houston, TX, a friend and I went to Dallas, TX to take the 2-day Enteral Sedation Course, which was co-taught by two teachers Dr. Clark Whitmire and Dr. David Canfield. I took this course before I even had a job, because I knew it was a tool that I needed to have in my toolbox. Since then I have taken renewal CE in 2011, 2014, 2016, and 2018. Some of the most valuable training you gain in sedation is your clinical practice of sedating patients. Our office has safely completed hundreds of Level I Enteral Conscious Sedation procedures on the full spectrum of normal healthy patients to medically-complex special needs patients.

Strategic parternership started with ATCIC, (Austin Travis County Integral Care.) When we got on board with ATCIC, that really opened our doors to seeing increased special needs patients. It has proved to be a very rewarding connection, on a personal and professional level. We try to treat the care takers of these patients with a great deal of respect and kindness. As time has marched on, the state has splintered it’s dispensation of the dental healthcare dollars from the centralized control of ATCIC to now include many of the group homes and facilities that house these IDD patients. [So, now we are partnered with additional entities (e.g. Draco, Bluebonnet, et. al.)]

When we decided we were going to increase our connection to this underserved* patient population (IDD patients,) I knew I needed to build consensus from the McFarlane Dental staff, because decisions do not exist in a bubble. At the time, I knew I needed to make sure I had a hygienist who could roll with the punches of treating the needs of these patients. So, she and I sat down and discussed what we thought would be realistic possibilities. We talked about measuring success and understanding that these cases would probably present new challenges. We specifically discussed how her ideas about delivering a perfect cleaning might have to come second to treating these patients with gentleness and doing our best to help them maintain their autonomy, whenever possible.

The rewards of treating this patient population has been on many levels. We have felt the encouragement from being engratiated into the family of caretakers. We’ve become part of the families of the individuals who are brought in by their aging parents or siblings. And of course, we are able to make a living, doing the work we love, caring for these individuals. It’s also very common for us to become the dental office for the whole family of these patients.

If you have a special needs person in your life, check and make sure they are getting the dental care they need. If you need a dental office with experience treating special needs IDD patients, we might be a good fit for you.

If you are a dentist who would like to get more involved treating IDD patients, call me and I would be happy to help you draw up a road map to help you make that a part of your practice.

Before and After Same Day Resin composites to close diastema

before-and-after-same-day-resin-veneers Click the picture to see it enlarged

Before and After Photos are favorites for people discovering what is possible. This patient presented with a history of her friends making fun of her and telling her that “she looks British.” This jabbing hurt her feelings and she asked if there was anything we could do about it.

Patients who have an open diastema, which is the technical name for the space between the teeth, have 2 primary options when closing the space.

  1. A minimal (or) no prep veneer, such as a Lumineer.
  2. Same day in-office treatment with a white resin composite.

A porcelain veneer has a very beautiful finish and a very high shine. Porcelain veneers tend to last 10 to 15 to even 20 years. They stay very shiny. Usually they have esthetic failures at the gumline, due to recession and/or staining at the margin. It is realistic to assume that you will replace a set of veneers every 10 to 20 years.

Same day resin composites to close diastema can be applied in the office using a bright composite applied directly to the teeth after etching and bonding. This procedure is sometimes called composite veneers, bonding, or resin veneers. The advantage of this procedure is that it is less expensive because there is no lab fee. Also, it can be applied right away with no waiting for porcelain to be made ready.

This patient left with same day resin composites and was thrilled because she hopes to longer hear the jabs from her friends about her teeth.

Before and After In-Office Whitening (photo with no flash)

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This is a before and after in-office whitening. This took 5 (15-minute) sessions all completed in one sitting. The teeth moved up the shade guide considerably. This was taken using ‘No Flash.’ Because it is hard for a camera to capture the real effect your eyes can see with an in-office whitening. This is because when a camera flashes it resets the white balance. So, these images with no flash are a better representation of what your eyes actually see when it comes to color change. It is harder to get a perfect focus without a flash. 🙂

Immediate Bridge Using Natural Tooth And Ribbond

The patient has had a lower anterior tooth that had gradually lost all the attachment around it as a result of localized periodontal disease. This left the tooth mobile and hopeless and it was starting to become uncomfortable chewing with it.

Before and Afters Of Immediate Bridge using Natural Tooth
Before and Afters Of Immediate Bridge using Natural Tooth

Once we determined that the tooth was hopeless, we set out to make the mouth healthier by removing the tooth. Then, we used the removed tooth to make a bridge between the teeth that will act as an immediate bridge. To make this possible, we anesthetized the area and extracted the tooth. Because it was already mobile and had very little attachment remaining, there was not very significant bleeding. We then, sectioned the tooth to get it out of the unhealthy pocket so that the periodontal tissues below it can heal. Then, we backfilled the root canal space internally in the tooth with bonding agent and flowable composite. We made a channel in the two adjacent teeth and the extracted tooth, then, using unfilled bonding agent on the Ribbond, and normal (etch, Scotchbond Universal) bonding agent on the teeth, placed a thin layer of composite and bonded 2 strips of ribbond into the channel to reinforce the teeth being intracoronally splinted together. We then, placed additional composite over the top, and I added a small amount of flowable composite from the facial interproximally to finish. Then, I touched up the occlusion with an ortho disc and smoothed off the edges of the composite in the channel with a flame diamond.

Fractured Tooth Emergency Repair with Same Day Crown

Patient presented with a fractured off tooth, which we were able to repair in-office same day with an all ceramic crown.

Fractured Tooth Repaired with All Ceramic Crown
Fractured Tooth Repaired with All Ceramic Crown

We used the laser to lower the gums, so there is some slight coloration in the gums (right now temporarily) from the use of the laser. That mild discoloration at the gumline will be gone in 1-4 days.

We used 1 cartridge of 4% Articaine given via infiltration locally on the tooth. This did not require a full Inferior Alveolar Nerve Block. The tooth was carefully prepped and the gums lowered to allow an adequate ferrule for retention.

The ‘A1’ shade Obsidian Block was characterized with some cream coloration to help match the natural teeth which have mild light horizontal striations. We were able to seat this crown, same day and this tooth is taken care of and the patient does not have to walk around with a very nearly exposed pulp chamber. The patient had not felt any serious pain on this tooth, and so we are not expecting to need a root canal for this tooth.

Hope you like it,

JRM

Before and After In-Office Whitening

Enjoy the before and after:

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On this case we completed today, we moved a patient from a A4/C4 to a B3. In-office whitening uses a process where we retract the lips and isolate the gum tissues using a soft light cured resin. The process takes about 1 hour. We do 3 applications of 38% H2O2 bleach gel to the teeth. Each session of the three applications is kept on the teeth for 15-minutes. Then, between each set we clean the teeth off and reapply fresh whitening gel.

Retraction in place
Retraction in place

To get a sense on the shade guide organized by hue, chroma, and value from lightest to darkest. Here is what it means to move from C4 to B3.

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So, the before and after on this case was really an awesome improvement.

Hope you like it,

RM

Responsible Esthetics: No Prep Veneers with Lumineers

I recently sat in a Hands-On course with Dr. Peter Harnois. We spent several hours discussing veneers. The primary topic was a discussion of prep design, tooth preparation in order to get the tooth ready to receive a veneer. Specifically, Dr. Harnois discussed Lumineers, which use strong lithium disilicate, and can be as thin as 0.5mm. The bonding of veneers with a resin cement is central to the combined strength as this prevents displacement and prevents flexure of the veneer.

Denmat is the dental lab that is responsible for the Lumineers and minimal prep and/or no-prep veneer options. I was compelled by the results that Dr. Harnois showed off. Here is a virtually no prep case that I completed with a single veneer for a lateral for a patient this past week. Click for FULL SIZE VIEW

Veneer Before and After
Virtually no prep veneer. Dusted off the sharp edges with a Sof-Lex disc before sending to lab.

What about small fractures? Or is there more to the story?

Enjoy the before and after!

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Patient could tell something didn’t feel right, it hurt initially, and a small piece broke off, but, then, the pain temporarily subsided. There was meaningful decay into the dentin in the area where the chipping occured. We removed the old amalgam, the caries (decay), and restored with a composite. Recurrent decay with associated fracture: #19 – DOB

He wore through the cusp tips from grinding. I did not extend the outline of the filling into the areas of erosion on those cusp tips, as the patient’s grinding was largely historic from having very large tonsils in his youth. He did not have his tonsils out until 18 or 19-years-old. The airway disturbance, akin to Obstructive Sleep Apnea, caused associated bruxism. If we did extend the outline of the filling into those areas, the tooth would be very weak and would require a crown and would be at high risk of fracture.